“what am I missing; I keep relapsing and don’t know why I have such a difficult time remaining clean and sober?” 

 How we treat addiction in treatment must change.  The idea that we can provide information and teach an individual how to remain clean and sober is a fallacy.  Most addicts and alcoholics are above average in intelligence and the question is “Don’t you think if they could be taught how to stop destroying their life they would merely read a book and the problem would be eliminated?”  The answer is “Of Course.” Who would choose to drink, drug, or addictively act out knowing their life is over if they do?”  Nobody.  Thus, people know and they still partake in these behaviors.   

 Therefore, the answer is not merely education.   

Facts: 

• 9% of the U.S. population meets the criteria for substance use disorder (SUDs) (Substance Abuse and Mental Health Services Administration 2010); 

• Drug-related suicide attempts increased by 41% from 2004-2011 (Drug Abuse Warning Network (DAWN);

• Therapeutic alliance is one of the greatest predictors of positive treatment outcomes (Straussner, 2012). 

“Until an addict or alcoholic develops the capacity to establish mutually satisfying relationships, they will remain vulnerable to relapse and the continual substitution of one addiction for another (Phillip Flores)  

What is Attachment Theory? 

“Most of the psychopathology seen in the alcoholic is the result, not the cause of alcohol abuse.” (Valiant, 1983). 

If we don’t begin treating the problem, which quite possibly stems from a lack of secure attachment modeled during childhood, as opposed to the solution, addictive behavior, we can count on continued treatment failure, often called resistance to treatment.  Resistance to treatment seems to be a way of saying it’s the patient’s fault not ours.  Therefore, we put the cart before the horse. 

The result of putting the cart before the horse is the following: 

• We admit a patient to treatment with distorted definitions of concepts learned as a child, i.e., honesty, hope, faith, courage, integrity, willingness, humility, brotherly love, discipline, perseverance, awareness, service 

• The patient learned these definitions from their caregiver or parent from the models presented to them as children.   

• How would the patient know these definitions are potentially dysfunctional if it is all they know?

• How effective will step work be if the patient doesn’t have a model or healthy definition of what the principles of the steps espouse?   

Attachment theory assumes that the experience of childhood relationships shapes adult attachment styles.  These experiences create the road map or internal working model for how the individual will perceive himself and others relationally (Bowlby, 1973).   

The basic premise is that we only know what we know.  For example, two men are sitting in the park discussing zoo animals.  The one man asks the other if he has ever seen an elephant, to which the other man replies ‘no, what does it look like?’  The man states, ‘it is a large grey animal that has four hoofs, rough skin, floppy ears and trunk in the front’.  The other man states ‘you mean like the tree trunk outside?’  The man replies ‘no, not a tree trunk’.  To which many asks ‘You mean like the trunk of my car?’  The point is that the man will only know what an elephant looks like if he sees a picture or goes to the zoo.  Similarly, if a child grows up with caregivers who are physically present although not emotionally present, thus, lacking a functional definition of emotional availability and intimacy, the child is more likely to have a stunted view of being emotionally present for others in their life.  It is very possible that when this child becomes an adult, their innate need for secure attachment will not be met unless they see a model of what healthy attachment looks like. 

The basic principle of Attachment Theory is that those with secure attachment (stronger emotional relationship with caregiver) are better able to regulate emotions and have fewer relationship problems.  However, disruptions in the attachment system (insecure attachment) can lead to vulnerabilities in the sense of self and others as well as relationship problems; thus, leading to shame, co-dependency, and a need to numb pain via addictive behavior.  Therefore, if we don’t address and model secure attachments to patients, they will stay stuck in the solution of continuously seeking to avoid and discharge pain through addictiveness.   

 Research suggests that relationships influence brain development and “relationships have the capacity to rebuild certain parts of the brain that influence social and emotional lives; clinicians can help clients to alter their attachment patterns with a secure clinical relationship.  (Miehls, 2011, p. 82).   

The bottom line in defining Attachment Theory is that the goal of treatment needs to be focused on changing the definition and model of what it means to feel included, loved, and secure.  “The inability to establish healthy relationships is a major contributing factor to relapses and the return to substance use.”  (Flores, 2004).  Thus, the answer to “sh*t what am I missing?” is: Not having had a clear model of secure attachment because it was partially or completely missed during childhood.  As Flores stated: 

“Therapists must be able to challenge, soothe, care, love, and if necessary, fight with a patient if they are able to provide a full range of emotional experiences that can potentially come alive in an authentic relationship. (Flores, 2004, p. 259).  

To sum up part one of this article, unless we provide a solid definition of concepts that we see as normal (based on definitions that were modeled) albeit dysfunctional and damaging, the way we work the 12 steps will be flawed and based on dysfunctional definitions, lacking much change in behavior.  Alternatively, we can utilize the 12 steps as a corrective experience by interpreting each step as follows: 

 Interpreting the 12 Steps from an attachment perspective: 

Step 1:     The experience of abandonment; 

Step 2:     Permission to hope; integration to others; 

Step 3:     Taking a risk (vulnerability) to attach 

Step 4:     Taking a risk to attune with self 

Step 5:     Taking a risk to attach to another person 

Step 6-7:  Correcting and repairing relationship with self 

Step 8-9:  Correcting and repairing relationships with others 

Step 10:   Personal responsibility for securely attached relationships in my life 

Step 11:   Solidifying a secure attachment to my Higher Power 

Step 12:   Increasing my ability to model securely attached relationships to others 

Recovery from substance abuse is a long and complicated process. While much of the literature focuses on early recovery—a fragile and critical time—there are thousands of folks in long-term remission from substance use. The issues we face in long-term recovery are just as critical to our progress, relapse prevention, and ongoing health.

A person is considered in long-term recovery or remission when they have stopped or moderated their substance use and improved their quality of life for at least five years. The early stages of crisis stabilization are past, the damage drug use has inflicted is undergoing repair, and a “normal” life is being built. The critical issues of early recovery—staying clean, finding safe housing and employment, confronting legal consequences, and making new, sober friends—often feel more manageable by the time we enter long-term recovery.

At this point, a lot of us think we’re in the clear. We can breathe a little easier and begin to trust ourselves again. But we can’t make the mistake of thinking we’re done with recovery. With this false sense of complacency, we’re increasing our risk of relapse.

The truth is, long-term recovery has its own set of obstacles to overcome. It’s critical that we stay vigilant about our personal growth to increase our long-term chances of success. This can be done through self-study or by working with a counselor. Below are four tips to ensure success in long-term recovery.

4 Keys to Success in Long-Term Recovery

1. Healthy Relationship Skills

Many folks who struggle with substance use also struggle with finding and maintaining healthy relationships. Interpersonal struggles can wreak havoc on all areas of our lives, so it’s critical that we learn the skills to keep our relationships healthy. Whether our struggles are due to developmental trauma, unhealthy family relationships, or past hurt or abuse, developing healthy interpersonal skills is essential to continued success in recovery, stress management, and overall health.

Early recovery is often fraught with interpersonal difficulties that should stabilize as our lives and emotions do. However, intimate relationships can remain difficult at best. If this is the case, it’s important to engage in the work of building values, beliefs, and habits that support healthy, harmonious relationships.

Many of us with past substance use issues also struggle with a dichotomous personality. We feel there are two people living inside us: the person we were when we were using, and the person we are now.

2. Identity Integration

Many of us with past substance use issues also struggle with a dichotomous personality. We feel there are two people living inside us: the person we were when we were using, and the person we are now. The devil and angel sitting on each of our shoulders, both personalities try to pull us to their side.

It’s normal to want to push down our dark side in early recovery. We are scared of this other person living inside us and the damage they are capable of inflicting. Eventually we must integrate these two opposites and invite that dark side in. We must make peace with the person we were when we were using and become one whole human being.

3. Confronting the Wreckage of the Past

Bad decisions are one of the elements of substance use. These decisions can range from embarrassing to criminal. It’s normal to begin cleaning up that damage in early recovery, whether it’s completing jail sentences and probation, apologizing to loved ones, or living down a bad reputation.

But the impact of our past can last years into recovery, especially if our drug problems involved the legal system. This can be a source of great shame, stress, and embarrassment and can derail an otherwise strong recovery program if not managed appropriately.

4. A Balanced, Healthy Life

As many people in recovery know, stopping problematic substance use does not equal a healthy, happy life. In fact, early on we can be more miserable than ever as we learn to deal with stress while sober. Often, we are unhealthy people in general, not just in our relationship with drugs or alcohol, and we need to work on our physical, emotional, spiritual, and social health.

Developing and maintaining a balanced and healthy life is a critical piece of long-term recovery. This can include things such as exercise, mindfulness meditation, new relationships, eating healthier, or changing thought patterns.

Long-term substance use remission is a great achievement, but it is not a panacea for all our issues. In fact, this stage of the journey involves transitioning to different issues that must be addressed, including developing healthy relationships, integrating our dual identities, dealing with our troubled past, and establishing balanced lives.

Long-term recovery is a great time to review progress and set new goals for personal and professional development. As someone once told me, recovery is like going up a down escalator. You’re either moving forward or moving backward. The key is to keep going!

I would love to hear from those of you with five or more years of recovery. What are you dealing with? What should other folks entering this stage look out for?

Think you know about relapse prevention? Answer “true” or “false” to the following questions:

1. If you stop the use of a mood-altering substance and then begin using again, you have relapsed.
2. Relapse can be avoided with willpower and self-discipline.
3. You have to hit bottom before you can get better.
4. Thinking about relapse will make it happen.
5. There are positive addictions.

The answer to each of these questions is false.

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Myth: If you stop the use of a mood-altering substance and then begin using it again, you have relapsed.

Reality: Relapse is a process with identifiable signs and symptoms that occur over a period of days, weeks, or months, not a matter of hours or minutes. The goal is to identify your signs and to train others to recognize them so they can help you interrupt them.

Relapse also cannot occur until you acknowledge there is a problem and take active steps to correct it. Often a person’s “clean date” and “sobriety date” are different. Many people report they initially stop using because of external pressure from parents, family, the legal system, or health reasons. It is only once you stop using the substance AND make the choice to do something different AND implement appropriate lifestyle changes that you become sober.

* * *

Myth: Relapse can be prevented with willpower and self-discipline.

Reality: Willpower and self-discipline are important parts of recovery, but are only two components. You need knowledge of what is happening to you, especially because the first phase of relapse often is denial. This is significant because if you are pretending there is no problem, willpower will do nothing to change your unhealthy behavior.

You first need to acknowledge the presence of a problem. You need information on what to do when you are in the relapse process, and you need a support system to confront your denial and help you get healthy again.

* * *

Myth: You have to hit bottom before you can get better.

This is why it is so important to have a prevention plan in place, rather than just an emergency action plan. It is easier to prevent a crisis than to resolve one.

Reality: The belief behind the concept of “hitting bottom” is life has to be at its worst possible point before a person will take the steps to get better. The reality is you need to recognize you are experiencing some symptoms before you will seek help. It’s the same as recognizing a symptom like a fever or a sore throat before going to see a doctor.

But too much pain is not healthy. Your goal is to recognize the symptoms of relapse and get help before your situation gets bad again. This is why it is so important to have a prevention plan in place, rather than just an emergency action plan. It is easier to prevent a crisis than to resolve one.

Remember: A relapse isn’t just about using a substance. It is a signal something in your recovery is not working. Going through the relapse process can be a powerful experience of learning what not to do, identifying areas you need to work on, and reinforcing the attention that goes into recovery. The hope is to decrease the frequency, duration, and impact of a relapse.

* * *

Myth: Thinking about relapse will make it happen.

Reality: The opposite is true. If you do not think about the possibility of relapse, you are likely to place yourself in higher-risk situations. Think about why you fasten a seatbelt. When you click it, do you assume you are going to be in an accident? No, you do it to protect yourself, just in case. The same concept applies to paying attention to your environment and the choices you make concerning mood-altering substances. You need to be aware of your thought processes so if a risky situation does come up, you are better prepared to deal with it. If you do not think ahead and practice self-awareness, you can be caught off guard and make an impulsive decision that might not yield the best results.

On the flip side, if you are thinking about using and see only the good things about it, this indicates a problem. While you may have had fun while under the influence, your misuse of substances did become a problem in your life. The hope is when you do reminisce, you will recall the negative things that happened as a result of using. Forbidden thinking is not healthy because it tends to increase your cravings. A realistic weighing of the pros and cons relating to substance use tends to yield better results.

* * *

Myth: There are positive addictions that can be used to deal with negative ones.

Reality: There are no positive addictions. You may believe you can substitute healthier behaviors for negative ones. You may think it is better to smoke cigarettes than marijuana or to attend hours of mutual support meetings instead of spending hours in a bar. However, all addictions are harmful in some way. They usually indicate a loss of control and imply that the substance or behavior has taken over your thoughts and actions. Actions that might normally be considered healthy—such as going to church, exercising, and eating better—can have unintended consequences if taken to extremes.

If you cannot manage life without the behavior, it is a problem. The new, less destructive behavior is often covering up some other preexisting problem that needs to be addressed. The goal for healthy living is balance. Without it, some area of your life is likely to suffer.

For help with an addiction or substance use, contact a qualified counselor in your area.

References:

1. Gorski, T. T., & Miller, M. (1989). Mistaken beliefs about relapse. Independence, MO: Herald House.
2. Larimer, M. E., Marlatt, A. G., & Palmer, R. S. (1999). Relapse prevention: An overview of Marlatt’s cognitive behavioral model. Alcohol Research and Health, 23(2), 151-160.
3. Turner, C. (2017). Can I keep drinking? How you can decide when enough is enough. New York, NY: Morgan James Publishing.

Did you know one of the main predictors for having a substance use disorder is experiencing trauma?

A quick internet search yields many definitions of trauma. I think the simplest definition is this: an emotional response to a terrible event.

Note I did not specify what type of event or what type of response. These are all individualized. What might be traumatic for me could have little or no impact on you. A person experiencing trauma is in the best position to define their experience based on what they are thinking, feeling, and going through.

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In one survey of adolescents receiving treatment for substance use, more than 70% had a history of trauma exposure. Teens who experienced physical or sexual abuse were three times as likely to use substances than those who had not. And 59% of young people with posttraumatic stress (PTSD) develop substance use disorders.

Another study found 60% to 80% of Vietnam veterans seeking PTSD treatment have alcohol use issues. They tend to binge drink in response to memories of trauma. Of further concern, veterans over the age of 65 who have PTSD are at a higher risk of attempting suicide if they also have an alcohol use disorder and/or depression.

People who experience trauma and PTSD often turn to alcohol and other substances to manage the intense flood of emotions and traumatic reminders. They may also use it to try to numb themselves. Drugs and alcohol may initially dull the effects of trauma and help manage associated distress, but a dangerous cycle may begin.

After a traumatic event, a person may drink to deal with anxiety, depression, and irritability. Typically, alcohol initially seems to relieve these symptoms. When we experience a traumatic event, the brain releases endorphins that help numb the physical and emotional pain of the event. This is our body naturally helping us cope.

However, this interrupts the natural protective function the body was already doing. As a result, we create a type of emotional withdrawal that can set us up to deal with increased and prolonged distress that could lead to the development of posttraumatic stress.

Drinking may have been the “solution” you turned to, but it is likely making things worse. We will not take that coping skill away until we teach you new ones.

Drinking often can contribute to PTSD symptoms and increase irritability, depression, and feeling off guard. Some drink to deal with insomnia that results from anxiety, anticipating nightmares, and circular thinking. Drinking actually impairs the quality of your sleep, however, setting up a destructive cycle. Trying to avoid memories of trauma can make them emerge in your sleep. Drinking also can make therapy less effective because you are not allowing yourself to effectively deal with trauma in a safe, healthy setting with a trained professional.

People who use substances may be less able to cope with a traumatic event. They may have increased difficulty with emotional and behavioral regulation. When chemical use starts, development gets significantly impaired. As a result, the person may be more likely to engage in risky behaviors that can lead to additional trauma.

The combination of trauma and drinking can increase challenges related to getting close to people and having conflicts with the people you do have a relationship with. Heavy drinking often leads to a confused and disorderly life. The very thing a person needs is support and connection, yet those are often damaged as a result of drinking consequences and behaviors.

A good therapist knows drinking is generally not THE problem. It is usually a symptom of another problem. Often, the problem is trauma. In such cases, drinking is not generally about having fun. It is about managing the pain of what you are dealing with.

Effective treatment of trauma does not mean you have to talk about what happened. We don’t want you to reexperience it. That probably happens enough. We focus more on how it is affecting you today. Drinking may have been the “solution” you turned to, but it is likely making things worse. We will not take that coping skill away until we teach you new ones. There are many other, more effective ways to deal with the past than drinking.

References:

1. Bombardier, C.H., & Turner, A. (2009). Alcohol and Traumatic Disability. In R. Frank & T. Elliott (Eds.), The Handbook of Rehabilitation Psychology, Second Edition (pp. 241–258). Washington, DC: American Psychological Association Press.
2. Khooury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance Use, Childhood Traumatic Experience, and Post Traumatic Stress Disorder in an Urban Civilian Population. Depression and Anxiety. 27(12): 1077–1086.
3. National Child Traumatic Stress Network. (2008). Understanding Links Between Adolescent Trauma and Substance Abuse: A Toolkit for Providers, Second Edition. United States of America.
4. Trauma and Violence. (2015). Retrieved from https://www.samhsa.gov/trauma-violence
5. Volpicelli, J., Balaraman, G., Hahn, J., Wallace, H., & Bux, D. (1999). The Role of Uncontrollable Trauma in the Development of PTSD and Alcohol Addiction. Alcohol Research and Health, 23(4), 256-262.