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A Moment of Truth

July 1, 2006
by James M. Pedersen
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The Chinese word for “crisis” translates to mean both danger and opportunity. What an excellent description this offers for the situation facing the relapsed client in danger of a downward spiral, as well as the therapist who can help the client seize an opportunity to shape a stronger resolve.

The hours and days following a relapse, while fraught with danger, offer both the client and program staff a unique combination of circumstances to examine the course of treatment and form a more realistic plan. Thorough, timely responses on the part of the therapist and other members of the treatment team are critical in bringing the client back into active recovery.

Professionals should examine several general considerations to help ensure that they first deal with the danger, then carefully help the client move from the depression of a defeat to the insight of new possibilities.

Immediate response

The first meeting with the client post-relapse is critical. If a genuine, trusting therapeutic relationship has formed, most clients actualize this experience as a time to “face the music,” and they are understandably anxious. Most often, the first meeting after relapse can reshape the relationship, setting the tone for future approaches to treatment.

The therapist must pay particular attention to his/her own feelings of anger, frustration, and disappointment stemming from the idea that this blatant noncompliance on the client's part is a personal affront—a rebellious act toward a brilliantly conceived treatment plan. For the nascent, often overinvested therapist, a client's relapse offers a serendipitous opportunity to learn more about countertransference issues.

For the client, the range of responses seems to travel a spectrum with compunctious guilt and suicidal ideation on one end and an almost cavalier, adolescent-like eagerness to “keep the party going” on the other. Whatever the response, careful preparation before the initial postrelapse meeting will prove invaluable.

I learned early in my career that the first postrelapse consideration must involve a good physical assessment, to ensure that the client is able to begin the journey back to recovery. It is not uncommon during relapse for the client to have let good nutrition, sleep, and medication regimens take a back seat for days, even weeks, before presenting in detox or the emergency room. A well-documented exam by qualified medical personnel must be the first consideration. Particular attention should be paid to any information that detox staff or family members can provide about falls, cuts, or other injuries sustained during the episode. Sleep at this stage, even if it is the classic avoidance sleep, is often necessary.

As soon as possible, a brief but thorough legal and financial history should be gathered from family members, law enforcement, etc. The idea here is to get a clear, concise understanding of the client's relapse activities and possible consequences from them. These are the kinds of questions that should be asked:

  • Are there any charges pending?

  • From whom did the client steal, and how much?

  • How will this relapse affect the client's living situation?

  • What revisions are needed in the treatment contract?

  • Is rehab/alternative placement indicated?

  • Should the current medication regime be reassessed?

A clear, factual understanding of the relapse from multiple sources gives the therapist an excellent decision-making tool for recognizing and creating consequences that may be incorporated into the treatment plan.

Perhaps obvious, but often overlooked, is a careful review of the client's relapse history. Before approaching the client the first time after relapse, the therapist should get a good sense of his/her relapse history:

  • Does any theme emerge?

  • Can any new precipitants (triggers) be identified?

  • What established precipitants seemed to resurface?

  • What was the client's behavior and emotional state after other relapses?

  • Is this the first relapse in years? Days? Is the pattern seasonal or otherwise cyclical?

  • Was the previously identified drug of choice used? How much? With what other substances?

  • What approach was used by the therapist(s) before? How well did it work?

Assured of the client's physical health and armed with facts and a working sense of the client's relapse history, the therapist now must guide the client safely back into active recovery.

Fact-based approach

Rather than present an admonishing approach (perhaps eliciting guilt) or a warm, supportive approach (perhaps allowing the client to minimize), the therapist might well consider adopting a straightforward, nonjudgmental, non-emotional approach focusing just on the facts—getting the story from the client sequentially and simply. This is done simply by asking the client to relate what happened “from the beginning.” A neutral, fact-finding approach lets the therapist “compare notes” between the client's version and information gathered in the previously described stage. This helps the therapist detect and eventually address issues of blackouts, denial (a subconscious defensive mechanism), and lying (a volitional act usually involving omission or fabrication).

When the client is required just to stay with the facts, it is difficult if not impossible for the client to try to tell the therapist what he/she wants to hear (emotionally), since there is no feeling cue coming from the therapist. Note the difference in the following two dialogues.

Dialogue #1

Therapist: You seem to be really sad about what happened with Mary.