Relapse Prevention

Textbook: Staying Sober: A Guide for Relapse Prevention
Terence T. Gorski and Merlene Miller. Based upon the CENAPS Model of Treatment


Chapter 1: Relapse in Addictive Disease
Chapter 2: Addictive Disease
Addictive Chemicals
The Disease of Addiction
Withdrawal
Progression
Delusional Thinking
The Addiction Cycle
Recovery
Chapter 3: Post Acute Withdrawal (P.A.W.)
Symptoms of PAW
Patterns of PAW
Managing PAW Symptoms
Chapter 4: Recovery and Partial Recovery
The Pretreatment Period
The Stabilization Period
The Early Recovery Period
The Late Recovery Period
The Maintenance Period
Partial Recovery
Chapter 5: Mistaken Beliefs about Recovery and Relapse
Mistaken Beliefs about the Role of Alcohol and Drug use in Recovery
Mistaken Beliefs about the Warning Signs of Relapse
Mistaken Beliefs about Motivation
Mistaken Beliefs about Treatment
Chapter 6: Understanding the Relapse Process
The Role of Substitute Addictions
The Role of Caffeine
The Role of Compulsive Behavior
Positive Outlets versus Compulsive Behavior
The Process of Relapse
Sobriety-Based Denial
Chapter 7: The Relapse Syndrome
Interrupting the Relapse Syndrome
Phases and Warning Signs of Relapse
Chapter 8: Relapse Prevention Planning (R.P.P.)
Stabilization
Assessment
Education
Relapse Warning Sign Identification
Warning Sign Management
Inventory Training
Review of Recovery Program
Involvement of Others
Follow-up and Reinforcement
Chapter 9: Family Involvement in the Relapse Syndrome
Relapse Warning Signs for Coaddiction
Relapse Prevention for the Family
Chapter 10: The Relapse Prevention Self-Help Group
Meeting Format


Chapter 1: Relapse in Addictive Disease
The book is about how to prevent relapse. It seeks to address several mistaken beliefs.
1. The mistaken belief, that relapse cannot be prevented. (Relapse Prevention can be learned.)
2. The mistaken belief, regarding the addicts self-blame for past relapses and their attribution (the way they think about things), that they are now hopeless (constitutionally incapable) of preventing future relapses.
3. The mistaken beliefs about the relapse process, is that abstinence is recovery.
The goals of the Staying Sober book are to provide hope that mistaken beliefs can be corrected with accurate information, and for addicts to be set free from the hopelessness of repeated relapses.
Recovery is more than just bringing your body to meetings.
Abstinence is not recovery!
Many people can be sober and at high risk of relapse because of the addictive disease.
Relapse is a problem that applies to a variety of addictions.
Addiction is a bio-psycho-social disease (body, mind, and relationships).
It is a disease because many people experience abnormal reactions even when they are NOT using (abusing) a substance, or in active addiction.
Post-Acute Withdrawal (PAW) is the emergence of sobriety-based symptoms that accompany abstinence, the dry-drunk. PAW is the result of the persons dysfunctional attempts to cope with uncomfortable life events (emotional pain).
PAW can be managed.
Partial recovery is when the recovery process is incomplete and the addict gets stuck when they lack the skills to deal in a functional manner with life-issues.
The process of relapse begins long before addictive use starts. People become dysfunctional in sobriety before they begin addictive use or instead of addictive use.
The relapse process is the movement away from recovery. If you are not paying attention to your recovery, you may be unconsciously moving in the direction of relapse. If you are stuck in partial recovery you are in high risk of relapse.
Recovery from addictive disease starts with accepting the fact that you cannot safely use alcohol or mood altering drugs. Not using addictive chemicals is abstinence, but is not enough for recovery. Abstinence simply allows the recovery process to begin.
The addict must learn to cope with life in a non-addictive manner.
Relapse tendencies are a normal part of the recovery process.
The relapse syndrome occurs when the person chooses to drink or use drugs to gain temporary relief from their emotional pain. Others do not drink or use drugs, but develop serious health problems as a result of their dysfunctional coping methods.



Chapter 2: Addictive Disease
People often fail to recover because they do not understand their addiction or they fail to do those things that could help them to avoid relapse.
Addictive Chemicals
Mood-altering drugs are chemical agents that produce changes in brain function by altering the chemistry of the brain. Once brain function is altered a person experiences physical, psychological, and behavioral changes as a direct result. All mood-altering drugs have the potential to damage the mind, body, behavior, and relationships whether or not they are used addictively. The extent of the consequences depends upon the person, the drug used, and the circumstances.
The Disease of Addiction
Addiction is a condition in which a person develops a bio-psycho-social dependence on any mood-altering substance. An addiction causes a person to use a drug for short-term gratification; but there is a price to be paid. The addiction causes long-term pain and discomfort. An addiction is accompanied by obsession (constant thoughts about using, or anticipating drug use), compulsion (a strong desire to use), and loss of control (when you ability to make good decisions is compromised). Addiction dictates the frequency, the quantity, and the nature of substance use. All addiction begins with use, but all use does not lead to addiction. Although addiction is generally accepted as disease there is a common belief that its primary cause is psychological. Some studies suggest a genetic and heredity basis for addiction. People with a genetic disposition for alcoholism, are not predestined to develop the disease, but they are in high risk because of the way their bodies respond to alcohol (or other drugs).
People become addicted for physical reasons. They develop tolerance; it takes more of the drug to produce the same effect. Drinkers seem to be able to handle the booze better, without realizing that their body is learning to depend on the alcohol to feel normal. The cells of the body adapt to high levels of the drug and begin to function normally when it is present. This leads to dependence. The body comes to need the drug; absence of the drug will result in physical withdrawal causing discomfort and illness.
The more people use chemicals to feel good the less they learn to use more effective ways to experience and cope with feelings, situations, and people. They do not learnor they forget to useother methods of coping. Their dependence has become psycho-social as well as physical. All life areas are affected.
Withdrawal
Withdrawal is the pain that develops when an addicted person stops using alcohol or drugs. Withdrawal is bio-psycho-social. Part of the pain is physical damage created by the bodys need for the addictive substance. Part of the pain is caused by a psychological reaction to losing the primary method of coping with lifethe use of addictive substances. Part of the pain is social, caused by the separation from an addiction-centered lifestyle. Physical withdrawal (from alcohol) develops in two phases. The first is called acute withdrawal and lasts for three to ten days. Long-term withdrawal (also called Post Acute Withdrawal) can last for months or even years into sobriety.
Progression
Most alcoholics will progress through three predictable stages of manifesting symptoms.
1. Early Stage marked by growing tolerance and dependency. The user seems to be adjusting or adapting in all ways to a substance using lifestyle. There is little denial as there are few observable problems.
2. Middle Stage marked by a progressive loss of control. The use is slowly changing from a desire to use to a need to use. As the physical damage to the user gradually increasestolerance to the substance slowly decreases. The person seems to get intoxicated on smaller amounts of the substance, but is unable to function without using. Denial is strongest at this stage, as many of the problems can still be blamed for a while on other things, rather than addictive use. This is the time when family, friends, and employers, clearly can see that the person has a problem, though they may still try to deny it. Once the physical damage to the user has increased to the point where tolerance has droppedmost often, the only choice is treatment and total abstinence.
3. Chronic Stage marked by a deterioration of bio-psycho-social health. The substance users life is marked by deteriorationphysical, psychological, behavioral, social and spiritual. Mood swings are common, and the person uses the drug to feel better, but is unable to maintain the good feeling. Their life becomes even more drug-centered and they seem to have less control over their behavior. They create a unique cycle of: using, recovering from using, seeking the substance, protecting their using (or stash), and gradually isolating themselves from everyone who does not support their lifestyle.
Delusional Thinking
Addiction is a chronic disease (condition), which is marked by an increase in neurological impairments, distorted reality, and perception and memory problems such as black-outs. Denial of the problem is part of the condition. Denial blocks motivation for recovery by masking the painful reality of a life caught in a cycle of pain, denial, and alcohol/drug use from which there seems to be no way out.
The Addiction Cycle
Substance users commonly follow a predictable cycle of addiction:
1. Short-term gratification is the desire to feel good, or escape pain. Substance use, as an immediate coping mechanism is a strongly reinforced behavior.
2. Long-term pain and dysfunction is the part in the cycle caused by physical withdrawal and the inability to cope psycho-socially without using addictive-drugs.
3. Addictive thinking begins with obsession and compulsion. It is only thinking about the positive effects of substance use, combined with an irrational urge or craving to use the drug. Even though users know what the negative consequences of using will be, they quickly learn to rationalize their use through denial and blaming other people, places, things, and situations outside of themselves.
4. Increased Tolerance is when more of the drug is needed to produce the same effects.
5. Loss of Control is when the obsessions and compulsions become so strong that the users feel that they have lost control of themselves (their thinking, feelings, and acting). The subjective discomfort (unhappiness) caused by the disease is marked by the stress of not using, being almost as much as the pain caused by using.
6. Bio-psycho-social damage Eventually there is damage to the health of your body, your mind, and your social relationships. As the pain and stress get worse, the compulsion to use the addictive substances or addictive behaviors to relieve the pain increases. Unless the person gets help the cycle keeps repeating.
Recovery
Total abstinence is necessary to recover from an addiction. Promises to cut down are promises that cannot be kept. Any use will keep the addiction active. Abstinence is a necessary first step. Abstinence alone is not recovery, and in most cases must be accompanied by treatment of some type. Detoxification is removing the toxic substance from the body. Acute withdrawal symptoms that emerge when the chemical is removed can be very serious. Withdrawal is a medical problem and should be treated by a physician. A common method of detoxification is administering a substitute drug and gradually decreasing the dose until the withdrawal symptoms have subsided. It should be noted that the person is not fully detoxified until the substitute drug has also been removed and the person is drug free.
Detoxification alone is not adequate treatment. Addiction affects all aspects of a persons life. Therefore recovery requires holistic treatment that leads towards long-term physical, psychological, behavioral, social, and spiritual change. Education is an extremely important aspect of treatment. Because recovery from addiction requires self-management, it is essential for addicts to learn as much as possible about their disease and how it is managed. Apart from learning about their addiction, and how to manage the sobriety-based symptoms of Post Acute Withdrawal (PAW), the recovering person will often need to deal with specialized problems including: financial difficulties, marital or relationship problems, emotional or psychological disorders (Concurrent Disorders / Dual Diagnosis), or behavioral problems that are the direct result of addiction.
Management of long-term withdrawal symptoms is essential to maintaining sobriety. This includes understanding and accepting the symptoms that interfere with the ability to remember, think clearly, and manage feelings and emotions. It also includes overcoming the shame, guilt, and fear of being crazy that are often associated with these symptoms. It includes reducing/managing stress, memory retraining, and balanced living.
Sobriety is essential for good health, and good health for sobriety. The first rule of good health for a recovering person includes abstaining from all mood-altering drugs. Good nutrition is vital for recovery. Malnutrition and alcohol & drugs have damaged the body, and it must be rebuilt through a balanced diet. Because recovering people are stress sensitive, stress-producing substances such as concentrated sweets, caffeine and nicotine should be avoided. Exercise is important to help rebuild and maintain the body. Aerobic exercise is especially beneficial in reducing and managing stress. Time for relaxation should be structured into the life of every recovering person. Recovery requires the resolution of family, work, and social problems that were created by the addiction.


Chapter 3: Post Acute Withdrawal (P.A.W.)
When most people think about alcoholism they think only of the alcohol based symptoms and forget about the sobriety-based symptoms. Yet, it is the sobriety-based symptoms, especially post acute withdrawal, that make sobriety so difficult. The presence of brain dysfunction has been documented in 75-95% of recovering alcoholics tested. Research indicates that the symptoms of long-term withdrawal associated with alcohol and drug related damage to the brain, may contribute to many cases of relapse.
Post Acute Withdrawal – is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals. In the alcoholic, these symptoms appear 7 to 14 days into the absence period, after stabilization from the acute withdrawal.
PAW is a bio-psycho-social syndrome.
Recovery causes a great deal of stress. Many chemically dependent people never learn to manage stress without alcohol and drug use.
The severity of PAW depends upon, the severity of the brain dysfunction and the amount of psycho-social stress experienced.
Symptoms of Post Acute Withdrawal
1. The addicted person seems to experience an inability to think clearly, such as problems concentrating, and rigid and repetitive thinking patterns.
2. Memory problems, including short-term memory problems, and problems remembering events from the past. This may cause problems in learning new sobriety-coping skills and learning from past mistakes.
3. Emotional over-reactions or numbness, are common. This includes outbursts of anger, frequent mood swings, more anxiety than is warranted for the situation, or the person feeling overwhelmed so that they seem to shutdown emotionally.
4. Sleep disturbances, such as problems getting a good nights rest, or problems staying awake. These may be temporary, and some are life-long. Also unusual dreams and using dreams (euphoric recall) seem to plagues those in recovery.
5. Physical coordination problems, such as dizziness, trouble with balance, problems with hand-eye coordination, and slow reflexes. This clumsiness is sometimes called the dry-drunk syndrome.
6. Stress sensitivity, is often the most confusing and aggravating part of recovery. Recovering people are often unable to distinguish between low-stress situations and high-stress situations. They may overreact to low-stress concerns, and almost ignore important or potentially higher-stress issues. In general the higher the stress the greater the severity of post-acute withdrawal syndrome.
The Recovery Paradox Recovery from the damage caused by the addiction requires abstinence. The damage itself interferes with the ability to abstain. This is the paradox of recovery. Alcohol can temporarily reverse the symptoms of the damage. If the alcoholics drink, they will think clearly for a while, be able to have normal feelings and emotions for a little while, and feel healthy for a little while. However, they will soon lose control again and regress to an even lower level of functioning. For this reason it is necessary to do everything possible to reduce the symptoms of post-acute withdrawal when the person is sober so that they do not go back to drinking or substance use to get some stress relief.
Patterns of Post Acute Withdrawal
Regenerative – gets better over time. (Moving towards recovery.)
Degenerative – gets worse over time. (Moving towards relapse.)
Stable – stays the same over time. (White-knuckle sobriety.)
Intermittent – comes and goes. (Characteristic of long-term recovery to discovery.
The symptoms gradually keep lessening until they are gone.)
Managing PAW Symptoms
Recovery is an ongoing process that you need to pay attention to. Ignoring your recovery program, or not taking sufficient care of yourself, puts you in a high-risk situation and makes you vulnerable to relapse.
Be Aware of Stressors
If you are going to recover without relapse, you need to be aware of stressful situations in your life that put you at risk. Since you cannot remove yourself from all stressful situations you need to prepare yourself to handle them when they occur. It is not the situation that makes you go to pieces; it is your reaction to the situation. Because stress triggers and intensifies the symptoms of PAW, controlling it is a matter of learning how to manage your stress. To do this you must identify the sources of stress and develop skills in decision-making and problem solving to help reduce stress. Proper diet, exercise, regular habits, and positive attitudes all play important parts in controlling PAW. Relaxation can be used as a tool to retrain the brain to function properly and to reduce stress.
Stabilization
If someone is experiencing severe post-acute withdrawal symptoms, it is important to bring them under control as soon as possible. Here are some suggestions that may help and suggested areas to pay attention to that will help the person achieve a stable recovery pattern.
Verbalization – Talk to others, who will be supportive and non-judgmental.
Ventilation – Talk about your feelings and thoughts, learn to hear yourself.
Reality Testing – Ask someone if you are making sense, and doing the right thing.
Problem Solving and Goal Stetting – Think about a healthy substance-free future.
Backtracking – Think back over how relapse episodes started, and see where you can choose new solutions from here on in.
Education and Retraining – Learn about addiction, recovery, and life skills. Practice what you have learned.
Self-Protective Behavior – You are responsible for protecting yourself from anything that threatens your sobriety, or anything that triggers PAW. Learn stress protective behaviors. Stop putting yourself at risk, or in high-risk situations.
Nutrition – Eat a healthy well balanced diet. Cut out the caffeine and sugar!
Exercise – daily to reduce stress and get your brain working (aerobic exercise).
Relaxation – not just when you sleep (smile, and laugh a little, enjoy life).
Spirituality – get in touch with the eternal (Let God worry about the big stuff).
Balanced Living – maintain bio-psycho-social harmony in your life (self-esteem).


Chapter Four: Recovery and Partial Recovery
Although addictive disease can be controlled, it can never be cured. There is always the possibility of relapse.
1. Recognition that addiction is a life-threatening disease associated with the use of drugs or alcohol.
2. Abstinence total abstinence is necessary for life-long recovery.
3. Daily Program of Recovery to support and assist the person staying sober each day.
4. Recovery is a process that requires a long period of time. (It takes eight to ten years for the average alcoholic to fully return to normal.)
Developmental Model of Change
The recovery process is developmental that means that recovery is a process of growth and development that moves from basic to complex recovery tasks. The progression is from abstinence (learning how to stop using alcohol and other drugs) to sobriety (learning how to cope with life without alcohol or drugs), to comfortable living (learning how to live comfortably while abstinent), to productive living (learning how to build a meaningful sober lifestyle).
Pretreatment – Recognition of addiction, learning from consequences.
Stabilization – Withdrawal and crisis management, regaining control of self.
Early Recovery – Acceptance and non-chemical coping, learning to function.
Middle Recovery – Balanced living, managing stress, focusing on life activities.
Late Recovery – Personality change, examining and correcting faulty beliefs, values, styles of interacting in relationships, and childhood trauma issues that are still causing problems with ongoing recovery.
Maintenance – Growth and Development,
Partial Recovery
Recovery from addictive disease is not a process of straight-line growth. Most persons recover in stages over time. They develop a new understanding of their disease and recovery. They spend time applying and integrating that new knowledge into their daily lives. They then become comfortable and coast for a while before the need for new knowledge develops. It is common for people to backslide in their recovery. This often happens when they are attempting to put new knowledge to work. The stress of change temporarily gets the best of them and they back off for a while. As the stress goes down, they talk about how to better manage the situation, they roll up their sleeves and they get started again. Many recovering people eventually achieve long-term and comfortable sobriety.
Partial Recovery – happens when people confront a recovery task that they believe to be unmanageable or insurmountable. This then becomes a sticking point. Being stuck causes them to fail to complete all of the recovery tasks. They become stuck at a particular stage of recovery and their stress begins to mount. The consequence is that they remain uncomfortable and experience a low-quality sobriety or white-knuckle sobriety. Hanging desperately onto meeting support or over-relying on factors outside of themselves to keep sober.
The Role of Denial in Partial Recovery
A healthy and productive response to hitting a stuck point is to temporarily back off in order to lower stress. The next step is to examine the stuck point by discussing it with other people and then to seek appropriate help in coping with the stuck point. Instead of following the above steps many people use denial to cope with the stuck point. The person says: My recovery is fine. There is nothing wrong with me meanwhile their stress just keeps increasing and their post-acute withdrawal symptoms get worse.
Stress and Partial Recovery
The denial of the stuck point produces an increase in stress. The increased stress leads to a state of free-floating anxiety and compulsion. The person feels compelled to do something to lower their stress and often resorts to compulsive behaviors to cope. These behaviors can produce additional long-term problems in exchange for short-term relief.

Substitute Compulsions
In an effort to cope with stress, substitute compulsions such as overworking, overeating, overspending, etc. are used. These compulsive behaviors bring short-term relief but increase stress in the long run.
The Relapse Process
Eventually the stress becomes so severe that the relapse process, marked by progressive internal and external dysfunction, begins to develop. The person recognizes the risk of relapse.
Repeating the Cycle
The person reactivates a recovery program and progresses until the same stuck point is reached and the cycle begins again. This is the problem of partial recovery.
Partial recovery = stuck point -> increased stress -> substitute compulsions -> risk of relapse (or actual relapse) and reactivation of recovery program again until they get stuck. The big book of AA calls this half measures.
Finding Full-Recovery
It is not all right to waste your life in partial recovery. You are worth more than that. There is something better than that. The consequence of partial recovery is living a life of low-grade crisis, pain, and discomfort. The stress of partial recovery can and does cause stress-related illnesses that can and do shorten life. You CAN recognize the stuck points and move beyond them into full recovery. The cycle of continual relapse or of partial recovery can be broken!


Chapter 5: Mistaken Beliefs about Recovery and Relapse
The first step in preventing relapse is to understand what it is and what it is not. There are a great many mistaken beliefs that trap a relapse prone person into a state of hopelessness.
Mistaken beliefs about relapse create self-fulfilling prophecies. When mistaken beliefs become truth to you, you ACT as if those beliefs are true.
The problem with mistaken beliefs is that they prevent the effective problem solving that needed to interrupt the cycle of relapse or partial recovery.
Mistaken Beliefs about the Role of Alcohol and Drug use in Recovery
&nbsp &nbsp &nbsp &nbsp Many relapse prone people believe that recovery is abstinence from alcohol and drug use and that relapse is the use of alcohol and drugs. This leads them to believe that any time they abstain they are in recovery, and that the primary goal in recovery is simply to abstain. Abstinence is the prerequisite for recovery (according to Gorski).
Dougs note: You can still do a lot of work with addicts who are not ready yet to quit. This can be done in a prevention and education framework, or as part of pre-treatment.
Other addicts extend this mistake belief that abstinence is recovery even further to believe that any time they are not using alcohol or drugs they are fully in control of themselves and their behavior. Thus the only way to lose control is to use alcohol and drugs. This thinking pattern is wrong, and leads to the conclusion that substance use is a conscious and willful decision, and does not take into account the post-acute withdrawal symptoms (and all the little mini-decisions that lead up to someone using). Many addicts who relapse report that they became so dysfunctional in recovery that a return to addictive use seemed like a positive option. They were in so much pain that they came to believe they had only three choices left:
1. Use alcohol or drugs to medicate the pain,
2. Suicide, or
3. Insanity.
Learning how to live a meaningful and comfortable life without alcohol or drug use is the primary goal of recovery.
Mistaken Beliefs about the Warning Signs of Relapse
A common mistaken belief is that relapse, just suddenly and spontaneously occurs without warning signs. This belief produces a feeling of helplessness and powerlessness. Relapse remains a mysterious process over which recovering persons have little or no control. All they can do is hope and pray that relapse does not occur.
The truth is that there are many warning signs that precede a relapse. Once you learn to recognize and manage the early warning signs of relapse you can stop the relapse process before it has a chance to get started. Common warning signs are: thinking about substance using, allowing yourself to develop a compulsion to use, placing oneself in situations where use is happening or likely to happen, stopping attending self-help groups or other recovery activities. Not being aware that their own denial is preventing them from recognizing all their own individual warning signs.
Mistaken Beliefs about Motivation
Most recovering persons observe the-fact-that relapse is a relatively frequent occurrence. As a result they must develop some way to explain it, and create the following set of erroneous beliefs:
1. If I relapse, I am not motivated to recover.
2. I will recover, when I hurt enough (or have hit bottom) as a result of my alcohol or drug use and want to recover.
3. If I have relapsed, I have not hurt enough to want to stay sober.
Wrong conclusion: Relapse prone people need to hurt more in order to interrupt their relapse patterns. This is a devastating conclusion for relapse prone people to reach. It may cause you to question your sanity, if you know that you want to get well but are unable to do it. This destroys self-worth, and self-esteem and produces shame and guilt. Emotional pain only increases the risk of relapse.
Most relapse prone people are in so much emotional pain that they have a hard time functioning when sober and struggle to find even small benefits from their recovery program.
Mistaken Beliefs about Treatment
Many people, recovering from an addiction (addictive disease) work very hard to recover. They attend counseling and group therapy. They regularly attend 12-step self-help groups. Yet they fail to recover. These people develop one of two equally destructive mistaken beliefs. The first mistaken belief is that: No form of treatment or self-help can work, or the opposite that: Treatment is 100% effective and if it does not work then it is the clients fault and there is something wrong with them. These are the people who feel that they are constitutionally incapable of recovering. The truth is that treatment may be effective for some and not for others, and has as much to do with the addict learning the skills needed to stay sober as much as the type of treatment they get.
The importance of Relapse Prevention Planning
Chances are good that if an addict finds a program that uses relapse prevention planning, they will be able to achieve long-term sobriety or at least be able to stay sober for longer and longer periods of time and achieve a significantly improved life.


Chapter 6: Understanding the Relapse Process
What is relapse? If you say it is returning to substance use after a period of sobriety you are only partly right. If the focus is on learning how to live effectively and comfortably without addictive use, then the concept of relapse has as much to do with how an individual is functioning with normal life tasks, as it does with whether or not they are using an addictive substance.
The process of relapse includes becoming dysfunctional in sobriety. This dysfunction may involve physical, psychological, or social health. This does not mean that addictive use is not relapse. It means that the process of relapse is occurring even before addictive use begins. When addictive use starts, it is a result of the relapse process that is already occurring. Addictive use is a way to medicate the emotional pain of a dysfunction life.
The dysfunction begins as a mental process that in AA is called stinking thinking. That leads to a change in behavior that AA calls a setup. It finally leads to dysfunctional behavior in sobriety that in AA is called a dry drunk. This pattern may then lead to addictive use or some other form of serious dysfunction such as an emotional disturbance, physical collapse, or stress-related illness.
Many recovering addicts have remained drug free, but have committed suicide or have collapsed physically or emotionally. This is not recovery. Other sobriety based symptoms of alcohol or drug use are: depression, confusion, and anxiety that have emerged as part of the post acute-withdrawal symptoms. Thus, recovery from the damage caused by the addiction, must continue with the addict learning how to manage the sobriety-based symptoms of post-acute withdrawal, and on improving bio-psycho-social health. This allows life to be centered a round healthful living, and not substance use.
The Role of Substitute Addictions
Once a person becomes addicted or dependent upon one drug, there is a tendency to transfer that dependency to other mood-altering drugs. This is especially true of the drug is similar to the original drug of dependency. This process is called cross-addiction, and the addiction to the additional or substitution drug is rapid and progressive.
Chemically dependent people have come to rely on a primary drug of choice to cope with life. If when they abstain they are merely substituting a new drug, they are just creating a new dependency. If the substitute drug, is not as effective as the primary drug of choice, then they will continue to crave the original drug, leading to poly-drug use.
While there can be a harm reduction component of switching from a more harmful drug to a less harmful one, or cutting back significantly on the amount usedthe person is not considered to be in recovery. This includes those who use large amounts of nicotine, caffeine, or smoke marijuana. It is true that some addictions are more harmful than others, and that some chemical addictions such as to alcohol, cocaine, methamphetamine, or heroin, are more dangerous that addiction to caffeine or nicotine.
In most cases caffeine addiction will not cause the same type of severe problems that result from alcohol or marijuana addiction, and some people can continue the use of caffeine or nicotine without increasing the amount. But the truth is that the addictive use of caffeine and nicotine can be lethal. More people die from cancer caused by nicotine addiction that from any other drug.
The Role of Caffeine
Research has shown that caffeine can be used addictively, is harmful to health and functioning, and can reactivate the addictive cycle for people seeking to recover from alcohol addiction. Recovering alcoholics who are heavy caffeine users report increased symptoms of physical stress and anxiety when using caffeine. They also report headaches, severe irritability, and emotional overreaction when not using caffeine. These symptoms are part of caffeine withdrawal. Caffeine users may mistake caffeine withdrawal for something more serious such as for cravings for alcohol or other drugs.
The Role of Compulsive Behavior
Compulsive behaviors are actions that produce intense excitement or emotional release and are followed by long-term pain or discomfort. These behaviors can be internal (thinking, imagining, feeling) or external (working, playing, talking, etc.). Compulsive behaviors make you feel good in the short run, but weaken you in the long run. Some common examples are:
1. Eating / Dieting This includes compulsive overeating, compulsive dieting, (often called anorexia), and the combination of binge eating followed by compulsive dieting or vomiting (called bulimia).
2. Gambling The compulsive need to take risks.
3. Working / Achieving The compulsive need to keep busy or to accomplish things or excel at everything you do.
4. Exercising The compulsive need to stimulate the body through physical exertion.
5. Sex The compulsive need to have sexual experiences.
6. Thrill Seeking The compulsive need to experience stress or thrills.
7. Escape The compulsive need to avoid the daily routines of life.
8. Spending The compulsive need to buy or acquire possessions.
Positive Outlets versus Compulsive Behavior
The same behaviors can be used compulsively or non-compulsively. Compulsive behavior is not measured so much by what you do as it is by how you do it. A positive outlet is a behavior that provides pain-free pleasure. It feels good without creating pain later. Healthful exercise, for example is a positive outlet. Stressing over missing a single workout, may be a sign that your exercise program is becoming compulsive. Healthy sex is also a positive outlet. Sexual expression between people who love and care for each other and that is performed in a safe and responsible manner between consenting adults is an asset to both partners.
Compulsive behaviors are often used like drugs to evade or alter reality. Eating past the point of feeding your body is harmful. Taking unnecessary risks such as when gambling, for only a slim chance of long-term rewards is a sign of addictive thinking. Exercising to try to achieve a physical ideal or standard that is unattainable or cannot be realistically maintained is not a sign of a balanced life. Seeking out novel sexual experiences without forming meaningful relationships to complement that level of intimacy is a sign of emotional and physical escapism. Over-spending on items that are seldom used or needed are signs of power and control issues, in that the addictive behavior is used to compensate for other areas of the persons life that seem out of control.
The Process of Relapse
When you begin the process of dysfunction, you begin the process of relapse. Sobriety is: abstinence from substance use, and compulsive behaviors, and improvements in bio-psycho-social health.
Sobriety-Based Denial
It is very easy to take denial into recovery (keep denying the things or areas that are causing you post-acute withdrawal symptoms) and focus only on the positive things. The trade off for inaccurate awareness is a less than completely fulfilling life. Relapse prevention maintains a conscious awareness of current issues that interfere with recovery.


Chapter 7: The Relapse Syndrome
&nbsp &nbsp &nbsp &nbsp Recovery from addiction must be an active process. Recovering persons much work a daily program of recovery. They must remind themselves daily that they are suffering from an addition. They must have an active recovery program that provides guidelines for effective and productive living.
Recovery is like walking up a down escalator. It is impossible to stand still. The symptoms develop spontaneously in the absence of a strong recovery program, until the symptoms of post-acute withdrawal appear. This leads to a pattern of out-of-control behaviors called the relapse syndrome.
The Relapse Syndrome = PAW without symptom management.
The relapse process usually begins with change. Change is a normal part of life, but a major cause of stress. The change may be an external event that forces you to respond in some way, or it can be a change in your thinking, feelings, or patterns of behavior. Change produces stress, which if not responded to well, may lead to faulty coping behaviors and denial that there is a problem. The person then has the urge or desire to return to previous all-to-familiar temporary coping behaviors or may exhibit other symptoms of post-acute withdrawal. Without a strong social support structure, daily patterns and routines breakdown, and it becomes easier to lose control of your judgment.
The Relapse Progression -> Change -> Stress -> Denial -> PAW -> Behavior Change -> Breakdown in Social Structure -> Loss of Control or Judgment -> Loss of Behavior Control -> Option Reduction -> Acute Degeneration -> Addictive Use.
Interrupting the Relapse Syndrome
&nbsp &nbsp &nbsp &nbsp Managing the symptoms of PAW is the best method of relapse prevention. If the person is already in a state of dysfunction they may need some outside help to become re-stabilized and prevent further regression. Responses can range from re-establishing a calm and controlled environment, to taking some time off work or re-entering treatment, to seeking professional help with regards to suicide prevention.
Phases and Warning Signs of Relapse
Phase I – Internal Change:
Increased stress,
Change in thinking,
Change in feeling,
Change in behavior,
Phase II Denial:
Worrying about myself,
Denying that I am worried,
Phase III Avoidance and Defensiveness:
Believing I will never use alcohol or drugs,
Worrying about others instead of self,
Defensiveness,
Compulsive behavior,
Impulsive behavior,
Tendencies toward loneliness,
Phase IV Crisis Building:
Tunnel vision,
Minor depression,
Loss of constructive planning,
Plans begin to fail,
Phase V Immobilization:
Daydreaming and wishful thinking,
Feelings that nothing can be solved,
Immature wish to be happy,
Phase VI Confusion and Overreaction:
Difficulty in thinking clearly,
Difficulty in managing feelings and emotions,
Difficulty in remembering things,
Periods of confusion,
Difficulty in managing stress,
Irritation with friends,
Easily angered,
Phase VII Depression:
Irregular eating habits,
Lack of desire to take action,
Difficulty sleeping restfully,
Loss of daily structure,
Periods of deep depression,
Phase VIII Behavioral Loss of Control:
Irregular attendance at AA and treatment,
An I dont care attitude,
Open rejection of help,
Dissatisfaction with life,
Feelings of powerlessness and hopelessness,
Phase IX Recognition of Loss of Control:
Difficulty with physical coordination and accidents,
Self-pity,
Thoughts of social use,
Conscious lying,
Complete loss of self-confidence,
Phase X Option Reduction:
Unreasonable resentment,
Discontinues all treatment and AA,
Overwhelming loneliness, frustration, anger, and tension,
Loss of behavioral control,
Phase XI Alcohol and Drug Use:
Attempting controlled use,
Disappointment, shame, and guilt,
Loss of control,
Life and health problems.


Chapter 8: Relapse Prevention Planning (R.P.P.)
1. Stabilization Get control of yourself.
2. Assessment Find out what is going on in your head, heart, and life.
3. Relapse Education Learn about relapse and what to do to prevent it.
4. Warning Sign Identification Make a list of your personal relapse warning signs.
5. Warning Sign Management Learn how to interrupt warning signs before you lose control.
6. Inventory Training Learn how to become consciously aware of warning signs as they develop.
7. Review the Recovery Program Make sure your recovery program is able to help you manage your warning signs.
8. Involvement of Significant Others Teach others how to work with you to avoid relapse.
9. Follow-up and reinforcement Up-date your relapse prevention plan regularly.


Chapter 9: Family Involvement in the Relapse Syndrome
In many cases the addict is the first family member to seek treatment. Other family members become involved in order to help the alcoholic get sober. Many family members refuse to consider the fact that they have a problem that requires specialized treatment. These family members tend to deny their role in the addicted family and scapegoat personal and family problems upon the addicted person. They develop unrealistic expectations of how family life will improve with abstinence. When these expectations are not met they blame the addict for the failure, even though he or she may be successfully following a recovery program. Their attitudes and behaviors can become such complicating factors in the addicts recovery that they can contribute to relapse.
Family members can be powerful allies in preventing relapse in the addict. Relapse prevention planning utilizes the familys motivation to get the addict sober. Family members are helped to recognize their own Coaddiction and become actively involved in their own treatment.
When you try to control,
What you are powerless over,
You lose control,
Over what you can manage.

The person suffering from co-addiction develops physical, psychological, and social symptoms as a result of attempting to compensate for the debilitating effects of the stress of living with addiction.
Early stage of co-addiction: Normal problem solving attempts to adjust,
Middle stage of co-addiction: Habitual self-defeating responses,
Chronic Stage of co-addiction: Family collapse and stress degeneration,
Relapse Warning Signs of Coaddiction:
1. Situational loss of daily structure.
2. Lack of personal care.
3. Inability to effectively set and maintain limits.
4. Loss of constructive planning.
5. Indecision.
6. Compulsive behavior.
7. Fatigue or lack of rest.
8. Return of unreasonable resentments.
9. Return of the tendency to control people, situations, and things.
10. Defensiveness.
11. Self-pity.
12. Overspending / Worrying about money.
13. Eating disorder.
14. Scapegoating.
15. Return of fear and general anxiety.
16. Loss of belief in a higher power.
17. Attendance at Al-Anon becomes sporadic.
18. Mind racing.
19. Inability to construct a logical chain of thought.
20. Confusion.
21. Sleep disturbances.
22. Artificial emotion.
23. Behavioral loss of control.
24. Uncomfortable mood swings.
25. Failure to maintain interpersonal (informal) support systems.
26. Feelings of loneliness and isolation.
27. Tunnel vision.
28. Return of periods of free-floating anxiety and or panic attacks.
29. Health problems.
30. Use of medication or alcohol as a means to cope.
31. Total abandonment of support meetings and therapy sessions.
32. Inability to change self-defeating behaviors.
33. Development of an I dont care attitude.
34. Complete loss of daily structure.
35. Despair and suicidal ideation.
36. Major physical collapse.
37. Major emotional collapse.
Relapse Prevention for the Family
What happens to one family member affects the other members of the same family to greater or lesser degrees. Both the symptoms of post-acute withdrawal and the symptoms of co-addition are stress sensitive. Stress intensifies the symptoms and the symptoms intensify stress. As a result the recovering addict and co-addict become a stress generating team that unknowingly and unconsciously complicate each others recovery and create a high risk of relapse. The family relapse prevention plan consists of:
1. Stabilization.
2. Assessment.
3. Education about alcoholism, co-addiction, and relapse.
4. Warning sign identification.
5. Family validation of warning signs.
6. The family relapse prevention plan.
7. Inventory training.
8. Communication training.
9. Review of the recovery program.
10. Denial interruption plan.
11. The relapse early intervention plan.
12. Follow-up and reinforcement.


Chapter 10: The Relapse Prevention Self-Help Group
Relapse prevention is a way of life. The recognition and interruption of relapse symptoms must become a daily habit. As with any habit, relapse prevention is difficult to maintain. Many relapse prone people find that they need support to keep their relapse prevention plan working. They have found that meeting with others who are relapse prone is helpful. They set up regular meetings to discuss their relapse prevention plans and to exchange information. In some cases relapse prevention planning has been incorporated into AA meetings called: Golden Slippers Meetings. Still other groups do not want to include anything that is not convention approved.
The only qualification for membership in the Relapse Prevention Self-Help Group is a history of honest attempts at sobriety that have failed or a fear that a relapse may occur. The relapse prevention self-help groups recognize that relapse prone individuals have experienced many failures in recovery. The major factors that make RPP self-help groups so effective are: daily inventories that identify early warning signs, effort to stop the warning signs before they get out of control, talking openly and honestly about the warning signs and what you are doing to stop them, and listening to feedback from others.
AA tells that recovery is possible by following twelve basic steps. RPP builds on these steps. RPP suggests that there are pathways to successful recovery and pathways to relapse. The pathway to successful recovery can be described in a developmental model of recovery. The pathways to relapse can be described in terms of partial recovery and the phases and warning signs of relapse.
AA tells us that some people seem to be constitutionally incapable of recovery. RPP tells us that by studying these people and determining what is happening to them physically, psychologically, socially, and spiritually, we can figure out what needs to happen in order for them to become constitutionally capable of recovery. AA provides twelve steps to recovery. RPP applies them in a special manner to those who are relapse prone.
Meeting Format
1. The opening statement The name of the meeting, introductions and welcome and the reading of the introduction statement of Relapse Prevention Self-Help Groups, and the basic tools of the RPP S-H G.
2. A quiet time Two to three minutes for people to clear their minds and prepare them-selves to benefit from the meeting.
3. Reading of the topic material Relevant topic info is read.
4. The speaker Relapse prone person who has achieved recovery.
5. Break Decaffeinated coffee or cola, healthy snacks (not sugar).
6. Comments Open discussion.
7. The feedback session Personal recovery plan updates.
8. Adjournment Next meeting, speaker, and topic.
9. Duration of the meeting No more that two hours total.


Final Note: These lecture or seminar notes can in no way compare to the depth of material and content of the original textbook Staying Sober by Terence Gorski and are not meant to replace it, only to highlight some of the most relevant concepts. Please if you have benefited from reading this material – go out and buy the book!

Don’ts Of Recovery

  • Don’t regard Alcoholism/Chemical Dependency as a family disgrace. Recovery from this disease can and does happen.
  • Don’t nag, preach, or lecture. Chances are they have already told themselves everything you can tell them.They will take just so much and shut out the rest. You may only increase their need to lie or force them to make promises they cannot possibly keep.
  • Guard against the “holier than thou” or martyr-like attitudes. It is possible to create this impression without saying a word. Begin to look at your own attitudes and behaviors.
  • Don’t use the “if you loved me” appeal. Since the drinking/using is compulsive and cannot be controlled by willpower, this approach cannot Work. It’s like saying, “If you loved me, you would not have Diabetes.”
  • Don’t be jealous of the method of recovery that is chosen. The tendency is to think that love of home and family is enough incentive for seeking recovery. Frequently the motivation of regaining self-respect is more compelling than early resumption of family responsibilities
  • Don’t do for the alcoholic/chemically dependent persons what they can do for themselves, or that which must be done by themselves. You cannot take their medicine for them. Don’t remove the problem before they can face it, solve it, or suffer the consequences.

Do,s Of Recovery

  • Begin to understand and live one day at a time.
  • Begin to learn the facts about this disease and the role that you have in it. Be willing to assume responsibility for your own life completely and abandon any attempt to change him/her — even for their own good. Stop trying to manage their lives and begin to manage your own.
  • Begin to learn the 12 steps as taught in Al-Anon and apply them to your life on a daily basis as a recovery program. Start with Step 1, admitting powerlessness over another person and recognizing unmanageability in your own life.
  • Be willing to recognize that your former methods have not worked. You no longer must face this disease alone. There is a power greater than you — however you perceive that power — that can support you in your efforts to be free to choose instead of simply reacting.

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