Recovering from Recurrent Episodes

Several of my patients had recurrences of their addictions this week. Each one of them struggled mightily with feelings of shame and guilt. "Why do I keep doing this? I'm a smart person, I know what's going to happen. And I was doing so well!" My response in each case was different of course, and depended upon that particular person's situation, disorders, severity, past history, and so on. But here are some common things I do pretty much every time:

1. Stopping suddenly and permanently is a rare outcome, with or without treatment or rehab or AA. In one study that followed people with alcohol dependence for 10 years following an episode of treatment the proportion of people remaining continuously abstinent for the entire period was 8%. So the norm is to struggle with recurrences.

2. Most people take several years of persistent effort to finally establish long-term remission, on average 5-10 years. The most important thing is to keep working at it.

3. I've begun thinking in terms of "quit attempts," much as with smoking. How many times do most of us have to "stop" before it sticks? And even then, recurrence is common even years later.

4. Think of other types of behavior change. How often do any of us make a decision to eat better/less,  get more exercise, work less, work more, keep going at my meditation practice, try to be a better person, etc? And how often does that go smoothly, without slips and slides backwards? Almost never. So why would it be any different for changing substance use behavior?

5. The notion of counting sober days/months/years, sober dates, etc., is usually not helpful and may be harmful. So is the notion of "starting from scratch" after a recurrence. Every sober day is a sober day. Think more in terms of drinking or using days per month or 6 months or a year. Often I'll ask my patients to estimate the number of drinking or using days in the 6 or 12 months prior to starting treatment with me, and usually the answer is 90-100% of the days, or something like 180 days out of 180 days. Then, if they have had a period of remission, I'll ask how many drinking/using days they've had in the last 6 months, and often the answer is 3, or 5. So, 180 compared to 3. Is that an improvement? And nothing can take away those days of remission.

6. If we used the same outcome criterion for other disease as we do for addiction, here's how it would look:

• Someone with asthma should never have another asthma attack the rest of their lives
• Someone with high blood pressure should never have another reading above 140/90 the rest of their lives
• Someone with depression should never have another episode.
• Someone with cancer who is in remission for 3 years and then has a recurrence demonstrates a complete failure of treatment, and that period of remission is worthless.
• If permanent and complete remission is not obtained in any of these disorders, treatment is a complete failure. That is improvement but not complete and permanent remission is meaningless.

These example demonstrated the absurdity of the way we think about outcomes in substance use disorders. How about this alternative approach: the goal of treatment is to minimize the frequency, severity, length and consequences of recurrences. 

7. The worst thing one can do after a recurrence is to not learn from it. I ask my patients to reframe this experience thus: we have to examine how the relapse occurred, in order to understand how this disease works in you. It's different in everyone. But by examining recurrences, we can develop better approaches to prevent the next one.

8. Finally, it's not helpful to get distracted by shame and guilt. Recurrences happen. Stop it quickly, learn from it, pick yourself up, and move on. Look to the future, look to preventing the next one. 

MW