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Counselors process reality of relapse

February 23, 2016
by Gary A. Enos, Editor
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The threat of patient relapse never disappears from the psyche of the counseling professional, but its presence doesn't automatically destroy the spirit. Several of the respondents to Addiction Professional's Quality of Life Survey convey an outlook of celebrating victories while preparing for setbacks in the treatment of this complex disease, though some didn't arrive at that attitude easily.
“Early on, I had not practiced up very well on countertransference,” says J.C. Shiver, who works on the counseling staff at the Cumberland Heights residential program in Nashville, Tenn. “I would certainly be worried about people who I felt hadn't had their teeth fully sunk in recovery. Now what I feel is best to leave them with is acceptance and letting them know that there is no shame in coming back.”
The online survey, conducted last October and receiving 550 overall responses (see the Fall 2015 issue of Addiction Professional), asked two questions about clinicians' observations of patient relapse. Responses clearly pointed to the critical nature of the first year post-treatment, although maintaining one year in recovery certainly doesn't guarantee longer-term success either.
Asked to estimate what percentage of individuals treated in their community will relapse in less than a year, based on their observations, nearly six in 10 respondents gave an answer somewhere in the 50% to 70% range. Fewer than one in 10 cited a figure of 20% or lower.

The numbers were somewhat more encouraging on the question of how many treated individuals relapse after a year of sobriety. Only about three in 10 respondents cited a percentage of 50% or higher, with 30% and 40% being the general range cited most by respondents.

Anna Wheelock, a counselor in North Central Health Care's outpatient substance use treatment services in Antigo, Wis., received her first lesson in odds as a patient herself, when a therapist flatly told her and fellow clients in a group, “One out of seven of you will make it.” Her thought at the time: “That one is gonna be me.”
This February marks 29 years in recovery for Wheelock, now 67. Seeing someone in early recovery turn the corner now gets her through the week, she says, particularly at a time when she has been coping with loss and serious illness in her family life. She sees a lack of support as an obvious stumbling block to long-term recovery for many.
“You need people to understand you so you don't feel different,” Wheelock says. “You need hope.”

Supporting the Steps

Wheelock and many of her colleagues believe that the ongoing support so critical to patient wellness should include 12-Step involvement. They may not see the Steps as the only path (although some acknowledge they once did), but they find the messages in the Steps consistently relevant—even as advances in neuroscience and therapeutic interventions bring new perspective to treatment and recovery.
A total of 415 respondents offered their personal perspective on the 12 Steps, with more than half calling it a key element at all levels of care. Another one-third said the Steps are best employed in continuing care, as distinguished from primary treatment.

Mary Hales, a private-practice clinician who has worked in the Charlotte, N.C., area, says she uses the Steps as much as possible in therapy. But this doesn't occur in isolation from other education for patients.
“I'm a big 'neuro' person too,” Hales says. “I'm trying to get them to understand what's happening in their brain. But then I add, 'Now you need to be able to put something else back in there to foster positive emotions.'”
Wheelock says she uses much of what she learned in 12-Step groups as part of her therapeutic work. Old aphorisms such as “turning it over and letting go” hold important meaning on the recovery journey, and actually much of that resembles what is employed in cognitive-behavioral therapy, she says.
The 12 Steps were instrumental in Shiver's recovery and remain at the core of Cumberland Heights' programming. Shiver's employer makes it clear to prospective patients that “if you have trouble with the Steps, this is not a place for you,” he says.
Shiver adds, “There was probably a time when I would have said, 'If it's not AA, it's not going to work.'” That is not his mindset today, but he does state, “So far I have not seen any evidence that something works better.”

Obstacles not insurmountable

Overall, the responses to the Quality of Life Survey conveyed a group challenged but not daunted by barriers such as heavy caseloads, compromised support systems, and societal stigma. Hales bristles at an offhand comment she has heard more than once from friends.
“They say, 'I would never be a counselor—you never see anybody make it,'” Hales says. “That's a fallacy. In the long term, I see that once [patients] 'get it,' they're gone. And I've worked with people who have gotten it.” 


There's no doubt that "relapse" occurs more often than we, as professionals, would like to see. However, if we accept that addiction is a lifespan chronic disease it's likely to have periods of being stable and unstable, pretty much the same as any other chronic disease, it becomes more understandable (not necessarily more acceptable).
We also know from studies of patients who have followed to a five year treatment plan (e.g. physicians, pilots, and others) that long term abstinence is achievable.
My experience is that patients leaving the residential level of care are often provided with a discharge plan that they do not follow. Knowing this, the responsibility for jointly creating discharge plans that patients will follow falls on us.