The Real Definition of Relapse and Why it Matters
As an addiction family therapist, I see parents of teens and young adults who live in despair over the chaos that often comes from living with someone with an active addiction. It is difficult to exaggerate the heartache of a parent who fears the death of their little boy or girl because of addiction. They set their eyes on rehab with the expectation that it will put an end to this misery. They eagerly shell out $5,000 on an intervention and willingly prepare to spend the long-saved college fund – or take out a second mortgage – on a single episode of inpatient rehab, if only their child will agree to go!
But how many families are truly prepared for the realistic outcome following treatment? Addiction is not like an infection cured by a single course of antibiotics. Most people will use substances again after treatment and most will do it within a few months. Does this mean that treatment “didn’t work” and all hope is lost?
That depends on your definition of a relapse.
A couple months later he slips and has a few beers to comfort a heartbreak. Did he relapse?-Lara Okoloko
Consider 19 year old Jacob. He used marijuana and alcohol regularly in high school and then got into serious trouble with alcohol during his freshman year at college. After a night in the ER he agrees to inpatient treatment. Jacob returns home from rehab with 28 days of abstinence under his belt. Things are going well. He is in outpatient counseling and his goal is to maintain the abstinence he has started. A couple months later he slips and has a few beers to comfort a heartbreak. Did he relapse?
When I counsel families about their loved one’s new path of recovery, I always raise this issue. “Is there any difference between a ‘slip’ and a ‘relapse’?” I ask.
This isn’t an issue of semantics. How the family defines a relapse will shape how they respond when it happens.
If any substance use at all is defined as a relapse, it can actually increase the person’s future substance use. Imagine you have been on a new diet and sticking to it. You have even lost some weight. You go to an office party. You are hungry and everything looks so tasty. Nothing is within the parameters of your diet’s rules. Someone tells you that you must try the cookies they made. By the time you leave the party you have had at least two days worth of calories.
Here is when your definition of a relapse matters. Is all hope lost or is this a learning opportunity? There is a concept that the late addiction researcher Alan Marlatt referred to as the Abstinence Violation Effect. Or in layman’s terms, a bad case of the “screw-its.” If you think of this lapse as a failure in coping strategy for a high risk situation then you are more likely to go back to your diet tomorrow and bring a broccoli salad and supportive friend to the next office party. If you think of this calorie-binge as an indicator that you are a hopeless failure who will never lose weight, you are more likely to say “screw-it” and abandon the diet for the food you have always known and loved.
Many families find it useful to distinguish between a ‘slip’ or a ‘lapse’ as an instance of substance use by someone who has a goal of abstinence and a ‘relapse’ as a return to the pre-treatment pattern…-Lara Okoloko
Back to Jacob. He had a lapse in his abstinence, but did he relapse? Many families find it useful to distinguish between a “slip” or a “lapse” as an instance of substance use by someone who has a goal of abstinence and a “relapse” as a return to the pre-treatment pattern of substance use. When someone has fully relapsed, they slide back towards the heavy and frequent use of before. Problems that plagued them before treatment begin to return. The support system they held close is now rejected. They have likely abandoned their goal of abstinence, at least for now.
How will Jacob’s family respond? If they believe Jacob’s one night of drinking is a relapse, it is easy to feel that all hope is lost, that all gains from treatment have been thrown away. Their own reaction might unwittingly encourage Jacob to catch a case of the “screw-its.” His own counselor might do the same – telling him that he can’t return to his outpatient group now that he is no longer “sober.” I have read many “bottom-line” letters written by families coached by their loved one’s inpatient rehab counselors. Most have a common theme: even one instance of substance use and it’s back to rehab or on the streets.
What if Jacob’s family believes that not every lapse leads to a relapse? They are released from the overwhelming terror of the moment. They can take a breath and put things in perspective, allowing the fear to subside. They can encourage Jacob to reach out to his support people. They can remind Jacob of what he learned in treatment. They can tell Jacob how proud they are of the progress he has made in his recovery and let him know that all is not lost. They might encourage Jacob to use this as an opportunity to learn more about his triggers and strengthen his coping strategies. They can acknowledge the pain or fear that he might be feeling and ask how they can help. They can urge him not to “screw it all” but to stay on his recovery path.
They might encourage Jacob to use this as an opportunity to learn more about his triggers and strengthen his coping strategies.-Lara Okoloko
“Individuals with other chronic conditions usually learn to manage them, accepting that there will be some recurrence of symptoms, rather than see themselves as achieving complete remission,” says addiction writer Anne Fletcher. She conceptualizes her own recovery as a process that was “established” 31 years ago, even though she can’t claim 31 years of continuous and flawless abstinence.
This is the bad news and the good news of addiction recovery. For the family, as well as the patient, lapses are scary and disappointing. They are also a normal (although not a certain) part of the process of establishing recovery from the symptoms of a substance use disorder. Knowing this can help the family keep afloat when the waters get choppy. After all, not every wave is a tsunami.
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