Lapse versus Relapse

Nobody's perfect. It's just a fact of life. And when it comes to making significant life changes, imperfection is pretty much a guarantee. That means that "recovery" from any problem/addictive/compulsive behavior also tends to be imperfect. It is rare indeed for someone to make the decision to change their behavior, and to do so without any fits, starts, or backward glances.

No, it's much more likely that someone who decides to change their behavior will  also struggle to do so, start and then pause, slip, backtrack, regroup and move on. In short, "lapses" back into an old behavior pattern are an expected part of recovery. As such, a lapse need not signify a relapse - a full return to the problem behavior, and abandonment of the recovery process.

What determines whether the reemergence of old behavior is a lapse or a relapse? As with many things, it largely comes down to how one thinks about it.

Have you decided, explicitly or implicitly, to give up on recovery? That's a relapse.

Are you trying to replace old behaviors with new ones, but the new ones are just not always strong enough to prevent the old ones? That's a lapse.

However, a lapse can (quite easily) become a relapse, for two reasons: (1) it reignites the habitual pattern (neural and behavior), and (2) many people experience a lapse, and then give up on recovery efforts, interpreting the lapse as an indication of failure and relapse.

The first reason is something that can be overcome, as long as people stay motivated to continue their recovery efforts. That means it all hinges on the second reason: people who see a lapse as a relapse no longer think there is any point in trying to resist the pattern, because they think it's already too late.

This tendency is part of the Abstinence Violation Effect. The concept of abstinence is black-and-white: you are either abstinent or you are not. If you slip, or experience a lapse, you are no longer abstinent. It's automatically counted as a failure, and equated with being back at square one. Think about 12-step programs, where people report their length of abstinence. An alcoholic who had a single drink after three years sober is counted as having the same length of sobriety as someone who is just getting sober for the first time. Often this AVE is enough to turn a lapse into a relapse. One drink becomes a bender, because "I already ruined it, I might as well go all the way."

I think it's absolutely crucial to relapse prevention to reframe slips and lapses. To invite curiosity about what can be learned from a slip to fine-tune the recovery plan. Or what areas of vulnerability might require additional coping strategies. As long as people stay hopeful, a lapse can actually strengthen one's ultimate recovery. We need to move away from black-and-white thinking when it comes to change, and make room for the messiness of the process. It's really the only chance for stable, long-term change.

Face Time? Reflecting on Cell Phone Use in Treatment

We have interesting relationships with our phones these days. They keep us continuously connected to one another, least of all by phone calls, and more and more via text, email, social media, and even sometimes "facetime" (like a phone call with video). We live in a world where we expect instant access, instand information, to be constantly reachable, and to reach others constantly. It's almost an addiction.

An like an addiction, we may go through withdrawal if we have to be away from our phones and out of contact. I know that I, for one, get anxious and start to imagine what I might be missing. And I don't even use my phone that much (since it's web applications are too slow!).

Given the significance of the phone in our culture, what is its significance for treatment? Here, I'm setting aside the complex question of telephone calls between therapist and client, and simply thinking of the client's phone and what it represents.

There are layers to this question, as there seem to be layers to so many things in therapy. One interesting dynamic has to do with the role of phones in substance abuse treatment. If you've worked with this population, you know that they cannot have their own phones in treatment programs. The reason is that their phones represent a connection to the drug world. Not only do they most likely have contact information for deals and people they used with stored in the phone, but those people most likely also have the client's information, and may call to offer drugs, invite the person to "hang out" (and get high), or to ask the client to get drugs for them.

However, amputating people's phones doesn't really solve the problem. Not only can they still get drugs if they really want to, they also can't get in touch with supports for recovery. They can't call their sponsor, or other people from 12-step meetings, arrange rides to meetings, reach or be reached by their providers. It's always a frustration to me when I work with clients who are in a program and have no phone, because inevitably there is some occasion when they or I have to miss a session, and rescheduling is practically impossible.

Phones can also influence other kinds of treatment, particularly at any level of care other than standard outpatient individual therapy. People on inpatient units typically cannot keep their phones with them, and don't have phones in their rooms, with public payphones the only option. I understand the rationale. In medical facilities cell phones can disrupt certain medical devices, and in psychiatric facilities, there's always the risk that interacting with people from outside could be a stressor and lead to decompensation, or even aggression. However, as with substance abuse treatment, removing phones also isolates people from supports that could help the person stabilize and feel more hopeful about life outside the hospital. And more selfishly on my part, I'd like to be able to reach clients in the hospital, since all too often I'm not even notified if a client of mine is admitted.

In group treatment, phones take on a different role. Since most phones have cameras on them these days, phones represent a potential breach of confidentiality if people take any pictures during treatment. Texting and web access also open the possibility of breaking confidentiality, or even "subgrouping" - contacting other people in the group during or after group to talk about what is going on. However, in psychoeducational groups, phones with web access could be a way to check or gather related information. On the whole, however, phones seem to be at best a distraction, and at worst a way of derailing group process. However, with a large group it may be hard to always know if someone is texting, or just looking at their labs...particularly if the group is sitting around a table.

How do you see cell phones playing into treatment dynamics? Are there particular populations or settings where they seem most positive or negative to treatment?

The Pink Cloud

In AA and NA, people talk about the "pink cloud" - that period of time in early recovery when everything feels and seems good. The physical withdrawal has passed, so people begin to feel healthier, and more clear headed. They're not having many cravings, and become confident in their recovery. The losses that may have motivated them to recover have started to turn around - they can see positive changes in their relationships, life circumstances, and perhaps even opportunities. Recovery seems like a cake walk, especially when compared with the throes of a serious addiction. People may conclude that they have beaten the addiction, and become overconfident in their recoveries.

Unfortunately, the pink cloud invariably bursts. Life stops improving at the same rate it had been, or may even seem to be getting worse. The reality of the recovery process, with all of its related difficulties and discomforts, comes crashing down on the person. He or she realizes that life is still hard, and that recovery is a long-term commitment. People feel discouraged, and sometimes even resentful. Cravings increase, and the risk of relapse is high.

Although the idea of the pink cloud comes from substance abuse recovery, which is a unique physiological process, I think that the phenomenon is also psychological, and applies to recovery from a wide range of problematic behaviors. It is therefore something worth thinking about, whatever type of change we're helping clients to make.

Specifically, I think the pink cloud relates back to costs and benefits - of both recovery, and the problem behavior (i.e., the good ol' decisional balance). People usually become committed to recovery when the costs of the behavior, and benefits of recovery, outweigh the benefits of the behavior and costs of recovery. When they first change the behavior, this balance shifts. They experience relief from the costs of the behavior, along with the benefits of recovery (improvement in how they feel, relationships with others, and functioning in various life domains). Recovery seems clearly better and easier than continuing with the problem behavior.

However, after some time in recovery, the balance shifts again. Life doesn't continue to improve at the same rate it did initially, and the difficulty of change becomes more evident. The costs of change, in what the person has to give up to achieve it, as well as the discomfort of the process, are at the forefront. At the same time, the costs of the problem behavior feel more remote, and the person may begin to miss whatever benefits they derived from the behavior, leading to more urges to return to it. The pink cloud is gone.

The good news is that, if people can persist in their change efforts, they ultimately move into a balanced and stable part of the process. They don't return to the illusion that recovery is easy, but they regain their confidence and commitment, recognizing that recovery really is better than the alternative. This shift is a natural result of the costs of change lessening, and the benefits of change increasing.

Knowing that the pink cloud is a common part of the change process, which can - but doesn't have to - lead to relapse, what can we do to help our clients ride out the "storm?"

1) Educate them about the pink cloud and its aftermath, so that they know what to expect and can be prepared for the "crash."

2) Encourage them to persist in change efforts: highlight the benefits of change, and costs of the problem behavior, while assuring them that their current discomfort won't last forever.

3) When they first make a decision to change, consider asking them to write a letter to their future selves about what motivated them to make that decision. Then, have them read this letter when their motivation lessens, or they begin to glorify the "good old days" of the problem behavior.

4) Normalize slips as an expected part of recovery, and encourage clients to resume change efforts ASAP rather than letting a slip become a full relapse.

5) Keep track of the positive changes that have resulted from behavior change, and call attention to them when people begin to get discouraged.

6) ...what other strategies might you use?

Mixed Responses to Recovery Speakers

Anyone who has dealt with problematic or compulsive behaviors (addictions, eating disorders, OCD, etc.), either personally or professionally, has encountered the "self-help" movement in one form or another. The label "self-help" is really a misnomer, however: this movement is really rooted in mutual aid between individuals at various points in recovery from a shared problem. As a result, I prefer to call it the "peer support" model of recovery.

A cornerstone of the peer support model of recovery is the recovery speaker. Most widely recognized as a feature of many 12-step meetings, the speaker is someone who has made significant progress in recovery, and is no longer engaging in the problem behavior. He or she shares a narrative of recovery in order to motivate and guide listeners newer to recovery. Though speakers usually have a great deal of latitude in how they present their stories, a general framework involves talking about how things were when the problem was active, how they managed to stop the problem, and how things are now, in recovery. Examples are included in the text of the AA "Big Book," and many memoirs of recovery from a range of problems.

Many people find these stories moving, and say the stories help them progress in their own recoveries. However, there are also people who find such "war stories" triggering, saying they increase rather than decrease the desire to engage in the problem behavior. 

Sometimes this paradoxical response is related to a specific speaker's approach. There are some speakers who subtly glorify the problem when talking about their lives before recovery - as if they are reminiscing about "the good old days." Some may not glorify the problem...but may also not have a clear sense of how they recovered, and may therefore struggle to offer guidance to listeners. Sometimes the speaker simply spends too much time on the pre-recovery part of the story, and too little time talking about recovery and life thereafter.

The listener's response also depends upon where he or she is in the recovery process. Those who are new to recovery, are highly ambivalent, or feel hopeless/helpless about change seem less likely to find speakers helpful - the message doesn't "meet them where they are." Just hearing about problem behaviors, even when they're described in a negative light, can be triggering for these people. Others' successful change may also serve to heighten a sense of inadequacy or discouragement about one's own less effective change efforts. Finally, if the listener expects to be motivated - or triggered - by the speaker, it tends to become a self-fulfilling prophecy. 

I'm reflecting on this topic today because I accompanied a group of clients to hear a speaker on recovery from anorexia. My clients responded positively, but a few clients from other programs we so triggered they had to leave. Unfortunately, they left just as the speaker transitioned from talking about the problem to talking about recovery. I thought she had some good things to say, that reflected solid clinical theory and intervention...but I also thought some of what she said was potentially triggering, anxiety provoking, or both. If I felt those things, how much more so did the clients?

So, what are your thoughts on recovery speakers? When are they a positive tool for recovery, and when are they counterproductive?

Why I Think AA (etc) is a Double-Edged Sword

There's something about AA (and the spin-off 12-step programs for other issues) that definitely works. As one of their slogans says, "meeting makers make it" in recovery.

Specifically WHAT works seems to depend on whom you ask. From my perspective, however, I see social support as the program's #1 strength. There are 12-step meetings available every day of the week, at just about any time of day, in just about every corner of the globe. It's a powerful thing to find a community of people who really get what you're going through, because they've been there too. And it's an even more powerful thing to have one of those people (i.e., a sponsor) commit to doing whatever it takes to get you through the recovery process - including answering the phone in the middle of the night, coming to get you from wherever you've gotten yourself stranded, sitting with you in emergency rooms...and probably a lot of other scenarios my clients haven't shared with me.

I wish that kind of ready-made support group and mentoring were available to people without addictive or compulsive behaviors!

Beyond the support, some people really see the steps themselves as pivotal - an intentional changing of mind, body and spirit from willful to willing, by admitting powerlessness, accepting a higher power, taking moral inventory, making amends, and choosing to live differently moving forward. I have some theological issues with the specific steps, but on the whole, it's a decent description of the change process some go through.

Here's the thing, though: I'm not convinced that this process is necessary or helpful for everyone with this kind of problem. In fact, I think it can be counterproductive for people (often trauma survivors, but not exclusively) who are already struggling with learned helplessness, feelings of worthlessness and shame. To emphasize one's powerlessness and "moral failings" seems only to solidify these people's negative self-image. Sure, working the program may still help them stop their addictive or compulsive behavior...but at what cost?

The concept of "character defect" particularly gets under my skin. Here I am, working to empower my clients and build up their strengths, and they respond by telling me about their permanent, inherent character defects. From the perspective of narrative therapy it is incredibly challenging to develop a less problem-saturated view of oneself in the face of constant reminders to stay vigilant lest one's character defects cause relapse.

It's challenging to come up against this viewpoint in therapy, both because it flies in the face of much of what we're taught about practice, and because expressing disagreement with "the program" may feel threatening to clients who are very involved in AA (etc.). They may experience a loyalty bind between the program, to which they may feel they owe whatever sobriety they have, and the therapist - not a good scenario for client or clinician! Yet, when I feel like an aspect of the 12-steps (usually the character defect piece) is actually harming a client, I will introduce the idea that it's possible to take what works for them, and leave the rest - recovery doesn't have to be mindless acceptance of the whole AA package. However, because many clients are very attached to that model, I am always careful to affirm the excellent things AA teaches about sober living.

Since this is an issue about which many people have varied strong opinions, I'm curious how others address the 12 steps in their practice - particularly with folks whose perspective differs from your own. Leave a comment below!

In closing, another excellent contribution from AA, the "Serenity Prayer:"

God, Grant me the serenity to accept the things I cannot change,

The courage to change the things I can,

And the Wisdom to know the difference.