Counseling a substance abuse patient after a relapse
The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.
Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.
Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.
“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.
Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.
Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.
Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”
Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.
Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.
Dr. Weiss is clinical director of the alcohol and drug treatment program at McLean Hospital, Belmont, Mass., and an associate professor of psychiatry at Harvard Medical School, Boston.