Elisa A. Escalante/ LCSW/ 1-12-2022
“Telling someone what to do is one of the most counterproductive ways to get results’. -EaE
It’s been a good while since I have written a blog about substance abuse. With a growing number of clients coming to me for either sobriety or harm reduction goals toward their substances, I find it essential to discuss Relapse safety planning. Gone are the days of just telling people ‘Just quit and be sober and happy’. Gone are the days of crossing our fingers and just hoping they will be sober in the blink of an eye. Even in 2008-2014 when I was a mental health receptionist, the substance abuse counselor always reminded us that ‘relapse is inevitable’. So, if relapse is almost always inevitable, why aren’t we talking more about it? It’s quite taboo, and when someone expressed openly that they are on the journey toward ‘sobriety’, though it can result in a lot of optimism and cheers from our peers, it also creates a heavy amount of pressure… to stay sober… forever. And if you can’t stay sober, you may feel shame in that now your peers are counting on you, and you may be less likely to admit your relapses. This is quite dangerous. A mental health provider must remember; never shame a person that is trying to quit, when they admit they relapsed.
Why is relapsing often more dangerous?
If someone has been sober for some time, there’s a few reason’s a relapse could be very dangerous. 1- They are likely experiencing withdrawal symptoms; both psychological and/ or physical. 2- They miss their ‘vice’ a lot, especially in times of distress. 3- Whatever incident or series of incidents that led to the relapse is, it is likely a high stressor, and causing some serious emotional flair ups. When all of this comes to a head, a person that relapses is in a highly vulnerable state. ‘I miss my drug. I’m sick of not having it. Nothing else makes me feel as good. Nothing else calms me down as much. Fuck it.’ Getting back to a drug is heavily anticipated in this case, and the drug was missed. The drug was being craved for some time. The drug will then get used a bit too heavily. The body has done some withdrawal, but the behavior of the person addicted may be that of a binge due to the cravings. A relapse binge could be very harmful. There are celebrities that have died and/ or almost died due to this very thing. When ‘missing something’ meets emotional desperation, the behavior is no longer that of a logical choice. But rather, a compulsive/ emotional one.
Building my Safety plan for a Client:
First things first, 1-What did this drug medicate for you? Stress? Anger? Anxiety? Depression? Fatigue? Boredom? Loneliness? Etc etc. 2- How much of the drug did you need to medicate/ relieve said symptom?
Patient Example: ‘I drink to medicate my anxiety. It takes me roughly 3-4 drinks to calm the anxiety just enough so that I can socialize.’
Notice that I am first asking ‘how much it takes to medicate!’ (As opposed to getting shit faced) If the drug is about medicating (which to some extent, it always is) then we need to be honest with ourselves and know the minimum amount to ‘medicate’ an emotional flair up.
3- How much of the drug typically results in symptoms that are non-beneficial to you and/ or your loved ones?
Patient Example: Well, I have noticed that typically when I have 5 or 6 drinks, I start to forget what I’m doing, and that’s when I usually get into an argument with my spouse or friend. Then if I get to about 7-8 drinks I might throw up or black out.
*The patient is telling me based off their own history, that the effective dose for self-medicating their anxiety while NOT ‘impairing their daily functioning, is roughly 3-4 drinks MAX.
Question 4- Do you remember why you had some days where you drank 5 or more drinks? What led up to it? Triggers? Emotions? Events? And why did you want more? Even after being medicated just enough?
Common Patient Answers: A- ‘It was fun’. B- ‘I did feel it start to wear off, and I wanted more drinks so that I could keep that feeling’. C- ‘People were giving me more, so it was tempting because it was right there.’ D- ‘It wasn’t working the way it used to, I felt I needed more for the same effect’.
Question 5- (Within the Relapse Safety Plan suggestion): So, when or if you do relapse, do you agree to keep it at a 3-4 drink Maximum? Can you do this? You have mentioned you want to quit one day or engage in minimal drinking. But just in case you happen to relapse for whatever reason, I want to make sure you stay safe, safety is the most important thing. If you drink to medicate one day again, that is understandable. I would like to make sure you can, in fact, medicate, while not experiencing some of those consequences you had to deal with in the past.
Confirm & find a plan agreeable & comfortable to the patient: (The patient MUST agree to the plan. If they aren’t comfortable with them, work toward a compromise)
Patients are often very agreeable to their ‘relapse safety plans’. They love the fact that they ‘do not have to feel ashamed’ if they have a relapse. They love that they can tell me about it without fear of ‘reprisal.’ It makes sense to them that there is a certain amount that could help them medicate in emotional turmoil, but also, they know based off a history that ‘too much’ of any drug can result in negative consequences, and that is often NEVER the result they had been looking for. Most patients that have suffered from addiction have stories of regret. Stories that were terrifying, where they took things too far. Some have experienced permanent relationship discord with loved ones as well.
Harm reduction: (When sobriety feels impossible)
If the patient is not ready for attempting sobriety, then harm reduction goals are also very beneficial. Especially when drug withdrawal is harsh. (Alcohol/ Benzos tend to cause severe withdrawal symptoms in particular)
Harm reduction goal examples: I will go from smoking 10 cigarettes a day to 7-8 cigarettes a day for the next several weeks. Or I will practice purging my video game/ social media/ TV time. Instead of using these screens every single day, I will pick one day a week to purge and do other activities. (Even behaviors can be addicting and cause euphoria, not just substances we put in our bodies)
Again, always remember no sobriety or harm reduction plan works if we do not encourage replacement coping strategies! Gone are the days of “just be sober and then you will figure it out and be happy enough”. That’s BS. Lowering a drug or quitting puts people into a heavily vulnerable state. They will become more emotionally charged, they might experience cravings, when they inevitably get stressed, sad, angry, anxious etc again, they will no longer have their drug. They need other hobbies! Preferably, healthier ones. Preferably balanced days with various activities. The “Rat Park” Cage study initiated by Dr. Bruce Alexander (just google it) showed us that rats in an empty, cold and boring cage all by themselves, with heroine, used the heroine all the time to have some stimulation and fun. They would eventually overdose and die. ☹ They were bored/ sad most likely. Then rats in a fun cage with other rats, with an amusement park of activities to do, took the heroine significantly less. It was available to them just the same. They used it minimally, as they had other ways of coping; rides, sex, social time, play etc. This shows our social environment is very important to whether or not we continue to abuse drugs too. Hopefully, we are also around good homes, good people, good work environments, etc.