One More Time: Can We PLEASE Do Away with “Relapse?”
For four decades I’ve had back pain resulting from degenerative disc disease. Various non-surgical medical interventions have helped with pain relief, but more often than not, the pain returns over time. When this happens, do medical professional ever refer to the pain recurrence as a “relapse?” Never.
Seldom with medical conditions do we use the term “relapse” when the symptoms come back. So why is it that we can’t let go of the term when a person who’s been abstinent from his or her drug of choice starts using again?
The Term “Relapse”
Some experts in the field have been harping on this topic for a long time. One of them, the renowned researcher, William R. Miller, PhD, Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico, wrote an article titled, “Retire the Concept of ‘Relapse’,” published in 2015 in the 50th anniversary issue of Substance Use and Misuse. The entire issue was devoted to “ongoing flaws and unfinished issues” in the field. Miller wrote, “People with diabetes who appear in the emergency room in glycemic crisis are not told that they have relapsed.”
In another article, Miller reflects upon his realization that in U.S. disease model treatment, the term “relapse” connotes, very limited all-or-none thinking. Educating and warning people about “relapse” has implied that any use equals loss of control – either you abstain or you drink out of control. However, he refers to research in which he and colleagues found that post-treatment drinking is highly variable.
“There are indeed abrupt recurrences of heavy drinking,” he said. “But also many shades of grey. It is not uncommon for people who have been abstaining to have a drink or two and then think the better of it and return to abstinence.”
He wrote, “The sheer arbitrariness of any binary definition became obvious. How long did someone have to be abstinent in order to qualify to have a relapse? Is a single use the same as a relapse? If not, how much use or how many days of use are required in order to constitute a relapse?” Indeed, it is not uncommon for treatment professionals and clients who subscribe to the disease model to view any use of alcohol or drug of abuse as a “relapse,” although Miller acknowledges that the use of an intermediate concept like “slip” [or lapse] to indicate something in between abstinence and a “relapse” ameliorated “all-or-none” thinking to some extent.
For the most part (at least for researchers), however, relapse came to be seen as the extended full-blown return to use of a person’s drug of choice over an extended period, while a lapse has been considered one-time or short-term use, often of a lesser amount than in the past.
Although Miller says on his website that the concept of relapse was borrowed from medicine, respected addiction treatment and recovery historian William L. White and Sade Ali, MA, CADC provide evidence in a paper that the words “lapse” and “relapse” are rooted in morality and religion – not health and medicine – and therefore come with considerable “historical baggage.” They then note that “lapse/relapse” language emerged during the temperance movement to refer to people who had returned to drinking after publicly signing a temperance pledge. The phrase “falling off the water wagon” became linked in the public mind to low moral character and viewed as a product of badness. From there, such moral overtones extended into broader communications, ones still with us, such as referral to those who are drug-free as “clean” and users as “dirty.”
One of the problems with the traditional use of “relapse” to connote any use of alcohol or other drugs is that it can set a person up for a self-fulfilling prophecy or what I call, “the now-I’ve-blown-it phenomenon.”-Anne Fletcher
White and Ali point out that the terms “lapse” and “relapse” have current and historical religious/moralistic connotations including abandonment of religious faith (e.g., “lapsed Catholic), deviation from accepted standards due to carelessness (e.g., lapse in judgment), and return of slovenly character (e.g., lapse into bad habits.) As mentioned in one of my previous articles, White and Ali did an Internet search, comparing the number of times “lapse” and “relapse” were associated with various terms for alcohol and drug problems versus other medical and behavioral health conditions and found that the terms were used far more frequently for substance problems. In fact, the terms lapse and relapse were used as often in connection with alcohol and drug problems as was the term recovery.
One of the problems with the traditional use of “relapse” to connote any use of alcohol or other drugs is that it can set a person up for a self-fulfilling prophecy or what I call, “the now-I’ve-blown-it phenomenon.” To capture this phenomenon in professional terms, the late Alan Marlatt, PhD., director of the Addictive Behaviors Research Center at the University of Washington, called it the “abstinence violation effect.” That is, if you believe that one episode of use constitutes a relapse (or failure), you’ve lost control and essentially have nothing to lose. Therefore, you may as well keep using.
Progressive experts in the fields favor “recurrence” of a substance use disorder as opposed to “relapse.” “Use episode” is preferred for a one-time or short-term period of use. White and Ali offer some specific examples of less-loaded terminology than “relapse”:
- Instead of saying someone relapsed after attending an addiction treatment program, simply say that he or she resumed drinking or experienced a recurrence of his or her drug problem.
- Instead of referring to a person as a chronic relapser, say he’s a person who has recurring episodes of alcohol-related problems and/or who has not yet achieved stable sobriety.
- Rather than say someone has relapsed but is not as bad as she used to be, try “She’s in partial remission from her drug or alcohol problem but has come a long way.”
White and Ali conclude, “…we do think the lapse/relapse language will be more critically evaluated and eventually abandoned. It is time for this discussion to begin anew.”
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