Relapse

Relapse is a word therapists and clients tend to use often. ‘Taking a relapse’ is considered a normal thing or at least something happening often in the course of rehabilitation. The denomination is often used routine-like and without reflecting on whether other denominations or descriptions could be more useful for our clients.

The word is used as many other words in our language. By denominating (naming) a combination of complex behaviors we and our clients believe we know the meaning of those behaviors.

Every time you think someone ‘took a relapse’ or ‘relapsed again’ we think it is wise to think what it means for you. Many dedicated therapists gets deeply disappointed when a client has a relapse, especially when things has been going better for a while and one starts discerning an improvement in the clients situation. It may be of great importance if a relapse is described in terms of ‘a relapse’ or if the description becomes something like:

"Janne only took two shots this time. He cut loose immediately and so fast, that for the first time he could kick heroin without pills."

The addict and his family come to the fifth session. The client reports that he has ‘taken a relapse’ last weekend and he feels terrible about it. He has been off drugs for 4 weeks and has sensed real progress in many areas of his life. Everyone is disappointed, and maybe even you have a nudging feeling and wonders deep down inside if it is really possible to help addicts with only out-patient brief therapy.

It is often impossible to talk about anything else than the ‘relapse’ and the client himself is either very anxious to do so, or shamefully reticent and evasive. Many times ‘the relapse’ is seen as part of the usual pattern of periods with abuse, interrupted by short periods without. The clients own thinking often seems to circle around ‘why did I fall back?’ and that is also most often in the minds of relatives and professionals.

Don’t let desperation spread. Take a firm grip on the session and make up your mind to find out what has happened so you don’t passively accept denominations and denigrating allegations about the client or others, pronounced in the beginning of the interview.

With the questions below you focus on the relapse but on two different aspects. On one hand you focus on what the client did to terminate the relapse, and on the other; on what was different this time. It is important to investigate both these aspects in order to obtain different and useful descriptions of type; the relapse was shorter, less intensive, had less consequences for relatives, for work or school or anything that is important and useful in the client’s life. Talking about this makes the people present feel that you care about what is important without digging yourself and them down into the failure.

Open up space for – and confirm – pain, disappointment and grief both with the client and the family.

"This has really been tough for you." "Incredible you could stand the pressure of him starting to drink again." Etc.

You shouldn’t let this be dominant though, as this will inevitably lead to accusations. Remember that dedicated and angry people need to feel understood and validated in order to be constructive.

"How long did it last? Was this relapse shorter than the one before? What made you break earlier than ordinary?"

"In what way was this period/this relapse different? (How long, where, with who)".

"What made you decide to stop the drinking/abusing/eating?"

"What did you do this time that helped you stop turning on/stop drinking? What strategies did you use? How did you succeed with it?"

"What people was of help and what did they do?"

"What was new/different?"

"What did you learn from doing in this new/different way?"

"What do you think made him decide to abuse for a shorter period of time/in a different way?"

"What did you see him do to stop?"

"What did you he/she/you/others do that helped him decide/helped him do something different?"

"What was different for you during this period/this relapse?"

If the professional network is not present it can be useful to ask the client the same questions but in terms of "if ... was present, what do you think he’d say was different and new, and how would he describe what he did or tried to do to help you?"

"How did he manage to get to the session?"

"What made you (the client)/him/her decide to come here despite his condition?"

"What did you do that made him decide to come here?"

"What did they do that made you decide to come here?"

Work with such behaviors that are usually called relapses started already in the first session and the center of that work was the client’s goal. We can not emphasize enough the importance of listening for goals that contain other things than "the absence of the problem". Dead mans rule is a very good rule. It means that you confirmed and developed such aspects of the goal that can only be done by people who are alive. We have thus dissuaded from goals like; not drink for six months, not drinking at all, not have any relapses. That is – goals that can easily and successfully be performed by dead people. You should remember that goals should be small, possible to attain in the client's actual context, described in behavioral terms and described as the beginning of something rather than the end of something.

If and when a relapse occurs, it can and should be related to the goal(s) the client has set for himself: "These three days of doing drugs – do they affect your chances of doing such things you want to do?"

"How does this relapse (alternatively this period/ test of your ability) help you do more such things that you want to do?"

"What do you need to do to get back on track?" (only if the client seems to have gotten off track)

Via these questions you and your clients will sometimes reach the surprising conclusion that a relapse doesn’t need to have anything to do neither with the problem nor with the solution.

For you and your clients to be able to feel and think in this way, it is necessary that at least you keep the goals clearly in your mind, and both you and the client/family need to believe, think or feel that there is a movement in the clients life in line with those goals.

Jon’s summer has been OK, and he has had some success with girls. In the fall he starts high school and starts smoking hashish again. His mother calls and makes an appointment for him as she thinks he is behaving badly. When he comes he states that it is mother who has a problem with his behaviour, not him.

He has no plans to stop smoking hashish, but he wants to make it in school, be calm at home and he wants to develop his social life. He describes what he wants his social life to look like. Go out, meet girls, being able to talk to people and have something to say. At home he wants to be able to cope with his mothers nagging and her telling him what to do, and he wants to be able to respond calmly to her. The goals are small, concrete and seem possible to achieve in his actual life-situation.

In the third session he has suddenly decided that he wants to stop smoking hashish again: "I need to in order to manage school." He has resisted the urge for two days and with HK he talks about how it is to talk to girls and what he needs to do continue in the direction he has chosen.

He looks ashamed when he appears at the fourth session one week later and is not as talkative as usually. After a while HK asks him what he is sitting on. He then recounts that he didn’t smoke hashish for eight days but now he smoked yesterday and the day before. HK wonders what was different when he didn’t smoke.

"Nothing", he responds "I did the same things with the same people as usually, and it’s been boring."

HK insists several times: "What was different when you didn’t smoke? Something must have been different!" and eventually Jon gives in and recounts that Anna talked to him. She doesn’t normally do that because she doesn’t like hashish-smokers, and the proof for this is that she hasn’t talked to him for the last two days when he smoked. "She doesn’t even say hello," he says resentfully. "How does she know you didn’t smoke?" asks HK and he answers: "One can tell." HK wonders: "How?"

"You can tell by my eyes," he says, and HK wonders what else is different when he doesn’t smoke: "What is it Anna sees with you that makes her think it’s worthwhile talking to you?" He answers:

"She doesn’t talk to me, she doesn’t even say hello."

"She talked to you when you didn’t smoke those eight days. You must have been different if you didn’t walk around with a flag saying; today I smoked and today I didn’t!"

Eventually Jon bends to the evidence and admits that he probably was more sociable and talkative those days when he didn’t smoke, and after this he shyly admits that he called Jenny (whom he has thought about for months). He talked to her on the phone and he didn’t feel his usual blocking, like not knowing what to say etc. On a scale from 1 to 10 it was as good as 7-8.

"Wow," says HK, rises and writes on the flip-chart "Talked to Anna, called Jenny. What else?"

"He thinks for a long time, and HK tries to help him by connecting to the goal: "Was it calm with your mother?"

"Yes," he answers, "we went and saw ‘Swan-lake’ last Friday".

"Wow," HK says again, "is that the kind of things you like to do?" Jon looks at him coldly but with a humorous twinkle in his eyes and says: "Let’s say I prefer to go to the movies."

"OK," HK answers, "I’m not to fond of ballet either, but was it fun to do something with your mother?"

"It was OK," he answers briefly and HK adds GOOD AT HOME to the flip chart. HK then stands and looks at what he has written, draws a circle around the three things (called Jenny, talked to Anna, good at home) and says:

"Aren’t these the kind of things you wanted to develop in your life? Be successful with girls, that is talking to them in a natural way, and have a nice time with your mother?" He admits this and HK asks: "So what else do you want to develop?" He thinks for a while and says:

"Something has to change. Something has to happen – something new." HK adds this to the flip chart: CHANGE, SOMETHING NEW, studies the flip chart for a while in silence and asks:

"So what do you have to do to continue to work in this direction that you have here and have at least partly succeeded, and besides increase your chances to do something new and different?

"What do you mean succeeded?" he asks and HK explains: "You did this talking to girls as well as 7-8, and that says something about your ability, doesn’t it?" He agrees and now looks very thoughtful. HK continues: "This was really quite different. What actually surprises me the most is that you made such big changes even though it was only your first week without hashish, so what do you need to do to continue this development that you want?"

Jon looks at him helplessly and says: "It’s hard to stay away from the pot." I know," HK answers, "it’s hard work, so what do you need to do to continue this development that you want? More sociable and all that. That is if you want to." Jon thinks for a long time and doesn’t answer. "If you want to," repeats HK, "it’s your life". Eventually Jon says: "I want to, but it’s difficult."

HK confirms: "It’s hard work, but you’ve already shown that you know how to talk to girls and you can be pretty decent at home and at school, so you’ve already gotten a bit of the way."

The conversation only goes on for a short while after this. Jon thinks that his chances are about 70% that he can manage the week after without pot and HK sums up before he leaves: "It’s good you did this test now. I think it’s useful for you to make the difference so clear to yourself." Jon nods in agreement and a new appointment is set up.

Relapse or not

Sometimes it is not clear what is a relapse

A ‘bulimic’ woman comes to her third session. She has vomited the day before. A relapse she says and she brings with her an overwhelming sense of failure. It takes more than 20 minutes into the session, before she reveals that before ‘the relapse’ she had 5 days in a row when she succeeded to keep her food. It is the longest vomit-free period for six months. The rest of the session deals with examining in detail these 5 vomit-free days.

Seeing her ‘vomit-day’ the day before as a relapse would be a serious mistake from our perspective. In the session we are impressed with her progress. Five days without vomiting is reason to carefully examine how she did and infinitely better than the 7 ‘vomit-days’ the week before.

A relapse is a significant step backwards. What is experienced like that varies from person to person, from situation to situation, and is very much dependent upon how one talks about it (the denomination and the frame it is given).

The denomination

It is not strange that clients test if they can manage to have the positive effects of drugs, alcohol, food, gambling, etc. after they have had a period of abstinence. If they come to conclusion that it is impossible this can be described as ‘insight-full’, ‘a successful experiment’, ‘a test’ or any other word that can describe what happened without being colored by all the negative feelings that follow with the word/description/ relapse.

Most people can function socially and have a drink now and then. It is not strange if addicts check if that works for them too. (A larger proportion of former alcoholics drink ‘normally’ than are abstinent.)

To create these more useful meanings, more complex descriptions are needed than ‘he took a relapse’.

When behaviors are connected to the goal a new description/denomination with different significance is created.

If Manfred’s goal is to be able to drink like anyone and this means to him that he shall be able to share a bottle of wine with his girlfriend on Saturday evening, than half a bottle of wine on Saturday evening is not a relapse for him even if the girl-friend considers it to be one. If this isn’t clear to you, the girl friend and Manfred, you will never find a working solution together.

A relapse is still a relapse. It doesn’t matter what the hell you call it, or what do you mean?"

Manfred is angry. The answer is a reaction to the therapist (HK) who suggested that what Manfred think he is doing since three days is not a relapse, but a test of whether he can handle alcohol. The therapist answers calmly: "Maybe you feel like that, but you’re sober now aren’t you?"

"Yes," Manfred answers reluctantly and the therapist continues:

"I don’t get this. For how long do you usually drink when you start?"

"Well, something like three weeks."

"How long did you do it now?"

"I had a glass of wine with supper Saturday evening and after that I got this need for a bracer and then I started drinking on Sunday evening and it went on all through Monday."

"When did you quit?"

"Yesterday evening. I haven’t touched a drop since six o’clock."

"OK, now we are Tuesday afternoon so that means you drank for 24 hours."

"Well, I started drinking Saturday, so it was two days," Manfred answers.

"Two days?" wonders the therapist. "Do you call a glass of wine Saturday evening, drinking?"

"No, but it is always like that. It starts with a glass of wine at supper and then I can’t finish. I empty the whole bottle and then I’m on it."

"OK," says HK, "so what was different this time?"

Manfred thinks for a long while and then answers tentatively: "I drank only a glass of wine in the evening and I didn’t finish the bottle until late the day after."

"Fantastic," says the therapist and Manfred looks at him with surprise. "You almost succeeded. You drank only one glass of wine and then you left the bottle alone, and when you started drinking the day after you stopped almost immediately. How did you do it?"

"I thought about not wanting to fall back into the shit."

"What else?" wonders the therapist.

"I decided I wanted to come here sober, and I thought that if I continued drinking, I would miss seeing my daughter next week-end, and I don’t want her to get disappointed with me again."

"OK," says the therapist, thinks for a long while in silence and then asks: "On a scale from 1 to 10 where 10 means that you have arrived at what we talked about six weeks ago. That is, drink a glass of wine at dinner and then not drink more, how far do you think you’ve gotten?"

"Well, a 3 or a 4" Manfred answers and continues: "Well no, maybe 5. It went well in the evening; I only drank one glass of wine. It was the day after that didn’t work". He pauses, thinks carefully and goes on: "The next time I make a test I’ll make sure I have something important the day after that I definitely don’t want to miss. Then I don’t risk falling back." He pauses again, slowly lifts a shaky hand that he looks at thoughtfully, smiles and says: "I think I shall wait a while with that."

The therapist laughs and says: "What do you have to do now so that these two days continue to be a parenthesis?"

"I have to keep myself occupied, and remember that I am seeing my daughter Saturday."

· Focus on the denomination (the word) ‘relapse’.

· Focus on how this ‘relapse’ was different from other relapses.

· Focus on how and what the client and others did to stop the ‘relapse’, helped stopping the ‘relapse’.

If the client is under the influence it is of course not reasonable to try the third above (as it hasn’t happened yet). Try with "How did you manage to pull yourself together so you could get here today"?

· Focus on the goals. Preferably in terms of how would this have been different after the miracle?

The client is under the influence but pretends nothing is wrong

Anton, 45 years old, has abused sedatives for many years. The situation has improved in the first five sessions, but when another two have passed and Anton is thoroughly and increasingly intoxicated, the therapist (JL-K), brings up that she feels that she is not of any help. Anton assures her of the contrary and talks about things that were much worse before. When questioned as to what he thinks his relatives think about the situation he avoids answering. It appears that Anton now again only sees his parents and brother sporadically. During the time the therapist thought that Anton was doing better, he had more contact with them.

The therapist is still not convinced that she is of any help and finally states that she needs to see the brother to get his opinion. Anton is hesitant, but the therapist sets this as a condition for continuation, as she is hesitant as to whether or not treatment is making a difference. Anton finally accepts and when the brother is involved in therapy Anton makes rapid progress and quickly becomes totally abstinent.

Bert:

Bert, 30 years, is court-ordered to go to therapy and has been off drugs for three months since he got out of prison. He has been going to school, he has not taken any drugs, and he has regained contact with his parents and siblings. He also got a girl friend. These four things were all in his answer to the miracle-question in the first session. In the seventh session he recounts sadly that the girl friend has broken up with him. His speech is thick, but he doesn’t say anything about having drunk or taken drugs.

In the beginning of treatment the probation officer participated, he was then relayed by the family and since some time Bert is coming alone.

Previous question concerning how the family and probation officer would react if he had a relapse have been answered with "They’d give up," "They couldn’t cope with it one more time," etc.

The session is focused on how the network would react "if they knew what a crisis it was for him that his girl-friend broke up?" and he recounts thoughtfully that he hasn’t shared what happened with anyone. The therapist wonders who would understand him best and he mentions his brother first and after that his mother. "Would it help you not to get involved in drugs if they knew and were there for you?" the therapist wonders and Bert answers: "It probably would."

In the summary of the session the team and the therapist suggests that the family and the probation officer should be invited to the next session, and Bert accepts.

He shows up sober to that session and tells his family and probation officer about his relapse and how thinking about his family helped him stop it.

In these two cases it was helpful to involve more people in the sessions. In other cases where the family participated and the change-process stopped or went in the wrong direction, we instead reduce the number of people. The rule is always: If it works – do more of it. If it doesn’t work – do something different.

Disagreement

Sometimes there is disagreement in the family, in the professional network and maybe uncertainty with the client himself if a given behavior at a certain time, that maybe occurred and maybe didn’t, was a relapse or not. Sometimes it can be extremely important for someone to get a clear label, for instance when a parents drinking is putting children at risk, or when an employer can not risk having a drunken employee on the shop-floor.

By discussing and reflecting upon what is a problem for whom, and through descriptions of non-problematic behaviors in that persons/authorities perspective, the situation will get clearer for everyone involved and it will become clear to the client what is expected of him.

Is there any difference?

Be observant. If you don’t get any positive changes in this relapse compared to the last (or treatment doesn’t seem to make any difference) consider seriously to terminate treatment. Consider that if things are getting worse instead of better, it is probable that you unwillingly have become part of the problem and is not a part of the solution. You should then consider withdrawing from the situation in order not to aggravate the situation even more for your client and his/her family. At least you ought to discuss it with them.

Aina, heavily addicted for many years has been coming to sessions sporadically for a year. She comes in after her fourth period during the year – a month spent with the street-addicts. The therapist brings up if she should continue treatment as these relapses are so destructive. Aina assures him with insistence that the sessions are useful to her.

"Before I drank for three months in a row, and then I was sober for one month. Now I’m sober for three months and I drink one." The therapist looks a little skeptic and wonders what difference that makes in her life.

"I haven’t been thrown out of any apartment since I started coming here," she says, "and I have some contact with my children. This is really helping me".

"Uhum" says the therapist and wonders, "so what is the next step?" She reflects briefly and answers:

"That I drink for a shorter period than two weeks and that I don’t miss the visits to my children. They were so disappointed this last time.

A similar example where the therapist is wondering if the treatment is of any use, leads to some important information.

The social worker looks terrified when Andrea 45, recounts that every time she has had a session she has had a beer in the evening.

"Oh," says the therapist, "if so we probably must stop these sessions."

"No-no", says Andrea, "I can handle drinking just one beer after I’ve been here. I can never do that at other times."