During emotional relapse, individuals are not thinking about using. They remember their last relapse and they don’t want to repeat it. But their emotions and behaviors are setting them up for relapse down the road. Because clients are not consciously thinking about using during this stage, denial is a big part of emotional relapse.

These are some of the signs of emotional relapse [1]:

The common denominator of emotional relapse is poor self-care, in which self-care is broadly defined to include emotional, psychological, and physical care.

One of the main goals of therapy at this stage is to help clients understand what self-care means and why it is important [4]. The need for self-care varies from person to person. A simple reminder of poor self-care is the acronym

HALT: hungry, angry, lonely, and tired.

For some individuals, self-care is as basic as physical self-care, such as sleep, hygiene, and a healthy diet. For most individuals, self-care is about emotional self-care. Clients need to make time for themselves, to be kind to themselves, and to give themselves permission to have fun. These topics usually have to be revisited many times during therapy:

“Are you starting to feel exhausted again? Do you feel that you’re being good yourself? How are you having fun? Are you putting time aside for yourself or are you getting caught up in life?”

Another goal of therapy at this stage is to help clients identify their denial. I find it helpful to encourage clients to compare their current behavior to behavior during past relapses and see if their self-care is worsening or improving.

The transition between emotional and mental relapse is not arbitrary, but the natural consequence of prolonged, poor self-care. When individuals exhibit poor self-care and live in emotional relapse long enough, eventually they start to feel uncomfortable in their own skin. They begin to feel restless, irritable, and discontent. As their tension builds, they start to think about using just to escape.

In mental relapse, there is a war going on inside people’s minds. Part of them wants to use, but part of them mental relapse long enough without the necessary coping skills, clinical experience has shown they are more likely to turn to drugs or alcohol just to escape their turmoil.

Fear is a common negative thinking pattern in addiction [14]. These are some of the categories of fearful thinking:

A basic fear of recovery is that the individual is not capable of recovery. The belief is that recovery requires some special strength or willpower that the individual does not possess. Past relapses are taken as proof that the individual does not have what it takes to recover [9]. Cognitive therapy helps clients see that recovery is based on coping skills and not willpower.

One of the important tasks of therapy is to help individuals redefine fun. Clinical experience has shown that when clients are under stress, they tend to glamorize their past use and think about it longingly. They start to think that recovery is hard work and addiction was fun. They begin to disqualify the positives they have gained through recovery. The cognitive challenge is to acknowledge that recovery is sometimes hard work but addiction is even harder. If addiction were so easy, people wouldn’t want to quit and wouldn’t have to quit.

When individuals continue to refer to their using days as “fun,” they continue to downplay the negative consequences of addiction. Expectancy theory has shown that when people expect to have fun, they usually do, and when they expect that something will not be fun, it usually isn’t [15]. In the early stages of substance abuse, using is mostly a positive experience for those who are emotionally and genetically predisposed. Later, when using turns into a negative experience, they often continue to expect it to be positive. It is common to hear addicts talk about chasing the early highs they had. On the other hand, individuals expect that not using drugs or alcohol will lead to the emotional pain or boredom that they tried to escape. Therefore, on the one hand, individuals expect that using will continue to be fun, and, on the other hand, they expect that not using will be uncomfortable. Cognitive therapy can help address both these misconceptions.

How individuals deal with setbacks plays a major role in recovery. A setback can be any behavior that moves an individual closer to physical relapse. Some examples of setbacks are not setting healthy boundaries, not asking for help, not avoiding high-risk situations, and not practicing self-care. A setback does not have to end in relapse to be worthy of discussion in therapy.

Recovering individuals tend to see setbacks as failures because they are unusually hard on themselves [9]. Setbacks can set up a vicious cycle, in which individuals see setbacks as confirming their negative view of themselves. They feel that they cannot live life on life’s terms. This can lead to more using and a greater sense of failure. Eventually, they stop focusing on the progress they have made and begin to see the road ahead as overwhelming [16].

Setbacks are a normal part of progress. They are not failures. They are caused by insufficient coping skills and/or inadequate planning, which are issues that can be fixed [8]. Clients are encouraged to challenge their thinking by looking at past successes and acknowledging the strengths they bring to recovery [8]. This stops clients from making global statements, such as, “This proves I’m a failure.” When individuals take an all-or-nothing, dichotomous view of recovery, they are more likely to feel overwhelmed and abandon long-term goals in favor of short-term relief. This reaction is termed the Abstinence Violation Effect [8].

More broadly speaking, I believe that recovering individuals need to learn to feel comfortable with being uncomfortable. They often assume that non-addicts don’t have the same problems or experience the same negative emotions. Therefore, they feel it is defensible or necessary to escape their negative feelings. The cognitive challenge is to indicate that negative feelings are not signs of failure, but a normal part of life and opportunities for growth. Helping clients feel comfortable with being uncomfortable can reduce their need to escape into addiction.

It is commonly held that the abstinence stage starts immediately after a person stops using and usually lasts for 1 to 2 years [1]. The main focus of this stage is dealing with cravings and not using. These are some of the tasks of the abstinence stage [2]:

• Accept that you have an addiction • Practice honesty in life • Develop coping skills for dealing with cravings • Become active in self-help groups • Practice self-care and saying no • Understand the stages of relapse • Get rid of friends who are using • Understand the dangers of cross addiction • Deal with post-acute withdrawal • Develop healthy alternatives to using • See yourself as a non-user

There are many risks to recovery at this stage, including physical cravings, poor self-care, wanting to use just one more time, and struggling with whether one has an addiction. Clients are often eager to make big external changes in early recovery, such as changing jobs or ending a relationship. It is generally felt that big changes should be avoided in the first year until individuals have enough perspective to see their role, if any, in these issues and to not focus entirely on others.

The tasks of this stage can be summarized as improved physical and emotional self-care. Clinical experience has shown that recovering individuals are often in a rush to skip past these tasks and get on with what they think are the real issues of recovery. Clients need to be reminded that lack of self-care is what got them here and that continued lack of self-care will lead back to relapse.

Dealing with post-acute withdrawal is one of the tasks of the abstinence stage [1]. Post-acute withdrawal begins shortly after the acute phase of withdrawal and is a common cause of relapse [17]. Unlike acute withdrawal, which has mostly physical symptoms, post-acute withdrawal syndrome (PAWS) has mostly psychological and emotional symptoms. Its symptoms also tend to be similar for most addictions, unlike acute withdrawal, which tends to have specific symptoms for each addiction [1].

These are some of the symptoms of post-acute withdrawal [1,18,19]:

Many of the symptoms of post-acute withdrawal overlap with depression, but post-acute withdrawal symptoms are expected to gradually improve over time [1].

Probably the most important thing to understand about post-acute withdrawal is its prolonged duration, which can last up to 2 years [1,20]. The danger is that the symptoms tend to come and go. It is not unusual to have no symptoms for 1 to 2 weeks, only to get hit again [1]. This is when people are at risk of relapse, when they are unprepared for the protracted nature of post-acute withdrawal. Clinical experience has shown that when clients struggle with post-acute withdrawal, they tend to catastrophize their chances of recovery. They think that they are not making progress. The cognitive challenge is to encourage clients to measure their progress monthto- month rather than day-to-day or week-to-week.

In the second stage of recovery, the main task is to repair the damage caused by addiction [2]. Clinical experience has shown that this stage usually lasts 2 to 3 years. In the abstinence stage of recovery, clients usually feel increasingly better. They are finally taking control of their lives. But in the repair stage of recovery, it is not unusual for individuals to feel worse temporarily. They must confront the damage caused by addiction to their relationships, employment, finances, and self-esteem. They must also overcome the guilt and negative self-labeling that evolved during addiction. Clients sometimes think that they have been so damaged by their addiction that they cannot experience joy, feel confident, or have healthy relationships [9].

These are some of the developmental tasks of the repair stage of recovery [1,2]:

• Use cognitive therapy to overcome negative self-labeling and catastrophizing • Understand that individuals are not their addiction • Repair relationships and make amends when possible • Start to feel comfortable with being uncomfortable • Improve self-care and make it an integral part of recovery • Develop a balanced and healthy lifestyle • Continue to engage in self-help groups • Develop more healthy alternatives to using

Clinical experience has shown that common causes of relapse in this stage are poor self-care and not going to self-help groups.

The growth stage is about developing skills that individuals may have never learned and that predisposed them to addiction [1,2]. The repair stage of recovery was about catching up, and the growth stage is about moving forward. Clinical experience has shown that this stage usually starts 3 to 5 years after individuals have stopped using drugs or alcohol and is a lifetime path. This is also the time to deal with any family of origin issues or any past trauma that may have occurred. These are issues that clients are sometimes eager to get to. But they can be stressful issues, and, if tackled too soon, clients may not have the necessary coping skills to handle them, which may lead to relapse.

These are some of the tasks of the growth stage [1,2]:

• Identify and repair negative thinking and self-destructive patterns • Understand how negative familial patterns have been passed down, which will help individuals let go of resentments and move forward • Challenge fears with cognitive therapy and mindbody relaxation • Set healthy boundaries • Begin to give back and help others • Reevaluate one’s lifestyle periodically and make sure the individual is on track

The tasks of this stage are similar to the tasks that nonaddicts face in everyday life. When non-addicts do not develop healthy life skills, the consequence is that they may be unhappy in life. When recovering individuals do not develop healthy life skills, the consequence is that they also may be unhappy in life, but that can lead to relapse.

Causes of Relapse in Late Stage Recovery

In late stage recovery, individuals are subject to special risks of relapse that are not often seen in the early stages. Clinical experience has shown that the following are some of the causes of relapse in the growth stage of recovery.

The most important rule of recovery is that a person does not achieve recovery by just not using. Recovery involves creating a new life in which it is easier to not use. When individuals do not change their lives, then all the factors that contributed to their addiction will eventually catch up with them.

But clients and families often begin recovery by hoping that they don’t have to change. They often enter treatment saying, “We want our old life back — without the using.” I try to help clients understand that wishing for their old life back is like wishing for relapse. Rather than seeing the need for change as a negative, they are encouraged to see recovery as an opportunity for change. If they make the necessary changes, they can go forward and be happier than they were before. This is the “silver lining” of having an addiction. It forces people to reevaluate their lives and make changes that non-addicts don’t have to make. Recovering individuals are often overwhelmed by the idea of change. As part of their all-or-nothing thinking, they assume that change means they must change everything in their lives. It helps them to know that there is usually only a small percent of their lives that needs to be changed. It can also be assuring to know that most people have the same problems and need to make similar changes.

Addiction requires lying. Addicts must lie about getting their drug, hiding the drug, denying the consequences, and planning their next relapse. Eventually, addicted individuals end up lying to themselves. Clinical experience shows that when clients feel they cannot be completely honest, it is a sign of emotional relapse. It is often said that recovering individuals are as sick as their secrets. One of the challenges of therapy is to help clients practice telling the truth and practice admitting when they have misspoken and quickly correcting it.

How honest should a person be without jeopardizing his or her work or relationships? Clients are encouraged to understand the concept of a recovery circle. This is a group of people that includes family, doctors, counselors, self-help groups, and sponsors. Individuals are encouraged to be completely honest within their recovery circle. As clients feel more comfortable, they may choose to expand the size of their circle.

Probably the most common misinterpretation of complete honesty is when individuals feel they must be honest about what is wrong with other people. Honesty, of course, is self-honesty. I like to tell patients that a simple test of complete honesty is that they should feel “uncomfortably honest” when sharing within their recovery circle. This is especially important in self-help groups in which, after a while, individuals sometimes start to go through the motions of participating.

A common question about honesty is how honest should a person be when dealing with past lies. The general answer is that honesty is always preferable, except where it may harm others [14,21].

Most people start recovery by trying to do it on their own. They want to prove that they have control over their addiction and they are not as unhealthy as people think. Joining a self-help group has been shown to significantly increase the chances of long-term recovery. The combination of a substance abuse program and self-help group is the most effective [22,23].

There are many self-help groups to choose from.

Twelve-step groups include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Marijuana Anonymous (MA), Cocaine Anonymous (CA), Gamblers Anonymous (GA), and Adult Children of Alcoholics (ACA). Every country, every town, and almost every cruise ship has a 12-step meeting. There are other self-help groups, including Women for Sobriety, Secular Organizations for Sobriety, Smart Recovery, and Caduceus groups for health professionals. It has been shown that the way to get the most out of 12-step groups is to attend meetings regularly, have a sponsor, read 12-step materials, and have a goal of abstinence [24,25].

These are some of the generally recognized benefits of active participation in self-help groups:

There is one benefit of self-help groups that deserves special attention. Guilt and shame are common emotions in addiction [26]. They can be obstacles to recovery, because individuals may feel that they have been damaged by their addiction and they don’t deserve recovery or happiness.

Clinical experience has shown that self-help groups help individuals overcome their guilt and shame of addiction by seeing that they are not alone. They feel that recovery is within their reach.

These are some of the reasons clients give for not joining self-help groups:

To understand the importance of self-care, it helps to understand why most people use drugs and alcohol. Most people use to escape, relax, or reward themselves [4]. These are the primary benefits of using. It helps to acknowledge these benefits in therapy so that individuals can understand the importance of self-care and be motivated to find healthy alternatives.

Despite its importance, self-care is one of the most overlooked aspects of recovery. Without it, individuals can go to self-help meetings, have a sponsor, do step work, and still relapse. Self-care is difficult because recovering individuals tend to be hard on themselves [9]. This can present overtly, as individuals who don’t feel they deserve to be good to themselves or who tend to put themselves last, or it can show up covertly as individuals who say they can be good to themselves but who are actually ruthlessly critical of themselves. Self-care is especially difficult for adult children of addicts [27].

A missing piece of the puzzle for many clients is understanding the difference between selfishness and selfcare.

The purpose of this rule is to remind individuals not to resist or sabotage change by insisting that they do recovery their way. A simple test of whether a person is bending the rules is if they look for loopholes in recovery. A warning sign is when clients ask for professional help and consistently ignore the advice.

Broadly speaking, once clients have been in recovery for a while, they can be divided into two categories: nonusers and denied users.

Non-users say that using was fun but acknowledge that it has not been fun lately. They want to start the next chapter of their life. Denied users will not or cannot fully acknowledge the extent of their addiction. They cannot imagine life without using.

Denied users invariably make a secret deal with themselves that at some point they will try using again. Important milestones such as recovery anniversaries are often seen as reasons to use.

Alternatively, once a milestone is reached, individuals feel they have recovered enough that they can determine when and how to use safely. It is remarkable how many people have relapsed this way 5, 10, or 15 years after recovery.

Clients are encouraged to identify whether they are non-users or denied users. A denied user is in chronic mental relapse and at high-risk for future relapse. Clinical experience has shown that everyone in early recovery is a denied user. The goal is to help individuals move from denied users to non-users.