September 18, 2013


Mutual-aid groups have been strongly evidenced to improve the long-term outcomes essential to payment-by-results. For both experts and those new to the concept, George DuWors shows how you can forge links in a single session.

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Download AddictionToday144- Relapse prevention

Fotolia_44441951_bahrialtayThis article describes a practical technique for showing clients, from their own experience, how relapse could be set up in the first days or weeks of abstinence. It also helps clients to link into mutual-aid groups before they leave your care: these are now recommended government policy for relapse prevention  backed by an ever-expanding body of research. If your organisation depends on payment-by-results funding, it will help your outcomes.

As the clients’ drug/alcohol worker or therapist, you need no knowledge of Alcoholics or Narcotics Anonymous, but you will need the ‘big book’ Alcoholics Anonymous for this exercise.

Fotolia_197237_Udo KroenerThe process starts with client experience.  Not just relapse and/or a painful spree, but the painful aftermath often described as “beating myself up”. You might catch this live during detoxification or early abstinence, when you will have to carefully gauge what the client can absorb or tolerate.

Otherwise, you might have to elicit the experience through directed questions and/or role-play. “How would you describe what you go through the first few days after you get clean and sober again?” “Do you beat yourself up during those first few days or weeks?” Even “Be yourself after you got clean and sober again – see if you can play out loud the sort of thoughts you were having about yourself.”

If they have never tasted dismay at their own loss of control, the exercise might have to wait!

If you can bring this experience (back) to their attention, or they share it spontaneously, enough that they are feeling it, you can offer them page 73 of the book. Highlight the two paragraphs in the middle of the page, starting with “More than most people…” and ending with “that makes for more drinking”. 

While they are reading, be at your most attentive, watching and listening for reactions to the text. Note their eyes and whole physical being when they look up from it. You might get a chance to encourage them to verbalise their nonverbal responses. “What was it that made you chuckle?” “What made you nod your head up and down?” At a minimum, you will want to know how much they identify with the experience of leading a “double life”.

Most important, you want to know if they experience their own post-binge memories as “nightmares” and have felt the grim determination of the alcoholic/addict as “he pushes these memories far inside himself”.
Open-ended questions might help the transition to the second passage. “What do you make of this?” “Any thoughts on where this fits with your own relapse experience, or how to prevent it from happening again?”

After reflecting and validating their thoughts as much as possible, you might ask them if they have a name for the feeling when facing those nightmare memories. If they do not recognise “shame,” you can offer it as a possibility, see if they think it fits their own experience.

Fotolia_164586_fredGoldsteinThe next question sets up the second selection for them to read, regardless of how they answer. “What do you think happens to those memories when you successfully push them inside?”  Even if they answer correctly, ask if they would like to look at another passage in the book, one which seems to be talking about the resulting problem.

Assuming the answer is “yes,” hand them page 24 and ask them to read the already-italicised paragraph which begins with “The fact is…” and ends with “the first drink”. The key sentence laments being “unable, at certain times, to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or month ago”.  Again, you track and elicit the nonverbal responses.

Have they, too, been unable to remember “with sufficient force” at the moment of picking up the first drink/drug of physical relapse?  This should be particularly so for those who began their relapse with the classic self-assurance that “one won’t hurt” or any other variation of wishful thinking.

Clients who picked up the first relapse drink/drug with a more emotional expletive – “dammit” or the less polite variations – might have better memories, but they can hardly argue their recall had sufficient force to stop them.

Having established their personal experience with the italicised description in the book, you can ask if they see any link between pushing shameful memories “far inside” after drinking/drugging and being unable to remember those very same events before picking up the first drink/drug and creating still more shame. Some will. Some won’t. One way or another, lead them to the conclusion described in the paragraph below:
“The alcoholic/addict, tormented by shame from the latest episode and beating him/herself up, is using a mental hammer to drive the shameful memories so far inside the mind they will lose almost all force. If remembered at all, they will have no deterrent power. They will not seem real.”

You might have to repeat and explain this more than once. It is both abstract and concrete. “You seem to see that the shame after your relapse was intolerable and you drove those nightmare memories deep inside? When you decided to pick up the first drink/drug again sometime later, those memories just weren’t there to stop you – yes?”. 

It seems counterintuitive that a person so unhappy with themselves for drinking/drugging again is, at that very moment, setting up the next relapse by suppressing their “mental defence”.  Maybe that is one reason they seem to have to repeat the cycle, again and again.

Fotolia_9723849_VolodymyrVasylkivThe book does not spell out the connection between two pivotal points in the relapse cycle: the hours and days after the last spree and the moment immediately before the first drink of the next one. It is the steps themselves which address it. Maybe that is why it took 40 years from the time this clinician first read the book until he connected the two descriptions, in spite of routinely working with shame.

Ask your clients if they see the dilemma. Perhaps you could summarise. “If you do not push those memories deep inside, you live in constant shame. If you do push them inside, you seem doomed to constant relapse.”  Again, watch for their reactions. Check if this makes sense to them as a personal dilemma. Raise the question of any ideas they have about how to remember their painful experience enough to not repeat it, without having to endure perpetual shame.

When you perceive they are ready, you might ask if they can see an alternative to pushing these memories far inside. “What would that look like? What would one do? If a person wants an opposite result, what is the opposite action?” You might even be literal and ask what it would look like to “push these memories far outside oneself”.

Clients vary in their ability to spell this out. Let them be the first to suggest alternatives. You can develop a list together for pushing memories outside instead of inside. It might look like this:
>>  allow the memories to be and tolerate the shame for the moment: accept vs reject
>> hold memories in the light of any sort of loving, higher consciousness, be it mindful compassion or a >>  theistic ‘higher power’: bringing to light vs hiding in darkness
>>  write down memories on paper, which puts them outside their body: objectify and externalise vs suppress
>>  read or share them out loud to another human being, which puts them in someone else’s mind, also outside their body: share vs hide
>>  with that other person, look for patterns or motivations which made that do the things they are ashamed of, even things they did while sober: understand vs hide
>>  make a list of the ‘victims’ of their shameful actions, the people they find hardest to face: objectify and externalise vs hide
>>  look these victims in the eye, take personal responsibility and perform any action that will undo or repair the shameful action or its consequences, pushing it into more people and into the past: repair vs deny/defend/avoid.

The above list would be reasonable results for a (group?) brainstorm on the subject of doing something that is the direct opposite of pushing shameful memories inside.

Fotolia_4983540_ beltsazarIt is also a reasonable synopsis of the most cognitive-behavioural of the 12 steps: 4-9. These steps include two lists, one of the memories themselves and one of people harmed. They include active self-disclosure and direct, behavioural amends. As a result, steps 4-9 directly address the psychodynamic of shame-suppress-forget-relapse-shame, replacing it with shame-face-repair-remember-recover. This detoxifies memories of shame, guilt and resentment.

Some clinicians will go straight to the 12 steps, without brainstorming. Others might offer a ‘decisional balance’ exercise for the pushing- inside’ behaviour. However you do it, the point is to give the client a clear picture, from their own experience, of how shame and suppression set up the next relapse. It also gives a clear alternative, a task that is as concrete as it is active – to clean up the mess that shames them instead of burying it.

Fotolia_88049_ Douglas FreerHowever you came by the knowledge, you can convey the power of those middle six steps to transform the deepest shame into powerful gifts. Gifts your clients can share with their fellow alcoholic/addict, the one who is still floundering on the dark side of shame and relapse. Every time alcoholic/addicts share their detoxified experience, they are “pushing it far outside” yet again. And they are refreshing memory that stands in the way of the first drink or drug with the full force of reality.
George DuWors MSW is an addictions specialist in private practice. He is the author of the new workbook Getting It: Building Motivation from Relapse and has developed the corresponding workshop for counsellors, Motivation for Maintenance: Developing Discrepancy From Moments of Addictive Relapse.  See www.motivationformaintenance.com or www.gettingitworkbook.com.



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