What is most difficult to understand about recovery from drug and alcohol addiction is for any client or family involved is that relapse happens, and addicts have a high risk of relapse. We call is relapse and remission, this is because addiction is a chronic disease. Anyone in recovery can be described as being in remission from their disease.
Based on research evidence the addict goes through the following 11 steps before s/he finally gets to a place where s/he thinks they have no choice but to use drugs again.
- Step 1: Unhealthy emotions
- Step 2: Denial
- Step 3: Compulsive behaviours
- Step 4: Triggers
- Step 5: Interior chaos
- Step 6: Exterior turmoil
- Step 7: Loss of control
- Step 8: Addictive thinking
- Step 9: High-risk situations
- Step 10: RELAPSE
- Step 11: Aftermath of relapse
Over the years, additional research has confirmed that the steps described in the Gorski and Miller study are “reliable and valid” predictors that commonly cause many of us in recovery to relapse. On this page we want to focus on relapse triggers and how to sharpen your relapse radar as it will help you to recognise the warning signs and take action to avoid the physical relapse.
A relapse prevention program helps identify your personal relapse triggers. A trigger can be anything that activates a craving or a using thought. Triggers are sometimes referred to as urges or cues. Urges can be common in early recovery so do not regard them as a sign of failure. Instead they will help you to understand you triggers. You win every time you defeat an urge to use. Urges get stronger every time you give in and feed them. Remember, if you don’t feed the monster it gets weaker!
Psychologists prefer the word cues, originating from research in which a reward or punishment is paired together with something else i.e. the cue together with food. For example: Dogs will associate the sound of a bell with food over time and will begin to salivate as soon as the bell rings. This is known as classical conditioning (based on the research by Ivan Pavlov known as the phenomenon of Pavlov’s dog or Pavlovian Response) and forms part of relapse prevention work.
Your biological body clock is a trigger to undertake any routine behaviour. All living creatures have an internal timing system that tells us what we should be doing at any given time to satisfy our needs. So whether it’s a lunch time drink, evening joint, bedtime pill, weekend cocaine, daily or sometimes hourly fix, you are programmed to expect it.
A pattern of relapse and remission is very common for those suffering with long-term addictions. However, it’s worth thinking about exactly what impact this has on your life and how it can be avoided. Remission can be followed by a likelihood of relapse so preventive interventions may stop future use. Post treatment relapse rates are very high so dedication and hard work is necessary.
Dual recovery refers to those with dual diagnosis so dual relapse prevention planning is necessary. Issues like a flare up of the psychiatric illness and symptoms such as obsessive behaviour or hallucinations are obvious triggers. Non-compliance with psychiatric medications can lead to self-medicating using alcohol, prescription and illicit drugs and not engaging in a support network or program often results in feeling overwhelmed and confused.
Relationships deserve a special mention as they are common relapse triggers and this is partly why it’s recommended not to pursue new romantic relationships in early recovery. Romantic and unhealthy sexual and non-sexual relationships can be a source of both euphoric and painful feelings, so to keep emotional stress at a manageable level they are best avoided if possible. However, forming healthy intimate relationships is very much a part of recovery and these can be with other recovering individuals, sponsor, therapist, family members, spouse, partner and children.
Environmental triggers are people, places or things that have somehow become associated with your using. Also known as external or sensory triggers that can combine with internal triggers such as emotions and thoughts, some of which are listed below:
People: Friends, family members, co-workers
Places: Bars, neighbourhoods, holidays
Things: Cash, paraphernalia
Events: Wedding, funeral, birthdays, weather
Emotional: Anger, depression, anxiety, euphoria
Sensory: Smell, sight, sound, taste
Euphoric recall or using memories that selectively filter out the negative consequences of your using are potentially very dangerous. Refusing to engage in conversations that glorify past using experiences, however tempting and exciting, is the wisest strategy. Music can be a powerful trigger possibly causing euphoria, using memories, depressed mood, anxiety or alternatively a positive connection.
When you first return home some urges are too strong to ignore. When this happens it can be useful to sit with your urge until it passes. In time everything passes. This technique is called urge surfing.
Think of urges like ocean waves: Small at first, then they grow in size and finally break up and disappear. Imagine yourself as a surfer riding the wave, gliding above rather than getting caught up in the chaos below. Staying calm and in control of your behaviour and actions helps more than fighting and getting stressed. That’s why meditation and relaxation techniques are so effective in these situations.
What is a craving?
A craving is a mental and physical desire to use: You know you’re experiencing a craving when you start to feel anticipation and it can be overwhelming. The compulsion to act on the craving despite previous unwanted consequences is what makes addiction so powerful and relapse so common.
Failure to accept having the disease of addiction/alcoholism is another common reason people pick up drugs or drink again.
We say relapse is a process not an event, but cravings are not something that you can always predict or guard against. You may not know when they are going to happen. You can get a craving whilst watching TV or while you are trying to work or go to sleep. All you know is that your body is telling you how much better you’d feel if only you took a drink, smoked a joint or took that drug.
Relapse prevention is all about learning what your triggers are and how to cope with cravings. You will create a personal recovery plan and attend groups that educate you on the best way manage this.
PAWS – Post acute withdrawal symptoms continue long after the physical detoxification process is over. The cessation of some medications can have lingering side effects. In general it is the symptoms of the disease of addiction that persist long after an addict gets clean and sober. A long term recovery plan, working a program and the rewards of a healthy life help combat nagging symptoms like depression, boredom and toxic feelings.
Relapse triggers to look out for
Distress: Feeling emotionally overwhelmed or disappointed with yourself, others and life.
Intolerance: Getting angry and not promptly defusing your unhelpful negative thinking.
Impatience: Things are not happening fast enough for you or others are not doing what you want them to do. Also trying to catch up on lost time and opportunities due to addiction.
Conflict: Arguing over small and insignificant points, indicating a need to always be right.
Expectation: Too much from others and self, “I’ve changed, why hasn’t everyone else changed too?”
Loneliness and feeling isolated, social anxiety around others becoming unmanageable.
Comparing my addiction to others and coming out better “I could use a lot more” or worse “what’s the point? I’ve already lost everything”.
Automatic-pilot: unconscious using behaviour or compulsive urges, such as going to the dealer or ordering a drink without thinking.
Frustration: Because things may not be going your way in your time you give up.
Anxiety & Depression: Overwhelming and unaccountable despair, low self-esteem and self doubt may occur.
Exhaustion: Allowing yourself to become overly tired and stressed out. Not following through on self-care behaviours. HALT stands for Hungry, Angry, Lonely, Tired.
Self-Pity: Feeling like a victim and refusing to acknowledge that you have choices and are responsible for your own life.
Co-dependency and Boundaries: Being enabled by loved ones or others expectations becoming an overwhelming pressure.
Old behaviour: Self-will, not taking advice, anger, going to bars etc.
Discipline: Letting go of recovery rituals: keeping daily inventory, repeating positive affirmations, going to 12-Step meetings, therapy, meditation and prayer. These are important structures for a new life in recovery.
Boredom: Waiting for things to change, not stimulated, unsatisfied and feeling unmotivated and lazy.
Complacency: Not working your program with the commitment that you started with. Having a little fear can be a good thing as it creates necessity for action.
Dishonesty: Denial begins with a pattern of small unnecessary lies to self and others.
Medications: Your doctor may participate by prescribing mood-altering medications and you could convince yourself that this time will be different.
Not had enough: Negative self talk such as “just one more” and reward-seeking or relief-seeking behaviour.
Defusing triggers and urges
Myths about relapse
An example of a very brief relapse prevention action plan:
Most recovering people learn that in order for their recovery to continue, they must constantly assess themselves. Part of this process includes making changes to their attitude.
Those that have relapsed, almost without exception, indicate that failure to attend support group meetings preceded their using.
Change is very much a part of living. It’s been said that the only unchanging thing in life is change. In general, addicted people tend to find it unusually difficult to accept an unpleasant reality. Perhaps that’s why they often look for “an easier, softer way” and thus gravitate towards addictive substances and processes.
One of the unpleasant truths involved in relapse prevention is that you need to feel the pain that your illness has caused you although it is uncomfortable. Why must one keep looking at the pain?
Once forgotten it becomes easy to regard that the past addiction wasn’t that bad or one drink can’t hurt me that much. Remembering the pain is one of the best forms of relapse prevention that is available. However, dwelling on painful past events can paralyse the recovering individual to a point of inaction and relapse. A balanced view of the past, present and future can stave off despair.
Recovering people are often affected by low self-esteem. While changing this can be a lifelong task, positive self affirmations can be helpful in changing bad feelings about ourselves. People practice affirming themselves in various ways as a means of improving mental and emotional health. A simple solution to raise self esteem is to take part in esteemable activities. Recovery is about action. It is also about love, joy, peace and contentment.
It is important for the addict, family members and loved ones to be prepared for this. But it isn’t a hopeless situation oran absolute given. Many people try to cope with their triggers and cravings by gritting their teeth and toughing it out. Some urges, especially when you first return to your old environment, are too strong to ignore.
So relapse awareness work is a fundamental part of treatment in-order to ensure you maintain your gains in treatment and your new life.
This involves finding new ways of taking care of your self, developing new approaches to life and new ways of thinking and behaving, especially socially and finding alternative ways to cope with difficult situations. The following exercise will help you make an effective plan.
With the probable relapse in the center of the radar, this diagram will show how relapse is a process not an event and can be prevented.
Relapse Radar was a phase coined by our former head counsellor Dylan Kerr, so we created this exercise to follow. A recovering person should have their Relapse Radar on at all times in order to see it coming.
This tool is a visual exercise which is more readily remembered than lists.
Relapse Warning Signs
To stop drinking or taking drugs you best get away from old associates “people places and things” that trigger you to want to use drugs and alcohol again. Hope counsellors call this “getting into a healthy environment.” If you hang out with friends who are drinking and using drugs your chances of staying in recovery are almost zero. Ideally you will choose to be around healthy people, places, and things that encourage a new life. When someone newly out of treatment starts going back to the old using and drinking associates and environments we call this an early warning sign.
A successful treatment and rehabilitation program will make sure that you learn strategies and techniques to help avoid the triggers that can cause relapse. They will also teach you to recognize the stages of relapse and specific coping skills that will help successfully manage these stages.
It important for you to be educated. The last thing you want is to struggle again with the pain and discouragement of active addiction and alcoholism. Working to get to the point of recovery is difficult work and you don’t want to lose ground, if at all possible.
By Simon Mott