One of my first and most memorable patients was a Native American man who I was treating for alcohol dependence (among many other complicating factors). On multiple occasions, he had been admitted to the hospital for detox with blood alcohol levels that would kill most humans.
He could drink a lot, but the problem was he also had a traumatic brain injury that required medication, so with every relapse came the potential for death and need for hospitalization.
After months of weekly individuals sessions, and despite frequent relapses, we had an incredibly strong therapeutic relationship – so strong that one day he came in to session and said…
Your approach isn’t working. I know you mean well, but the western way is hard for me to understand. Here is my bible
…and he handed me a copy of 
The story continues
Months later after reworking our treatment plan around the medicine wheel, he is still relapsing, ending-up in the hosptial for detox, and I am left wondering where I went wrong.
Fortunately, my Clinical Supervisor at the time was an insightful, experienced therapist who suggested I review all hospital detox admission records since he first entered treatment to gain some perspective on what was actually happening.
Since every relapse had been followed by a hospital admission, I was able to easily complile a graph of relapses over time, and when I did, something amazing materialized.
He was getting better
It was right there in the data. After plotting the relapses on a graph I was able to see that the time between them was increasing – actually doubling with every relapse. What on the surface seemed like failure to me, was in fact – after reviewing the data – success. And why should have I expected progress to be any faster?
This guy had years and years of drinking history behind him. Change is a process, and with addiction, takes incredible patience. We also know that addiction is a chronic medical condition where relapse is part of the process. When I presented the graph to him at our next session he was equally pleased, and even more motivated to continue the progress.
Six years into our work he had well over two years of sobriety. His relapses continued to decrease in frequency maintaining the pattern he began when he entered treatment.
The moral of the story
- Follow a recovery path that is right for you.
- Track relapses and other significant events because data can provide insight where memory fails.
- Change is slow – Patience is key.
- Relapse, even after significant abstinence time, should be an opportunity for learning and not a time for shame and blame.
We all make agreements with ourselves to do things; diet, exercise, New Years resolutions. We all fail at times.
Relapse is not an Addiction Phenomenon, it is a Human Phenomenon
I love this story on a variety of levels. It’s so easy with our addictions, to make even a small mistake and throw in the towel. Therefore, when blatant evidence depicts good progress in such a tangible way, it is hard to deny such accomplishments. Even you,the counselor, didn’t know he was getting better! I believe when this information is made accessible and obvious to the client (seeing the whole picture), the result will engender more positivity, confidence, and motivation for change. This is really such a simple, but abstract phenomenon, especially concerning addictions, as it is really about identifying the positive aspects, studying them, and building off of those strengths. Too often, we only see the negative failures, and obstacles; thus, I thought this was such an inspiring, powerful angle to gauge (when applicable) when dealing with long-term treatment.
Also, this story corroborates the crucial significance of the individual when designing treatment plans and the process of healing. This man was reaching out to you on a spiritual level of disconnect to “his” process of treatment, and offered you a window into his beliefs through the, “Seven Arrows.” How could anyone possibly commit and excel in a process they don’t believe in or understand? This illustrates efficacy in treatment as a direct result of taking into account all specific, pertinent, personal details about the client.
Nikki – thanks for the nice feedback. I absolutely agree that we need to build off strengths, and use data when possible to help elucidate things that may not be so obvious in our day to day lives.
J
I enjoyed reading this entry. While reading it, I noticed it was similar to what I’ve experienced. Struggling with anorexia and major depression (among others), I have lost count of hospitalizations. Each time I looked at them as failures. I was embarrassed to see staff again and thought it was useless – I obviously wasn’t getting any better after so many years. Yet, over the last two years we’ve been able to look back and see the progression. After a four month hospital stay, I stayed out of the hospital for a few months, only to go back after a traumatic event, which was only measured in days. I relapsed with my anorexia and was hospitalized again, but almost a year later. And only for two weeks. This is going from being in and out of the hospital every couple of weeks, and for long durations. Now, I’ve been out for several months and am doing great. I don’t plan on going back, but I know it’s there if I need it. I’ve spent six years in hospitals; I’m done. Ha ha.
It’s hard for outside people to see that this is progress. Some may ask, how is being in the hospital progress? Well, if I came in willingly, that was progress. If my labs were not horribly off, that was progress. If I stayed safe, that was progress. Recovery takes time. A lot of time. And as much as it sucks, wading through all of this, it takes patience from everyone. Sometimes family and friends don’t understand that at first.
My favorite part of this entry was how Dr. Fitzgerald recognized that addiction takes time to overcome, that there is by no means a “one-size-fits-all” treatment for any one human being. My sister suffered from methamphetamine addiction for so many years and she was finally able to come out of her severe and chronic episodes of abusing that drug (she became pregnant). However, there were many times that she relapsed, and for my father, he saw any lapse in character as a complete and utter failure. This entry brought me the realization that no one person is perfect and sometimes we have to take a step back to truly see the actual results of an individual struggling against addiction. Fitzgerald stated: “After plotting the relapses on a graph I was able to see that the time between them was increasing – actually doubling with every relapse. What on the surface seemed like failure to me, was in fact – after reviewing the data – success.” Why is it so hard for individuals to see what’s underneath the surface? I don’t understand why singular relapses are seen as complete failures, when in reality they are not. Is there a better way to educate the general public about drug and drug addiction that would allow for human error? Honestly, I cannot see any one person being absolutely perfect in the fight against illegal and abusive drug use. Thanks for reading.
This is a great story of what I believe we could all use a little more of, patience and persistence. It seems that in today’s fast paced world people are more prone to give up or move on to another tasks when they face adversity. Taking a step back and looking at the issue from a different angle is a great way to get a new perspective on a problem. By approaching the patients addiction from a perspective that may be different to you, but more comfortable for him, you are building trust and a sense of belonging for someone that has tried and “failed” in the past. Being able to look at a situation differently than other people can give you an advantage over others that cannot. You were able to incorporate the Sevens Arrows into the treatment and you were also able to look deeper into the “failures” and see that they were actually progress. Be persistent and patient when dealing with issues and you might be surprised what you learn.
I recently had a similar experience with one of my clients.
He had alcohol dependency with a history of relapse. He came into a counseling session distressed because of an episode of another relapse that took place during the weekend.
Remembering a chart that was introduced in class depicting a pattern of relapse, I encouraged him to talk about his relapse history. I drew a chart on a white board and filled it with the information as he gave his account. When did the series of relapse happen? What were his emotional and cognitive states? Did anything happen right before the relapse? As the chart progressed, the client became excited and took over the drawing. “I see…”, he said. “I am drinking less and less for every relapse. My depression lessened as well.” It was profoundly encouraging for him to see the evidence of his addiction improving.
He is a victim of childhood abuse, and has gone through a horrific accident several years ago. The recovery has been long and hard, but he is starting to feel that his life may be turning around. The weekend relapse was a disappointment, but seeing that it was getting less severe, and the grip of addiction was getting weaker gave him the additional encouragement and motivation he needed to continue his journey.
Your approach isn’t working. I know you mean well, but the western way is hard for me to understand. Here is my bible…
This isn’t just a story about addiction counseling, but it’s also a story of learning to be a culturally competent counselor. Often times practitioners fail to look outside their worldview lens which leads to failed treatment and frustrated clients. Every clients story it unique and just as we should not have cookie cutter treatment plans we should also not view our clients as one in the same.
In the history of our profession, we are just in the beginning stages of understanding and using multicultural counseling. Researched based treatment plans are not a one size fits all guaranteed success. Researchers do the best they can to ensure their population and sample demographics accurately depict the changing face of our nation, but we must not forget every client is distinctive. The more we truly learn to listen to our clients the more we gain insight into what best works for them…with or without plot lines. : )
Relapse is not an addiction phenomenon, it is a human phenomenon.
I like that line the best. It makes me wonder about all the things we relapse with. This week I have probably relapsed on staying up to late and on hanging out with friends more than I should. I’ve relapsed in not hanging up my clothes as soon as I pull them out of the drier and on staying in bed too long in the morning.
My life is full of patterns. I set up schedules for myself to help manage my addictions. I’m addicted to the fun of the moment instead of taking care of business. I’m addicted to going to bed late and lounging around in the morning, then drinking too much coffee all day long.
It is good for me to understand addictions, especially drug addictions, as a natural process that takes time. I’m not terribly hard on myself when I decide to stay up late, so why should I be hard on other people for their addictions?
It is also interesting to think about how much I change without other people realizing it. Recently I have been making great strides in my personal life. I have been taking action to complete some of the more daunting tasks. I think others may not recognize this. They would just see me as more happy or more busy. It is important to recognize that people may be going through a lot more than we realize and to not judge what is working solely off of what we see physically.
I think the last comment is powerful and the reality of why relapse occurs, not to mention the science behind how the brain changes during addiction. I am certain that having you as a professor has really opened my mind to what addiction is and I am excited that I believe to have found an area in which I feel would love to learn more about and work in….now back to relapse. I work in mental health crisis services and there is one guy there who is well known as “the drunk,” he has an alcohol addiction and has had it for years. It wasn’t until learning through this class that I ever questioned the treatment he’s received. One counselor I recall saying “we can’t do anything w/him, we get him into detox and then he always relapses!” With years of addiction and a lot of money being spent on his treatment and years of it, he is still addicted because treatment has failed him and his relapses are considered his choices, his error. This blog helps me remember that every little aspect matters. Like in class there was a diagram with different areas in which a person had issues…after discussing it in class…it was realized that the primary issue was that the person had sleep apnea and when that was tied to every other issue, there was a bright light…we have to look at all details of the persons life to provide adequate treatment and not look at relapse as failure as we all relapse in someway in our very own lives.
I took away two key messages from this blog. First, one type of treatment will not work for everyone. Even though this was something I was already aware of, this story really illustrated how important it is to make sure that the treatment we use is a good fit for each unique client. Also, it reminded me of the importance of being culturally aware. An understanding of cultural differences could make all the difference.
The second message is that relapse is a part of addiction and that tracking relapse can provide proof of continual improvement. Although many people are aware that relapse happens, the way that we view relapse needs to change. Relapse does happen, but what can we learn from it? It doesn’t need to be viewed as failure. It is a minor setback and a normal part of being human. I have never thought about tracking relapse in this way, but I can see how important it can be; as it can illustrate that change IS happening. It can be used to motivate those who are struggling to keep working through their addiction.
This is a great example to learn from. As counselors, if we become concerned with “perfection” or “fixing” people we will fail. What is important is helping people improve the quality of their lives. Focusing on progress is a more positive way to look at the work. We need to support our clients when they relapse and let them know that this is a normal part of the recovery process. We need to do this, especially, because the public at large and, more specifically, the people close to our clients most likely view the relapse as a personal failure and something to be ashamed of. Others are shaming our clients and increasing the likelihood of further relapses. We need to support them from chronic care perspectives and not be another relationship that judge’s them for their behavior.
This post made me reflect on the fact that there is not one way to recover from addiction. Relapse is a part of the disorder and is more common than success at first attempt. In fact, I have read that the more times a person tries to manage addiction, the more they begin to manage addiction. Time between relapses will often increase and levels of drinking and drug use will decrease. Seeing addiction in this way will help both clinicians and clients, in understanding that this is not a failure of either person, and certainly it is more likely that a client will relapse. This also causes me to reflect on the model of addiction treatment which tries to encourage “treatment” as if it is an acute disorder that will go away. Often, the disorder has been brought on by years of long term developmental deficits, and cannot be treated and cured at first try. Treating addictions based on what each individual person needs to recover in their own way, at their own time is being sensitive to the truth about addiction, that it is a different experience for everyone.
It’s great that you had the benefit of your insightful supervisor when assessing whether or not your client was improving in his addiction. I think this it is important not to “miss the forest for the trees” in terms of demarking real progress when an addict is actually getting better but still relapses. By normalizing relapse as an expected part of a chronic condition, it serves to combat against the inevitability that a “lapse,” or minor slip after having a lot of success, will necessarily become a full-on relapse. We also live in a very black and white, socially conservative era in many ways, where abstinence, whether when talking about sex or drugs, is seen as the best option. For many people, however, a life of total abstinence is not possible. I think it’s foolish to deny that there is real headway being made with a client, if that client is unable to be completely abstinent.
The story of this Native American client of yours is inspiring. It helps me to remember when working with clients to always think outside of the box. What works for one client will not always work for another. Being flexible is important. Often times clients have good ideas so remembering to keep them as an integral part of the process is essential. Rewarding and celebrating the small achievements, such as passing by a liquor store and not going in, is as important as rewarding the big achievements, like years of sobriety. Often time it may be hard to find the small achievements but showing the clients helps them have a more positive outlook about themselves rather than the negative thoughts they have about themselves and that others have said to them.