A moment of truth: effective postrelapse treatment requires a factual, nonjudgmental approach.

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.

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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 postrelapse 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.

(Emotional prompting--giving the client an opening to say what he thinks he should say, thereby possibly distorting what the client really is feeling and casting doubt on the client's truthfulness)

Client: Uh, yeah, that's right. I feel really stupid. You know, depressed.

(Thinking--"Is that what you want to hear? Yeah, poor me. I'm so dumb. So now tell me I'm OK! Make me feel better; forgiven.")

Dialogue #2

Therapist: So tell me, what happened after you went back to your apartment the second time?

(Mild command--a call to action; reference to a specific place and a factual, numbered sequence)

Client: The second time. Oh yeah, that's when I called Mary and started swearing at her. I'm still pissed at her, and that's why I started drinking again. That's the reason.

(Reference to "the second time" offers possible evidence of some cognitive recall. As the client begins to recall swearing at Mary, it reignites an anger that is probably more reflective of how he is really feeling. Additionally, the defensive mechanism of projection, as in "that's why I started drinking again," is much more likely to be an accurate picture of the client's pathology of avoidance, drawn out as it was by a focus on current realities.)

In this modality, the therapist must judiciously guide the relapsed client in and out of the facts and emotions in order to get a better diagnostic picture of how the client is really feeling. Not only does the fact-finding interview serve as an information-gathering technique, but it also provides a safe, factual setting for exploring emotional reactions to the facts.

In the initial postrelapse interview, I am guided by the belief that there is no such thing as an unplanned relapse. By careful processing, the therapist can help the client see how he/she moved, often subconsciously, from thinking about using (a normal activity in recovery) to a kind of relapse action plan. A thorough, chronologic review of these events helps both the therapist and the client identify relapse precipitants.

Final considerations

This process requires the therapist to walk a fine line between being supportive and being harsh. A good therapist knows when to be a good actor, by recognizing and utilizing the client's "good guilt" as a motivator to help bring him/her back into active recovery. But if overdone, the client's guilt can lead to a sense of hopelessness, stagnation, and a great excuse to use again. "Pep talks" that minimize the relapse's seriousness can give the client the feeling of being "off the hook" and slow the motivation for active recovery; at worst, this can provide another kind of excuse to use.

If the therapist believes that the client's genuine emotional state is one of hostility directed inward (guilt) and concomitant depression, immediate and careful consideration should be given toward risk of suicide. If the therapist believes the client's range of guilt is more of a natural adaptive reaction to relapse, the therapist should allow the client's guilt to serve as a precursor to insight and problem solving.

Rather than expecting the client to return to working a full-blown version of the prerelapse treatment plan, the therapist might consider an incremental, short-term plan of one to two weeks in duration. This interim plan helps the client actualize small successes by gradually putting back the pieces of his/her life in a more deliberative, less overwhelming way.

Issues that could be covered in this plan may include living situation, medical follow-up, return to work, financial status, legal status, family meetings, identification of "triggers" with an action plan on how to respond to them, and an increase in structure/time management. The idea here is to help create a sense of success for the fragile, relapsed client through a gradual reintroduction into active recovery.

As most seasoned therapists know, relapse is often part of the recovery process. Rather than seeing the relapse as an affirmation of futility, the skilled therapist should have a methodology within his/her skill set that follows a deliberate path toward bringing the client back into active recovery.

James M. Pedersen is a member of NAADAC, The Association of Addiction Professionals, and maintains a private practice in Madison, Wisconsin. He has worked in the addiction field for more than 30 years. To send comments to the author and editors, e-mail [e-mail].

RELATED ARTICLE: A relapse checklist

When a client relapses, the therapist must hold the current treatment plan in abeyance and begin a critical path methodology including, but not limited to, the following factors:

** Admission to emergency room/detox--ensure written medical clearance

** Gather information from significant others, law enforcement, treatment staff, etc.

** Examine relapse history--look for themes, old/new triggers

** Create neutral, fact-finding setting

** Determine client's emotional state (i.e., depression, minimizing, etc.)

** Create short-term treatment plan with built-in, small successes