Originally published on www.counselormagazine.com
In part 5, we covered the little-known Trigger Recovery Process. In this final article of the series, we will explore Relapse Warning Signs and provide a simple 3-part Relapse Prevention Education Series that is easily administered by any addiction professional. Remember that, despite its danger, many addiction professionals focus merely on teaching the tools of recovery to utilize once craving hits, rather than on how to avoid falling into the craving cycle in the first place. In this series, we are doing just that – demonstrating how to help our patients minimize the frequency of entering the craving cycle. We are accomplishing this by focusing on set-up behaviors and trigger events, two primary criteria that contribute to the craving cycle. By utilizing this information, patients can significantly reduce its frequency.
In his book, Staying Sober, Terence Gorski coined the term “relapse warning signs.” He writes that he conducted clinical interviews with 118 recovering alcoholics and drug addicts who had completed a 21 or 28-day program, recognized they were addicted, intended on staying sober post-discharge with the help of AA and outpatient counseling, and eventually relapsed. By compiling the responses of these subjects identifying the warning signs that might have told them they were on the road to relapse, he came up with a list of the most common responses – hence, the creation of Gorski’s famous 37 Warning Signs of Relapse (Gorski and Miller, 1986, p.140).
The importance of warning sign identification is based on the idea that relapse is not the event of picking up drugs or alcohol. Relapse is a process that happens over days, weeks, months, or even years and finally culminates in the actual use. This is good news for people in recovery because the intention is to avoid the “picking up” part. Warning signs can tell people they are in the relapse process. If a person can identify such warning signs when they occur, he/she can intervene on them before the substance is actually picked up.
It is important that our patients identify their warning signs early in recovery because, when they are in the relapse process, there is a tendency to have distorted thinking which makes identification of relapse warning signs extremely difficult. If they regularly view a list of warning signs they compiled when they were not in the relapse process, they will be able to identify symptoms they might not otherwise be capable of recognizing.
Warning signs and triggers are not the same, although there can be much overlap between them. Remember, a trigger is something that is connected to one’s using and activates the craving cycle. A warning sign is something that indicates that the person may be on the road to relapse. For example, seeing using friends can be both a trigger and a warning sign. As a trigger, seeing using friends often occurs simultaneous to, or just before, using drugs or alcohol. A connection is made between seeing using friends and drinking or using. This connection is what activates the craving cycle and makes it a trigger. Seeing using friends may also be a warning sign of relapse because exposing oneself to such people is dangerous to sobriety. Exposing oneself to such danger is clearly a warning sign that the person is setting up for relapse.
In my relapse prevention education series, patients are educated on warning signs and, using the same brainstorming method described in the trigger article, clients are asked to identify warning signs that might have indicated they were on the road to relapse. If they had no relapse history, they are asked to identify what warning signs they think might occur for them prior to relapse. As with the exercise described in the triggers article, the warning signs patients come up with are written on the board, the list is written down on paper, copied, and distributed. Again, I would have them highlight about 6 to 8 warning signs that might particularly apply to them and to review the list on a daily basis. Following is a list of warning signs that I compiled in a similar fashion to my compilation of triggers (Tyler, 2005). If you’ve read Gorski’s Staying Sober (1986), you will notice much overlap in these and his original 37 Relapse Warning Signs.
Isolating Loneliness Decreased sponsor contact
Decrease in meetings Not listening Increased anger/resentment
Quick temper Other compulsions Rationalizing
Justifying Mood-swings Seeking negative excitement
Fantasizing Hanging with users Increase in ego
Ignorance Return of denial Decreased spiritual program
Decrease in life structure Procrastination Decreased hygiene
Minimizing Poor diet Stopping psych medication
Over-sleeping Hanging in using places Refusing help
Obsession Increased self-will Increased craving
Old behavior Planning use Increased depression
Increased anxiety Increased fatigue Lack of sleep
Overconfidence Complacency Increased boredom
Decreased exercise Decreased step work Feeling overwhelmed
Apathy Negative thinking Comparing self to others
Breaking commitments Defensiveness Increased guilt/shame
Decreased phone calls Decreased willingness Increased sadness
Dishonesty Hoarding money Shutting people out
Insomnia Increased irritability Not open about feelings
Increased selfishness Taking other’s inventory Lack of gratitude
Major changes Hopelessness Early recovery “relationships”
Increased fear Increased confusion Desperation
Visiting purchasing places Stubbornness Drinking non-alcoholic beer
Sloth Arrogance Decreased 12 step reading
Projecting Self-pity Decrease in hobby activity
Sense of entitlement Sobriety loses priority Decreased journal writing
I really tend toward the brainstorming exercises as described above because they get our patients thinking. We want them thinking for themselves and the problem-solving skills that result from it. As we conclude this series, I want to recommend a simple three-part relapse prevention education series that includes what I described above.
No relapse prevention system is complete without educating on the tools of recovery and how to apply them to prevent relapse. They need to know what to do when they have a craving or have uncomfortable feelings they previously escaped by using alcohol and drugs. Therefore, along with the Triggers and Warning Signs education and lists development as described above, you can perform a brainstorming exercise on Tools of Recovery as well. You might ask the group: “Based on what you’ve learned thus far in treatment and perhaps from previous treatment episodes, what are the tools of recovery that are common to people who succeed at long-term recovery?”
As you are doing any of these brainstorming exercises, it may go silent after a while, but that’s okay. Why? Yes, you guessed it – when it is quiet, they are thinking! That’s what we want! If they are struggling coming up with some of the main tools, you can hint them toward the ones you want to make sure are on the list. Once the list is complete, you should take some time to clarify how certain tools are utilized and to answer any questions they may have about them. Again, this is a brainstorming exercise during which you will write down what they come up with on the board, have them written down on paper by one of the patients, make photocopies of the list, and distribute it to patients. Following is a list of Ingredients for Recovery compiled in a similar fashion to my compilation of triggers and warning signs above (Tyler, 2005).
Tools for Recovery
|Attend 12-Step meetings||Safely dispose of alcohol and drugs|
|Get a sponsor||Address other addictive behaviors|
|Practice meeting punctuality||Get adequate sleep|
|Share at meetings||Use good hygiene|
|Go to fellowship after meetings||Change bad habits|
|Develop sober support system||Eat proper diet|
|Make phone calls||Structure nutrition plan|
|Read 12-Step literature||¯ Caffeine, sugar and fat intake|
|Get meeting commitments||Develop/resume hobbies|
|Work the Steps||Structure life: work/school/volunteer|
|Develop spiritual program||Have fun|
|Pray||Avoid unnecessary major changes|
|Meditate||Avoid early recovery relationships|
|Be of service||Safely dispose of paraphernalia|
|Avoid drinking/using people||“Think it through”|
|Avoid drinking/using places||Avoid triggers|
|Be humble||Be aware of warning signs|
|Journal||Get professional counseling|
|Think positive||Consider sober living home|
|“Stick with the winners”||Avoid isolation|
|Take direction||Be open about emotions|
|Don’t drink or use||Stay busy|
|Make sobriety the top priority||Set realistic goals|
|Live in the present||Be responsible|
|Look for similarities||Avoid complacency|
|Accept feedback from peers||Practice relaxation exercises|
|Write gratitude list||Set boundaries with people|
|Ask for help||Avoid boredom/downtime|
|Avoid “stinkin’ thinkin’”||Have/get a sense of humor|
|Be Honest||Manage anger|
|Be Open||Avoid self-medication|
|Be Willing||Be gentle with yourself|
|Get/stay desperate for recovery||Surrender your ideas–go with others’ ideas|
|Create sobriety plan||Be persistent|
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In weeks two and three of the education series, you then conduct the Triggers and Warning Signs brainstorming exercises as described previously. Once complete, patients will have a copy of the Tools for Recovery List, the Triggers List, and Warning Signs List. You encourage your patients to keep these lists accessible so they can view them on a daily basis. You might recommend putting the three lists with their morning meditation book to make it part of their morning recovery ritual – starting their day with the morning meditation reading and then reviewing these three lists. This review will not take more than five minutes a day and is an invaluable resource to their recovery. I cannot over-emphasize the value of this for our patients:
- Reviewing a list of recovery tools that are used for successful long-term abstinence, allows for:
- daily education on what to do to stay sober
- daily reminder of tools they have not yet implemented, but plan to
- daily reminder of tools they may have previously been using, but stopped
- Reviewing a master list of Triggers which is highlighted with those that particularly apply to them, allows for:
- daily review of triggers to keep this phenomenon on the forefront of their mind
- reviewing one’s day to see if they will be exposed to any such triggers that day so they can arrange to avoid them, or create a sobriety plan if they can’t
- Reviewing a master list of Warning Signs which is highlighted with those that particularly apply to them, allows for:
- identification of any warning signs that can tell them they are on the road to relapse
- keeping their personalized warning signs on the forefront of their mind so they can prevent against slippage into such
- if they are in the craving cycle, the list may expose the source so they can intervene effectively
In summary, the Craving Cycle: Obsession, Compulsion, Physical Craving, and Drug Seeking Behavior happens to all alcoholics and addicts and always precedes relapse. So, along with providing tools of recovery they can use when the craving cycle hits, we need to help them avoid getting to the craving cycle to begin with. How we do that is my educating them on Physical, Psychological, and Social Set-up Behaviors, and Thinking, Feeling, Acting, and Relational Trigger Events. In this way, they will be able to avoid getting the craving cycle as often and, thus, decrease their chance of relapse. Some of this information can be formalized in a brief Relapse Prevention Education series utilizing a brainstorming technique resulting in lists containing Tools for Recovery, Trigger Events, and Warning Signs, which your patients can review on a daily basis – an excellent adjunct to anyone’s daily program of recovery.
I hope this course will add to your repertoire of relapse prevention tools, and that you continue honing your skill base in treating this dreadful disease. Thank you for all you do for our patients and I hope to perhaps see you at a conference some day!
Gorski, Terence T. (Speaker). (1988). Cocaine craving and relapse: A comparison between alcohol and cocaine (Cassette Recording No. 17 – 0157). Independence, Mo: Herald House/Independence Press.
Gorski, Terence T. (1989, April). Cocaine craving and relapse. Sober Times: The Recovery Magazine, 3 (4), pp. 6, 29.
Gorski, Terence T. (2001). Cocaine, craving, and relapse. [On-line].
Available Internet: http://www.tgorski.com/gorski_articles/co
Gorski, Terence T., and Merlene Miller. (1986). Staying Sober: A Guide for Relapse Prevention. Independence, Mo: Herald House/Independence Press.
Tyler, Bob. (2005). Enough Already!: A Guide to Recovery from Alcohol and Drug Addiction.
Humble House Publishing: Long Beach.
Bob Tyler, BA, LAADC-CA, ACRPS, SAP
While working in Inpatient, Residential, and Intensive Outpatient levels of care, Bob Tyler has been working in recovery since 1990. He serves as Compliance Officer at L.A. CADA, is owner of Bob Tyler Recovery Services (consulting, CD private practice, public speaking), is Past President of CAADAC, and is on faculty at LMU Extension in the Alcohol and Drug Studies Program. He authored the EVVY Award-winning book, Enough Already! A Guide to Recovery from Alcohol and Drug Addiction and has produced several educational DVD’s shown in over 1000 treatment centers across the country, including Craving and Relapse. Please visit our website at www.bobtyler.net.