Friday, October 5, 2012

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. 



  1. Once again you've given us a well-written, thought-provoking post that is sympathetic to the travails of those facing the trials and tribulations of addiction to a substance and you managed to give hope while being realistic and in noways overly "lenient" or "enabling."

    I've never stopped to consider the fact that counting days might be a harmful practice. It's a tough call because one can be proud (rightfully so) of the sober time that one has accumulated and people with time under their belt give hope to newcomers. I remember sitting in a meeting as a young person feeling great hope that someone might actually be sober for 10 YEARS!!! I also remember counting sober time in my head and daydreaming about how much sober time I'd have at age 25, age 30, age 35 and so on. It seems almost embarrassing now, but at the time it gave me hope.

    The problem is-- I didn't manage to stay consistently sober for any long period of time for a few years and even then I had return to use. I was full of shame after that return to use and it was particularly hard to go back to a meeting where people would ask me my sober date or "how much time do you have" and I was so self-conscious because I didn't think the things I shared about what I had learned in the program and where I was going was consistent with the amount of time I had. This feeling actually kept me out of meetings, out of working a program, and made it much harder to return to a recovery and back into the program.

    Hence, I wonder how we can simultaneously talk about time sober that allows people to be proud of the time they have stayed sober, that sets an example or goal to the newcomer who can barely imagine being sober a week let alone a number of years, but also is more realistic and doesn't unnecessarily burden someone who may have had a use recurrence/relapse and yet still has been sober all but 12 days over the past four years (i.e. had two short returns to use in the midst of some long term sobriety). I'd appreciate your thoughts about this.

    I imagine I'll post more later after I've reflect on your piece, but I was so engaged that I wanted to comment immediately.

    THANK YOU! And please do keep commenting (or maybe you'd be even write a feature article for) -- it is a site with wide readership and I think you could add so much to the discussion that is currently missing. Keep up the great work!

    God bless.

  2. If it's beneficial to you to "count time", I personally think it's most helpful to think about the length of time that you've been committed to working on your sobriety and not get hung up about a slip or relapse. As someone says in my forthcoming book,“We don’t have sobriety dates; we talk about when we started improving our chemical health.” Bear in mind, too, that sobriety is more than just "not using" - "count" your "returns" in other areas of your life such as relationships, health, mental well-being, etc. Focus on the things you "get back" rather than what you lose (e.g. "sober time") if you relapse and get back on track.

  3. I just stumbled across your blog and I am really learning a lot from it. We are dealing with a loved one's relapse right now and I printed off this post for him. I don't know if he'll read it but maybe it will be helpful for him. Thank you!

  4. Very helpful post, thank you! I had a recurrence after nine months for a period of two weeks, and I just celebrated six more months sober. Looking at the experience as you describe is far more helpful than I am less sober at six months than at my previous nine month stretch. A sober day is a sober day, and I am so grateful to be sober today!


Comments are welcome.