Saturday, March 7, 2009

Relapse Prevention

"I stopped drinking," he almost shouted at me. "I can't be an alcoholic if I can stop drinking."

Stopping drinking is good but staying stopped is where the rubber meets the road. The WHO early recommended that if a person did not feel they had a problem with drinking but others including their doctor might, or if they had some negative consequence from drinking, they should abstain from alcohol for 1 year (4 complete seasons). This was the acid test in the early days of our understanding of the disease of alcoholism. It was recognised early that true social drinkers could abstain for a year from alcohol without significant difficulty and would. Most others however might say they could but sometime within that year would find they 'needed' a drink. Interestingly too, because of the denial intrinsic to the disease of alcoholism they would have a ready excuse for why it was 'necessary' for them to have that drink. This was of course recognised as 'rationalization' . Failure to go a full year without drinking was sufficient indication to strongly recommend AA to a person who had difficulty seeing their problem as others did.

Long term studies have since shown that those who don't relapse most commonly share five features in common.

First they recognise that relapse is not about short term abstinence but rather refers to long term recovery. These people do not think that a few days without drinking is any kind of proof or certainty that they are 'cured' or don't have the 'disease'. Indeed those who are successful in recovery view the process as one of many years if not a life time. Studies show that of those who have a serious problem and return to drinking at even 3 years of abstinence, 70% will relapse to their former level of drinking or worse and at 5 years, 50% will and at 15 years of abstinence at least 30% will still revert to previous levels of abuse or worse. In contrast to AA literature which does not follow those who do have 'success' in returning to drinking, there is evidence that people can but it is worthwhile to note the odds and the rather long term effects of alcohol abuse on the probability of their succeeding. The scientific studies, simply because of the high cost of such endeavours, in contrast to the AA testimonial evidence, are limited in numbers and lack the lifetime experience. Further it is interestingly to note that those who do return to drinking, do not do overall as well as those who continue to abstain. The other measures of societal success show that abstainers do better physically, socially and occupationally in the long run. Further what the data consistently shows is that return to controlled drinking carries a very high risk of return to previous abuse patterns with the negative social and health consequences.

The second feature about those who do not relapse is that they have developed an aversion to alcohol. This means that they don't romanticize it or even their past association with it. It is clearly seen as a negative and avoided as one might a poison or other noxious agent. As one old fellow of long term sobriety stated, "I learned to respect alcohol. I don't take it lightly. For me one drink could be like flirting with the gorilla. If the gorilla responded the sex wouldn't be over till the gorilla decided it was over."

The third feature was an alternative addiction. Alternative addiction is how this is described in the literature but it's a bit confusing because of the inherrent negative associated with the term 'addiction'. Some have difficulty with the term 'positive addiction' as well. Perhaps, passion is a better word. Those who were successful had replaced their previous worship, loyalty and occupation of drinking and everything associated with drinking with another positive healthy pursuit. For some this is a new found involvement in their work or family, for others it's community service especially those helping other alcoholics and for many a 'hobby' , 'craft' or "sport" is elevated from an interest or 'past time' to a true 'avocation'. The risk for many is 'cross addictions', where by alcohol is replaced by the 'marijuania maintenance' program, gambling, 'sex addiction' or shoppaholism. These activities temporarily reduce anxiety but inherrently like alcohol carry a high risk for abuse.

The fourth feature may in fact be the most important one of all. Those who have the greatest likelihood for long term sobriety and are least likely to relapse have developed a supportive social group of non judgemental non alcoholic friends. This is certainly what AA provides but has also been provided by church, community clubs, and other institutions which have avoided being coopted by the alcohol industry as a place for secondary marketting or merchandising. Colleges in the US have begun to exclude alcohol from their places of higher education just as tobacco dispensers were earlier removed from high schools. Just as alcoholism is a leading cause for dementia and does cause brain damage, recovery is commonly associated for many with advanced education and a new found interest in learning and joining groups associated with these pursuits of interest.

Finally, spirituality has been a key factor in those with long term sobriety, It is a principle feature in relapse prevention. It is different from institutional religion which not ironically has a high density of spirituality but itself is rather frightened of it. Christian spirituality is most evidenced in monasteries and retreats which are separate and not uncommonly at variance with the political organizations that are the basis of religions and commonly serve the role of supporting the state. This gave rise to the famous Marx statement, 'religion is the opiate of the masses'.

However in the Christian church spirituality and religion have long been known as the Martha and Mary debate. Recovery clearly is benefitted by the 'better part' of Mary. Spirituality was also what Carl Jung referred to in his famous "formula" for the early AA members, "Spiritus contra spiritum". It was noted that that the craving for base "spirits" , ie the demon drink, has to be replaced by a higher desire for the so called "holy spirit". Even aetheists have found recovery and solace in spirituality contemplating wholeness versus the isolation and aloneness that comes with active alcoholism. Many are moved and uplifted by routine and regular communion with Mother Nature herself.

As one recovered doctor who'd left the monastery for medicine told me, "Anxiety is a measure of our distance from God but equally a measure of our humanity." From a psychiatric perspective the alcoholic has a predisposing anxiety disorder, or sensitivity, which makes them find alcohol so appealing and when alcohol no longer works for them they have increased anxiety in recovery which has to be dealt with to prevent relapse. Seen spiritually the alcoholic needs to shift the equation closer to God so that they experience less of the existential angst which is inherrent in human existence. Not surprisingly all the spiritual practices such as prayer, ie talking to God, or meditating, listening, chanting, group and individual study of inspirational and mystical works, have all contributed to the reduction in individual anxiety and thereby promote long term recovery and relapse prevention.

As AA recognised early no religion has a monopoly on these practices, to which end AA has as a fundamental tradition that it is not affiliated with any particular group so that aetheists and people of all religions can benefit from a fellowship devoted to helping the alcoholic overcome what they specifically call a 'spiritual malady".

These then are the features associated with long term recovery and in part or whole are incorporated into the very best recovery programs. Individuals and families seeking the greatest likelihood of success should indeed consider them seriously as the denial and rationalization of alcoholism is so strongly associated with the insistence on doing it My way. Indeed that is why the disease of alcoholism has been called the disease of "me". Locally a very spiritual long term recovered member of AA called Milton is fond of saying, "I don't know about alcoholics having a child within, but I'm sure that somewhere deep inside there's an adult struggling to get out". Recovery is that journey and relapse prevention incorporates the proven and tried ways demonstrated to date to effectively increase the likelihood of survival from the disease of alcoholism.

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