Relapse, viewed through the lenses of recovery, is framed very differently than it has been in the traditional behavioral health context. In a recovery context, relapse is not seen as a failure that reflects poorly on the person. The person is held accountable, but we also look at system issues that might have contributed to the relapse. This offers an opportunity for the person and the system to partner in reflection, honestly assessing what could have been done to prevent the slippage.
In the recovery context, we all make corrections and commitments to move ahead after a relapse, learning from each other's mistakes. A relapse becomes a learning opportunity for both the person (no longer referred to as a “patient” or “client” in a recovery context) and the system. We ask ourselves, What can we do differently? What can we learn from this relapse that will help us strengthen and improve what we have to offer? How can we improve our results next time?
Focus on the PersonGenerally speaking, in a recovery context most problems are best addressed by looking at them from the person's perspective instead of the system's point of view. Whether the problem is related to a single individual or to an entire system, we look to the people we are serving for guidance. We ask them to describe the solutions they are looking for, and we ask them what we can do to assist them.
This is different from having the people at the top come up with systems and programs, even those based on best-practice guidelines, and put them in place without ever including the voices and concerns of those receiving services. Looking for solutions at the “bottom” takes a great deal of integrity, courage, self-confidence, and maturity because we like to think that we know what's best, and we are used to planning and controlling services for others. In fact, when we aren't operating this way, we even may feel like we are abdicating our responsibilities. But we finally are carrying them out in a way that works best for those we are serving, which in turn gives us better outcomes—a win-win situation!
So when relapse happens, whether it be with someone experiencing mental health issues, substance use issues, or both, the first place to look for guidance is from the person involved. This keeps the ownership of the problem and the solution with the person, and gives him the support he needs to figure out a resolution. We can help by asking, What happened? What can we all learn from the relapse experience? What were the systemic issues that helped or hindered the recovery process? Are we missing something? Do we have big gaps in our approach that are letting people fall out at vulnerable moments? Are we getting in the way of the recovery process by holding onto choices and decisions that really belong to the person?
Don't Lose Momentum
The next most important step in recovering from relapse is to all get back up as soon as we can. Try not to lose the momentum of the successes the person and the system had before the relapse. We all need to hold onto the identity of recovery. The person is a recovering person who had a slip. The system is a recovering system that has an opportunity to learn better approaches.
The last thing any of us needs to do, especially the person trying to recover, is to allow the clutches of shame and guilt to snatch power away. We need all of the power we can muster to restart the recovery process. The person, program, and system need to stay in touch with their strengths and not get caught up in long, disempowering stories about disappointments and failures from the past.
If you aren't used to operating from this perspective, you may find it challenging and humbling at first. But trust us. If you are serious about transformation, this is a necessary part of the process. Operating on this level requires constant vigilance to keep from slipping back into a mode of managing that robs others of their rightful place in the planning and decision-making process. It is a challenging and sometimes difficult commitment to keep.
We were reminded of this recently while meeting with some great folks operating drop-in centers. During our conversation they realized that even they have slipped into operating in a fashion that keeps people from moving along the recovery path, because they are making too many of the decisions and calling the shots for the program, instead of encouraging and insisting that people take the lead. So even those who have received services themselves are tempted to step to the helm and make decisions without involving those who use the services.
Someone we know recently went headlong into relapse. Our first inclination was to step in and fix things—take his rights away so we could make decisions for him without him having the power to resist or interfere with what we thought was the best plan for him. Thank God we caught ourselves before we completely disempowered him and then blamed him for not cooperating.
We stopped meeting without him being present. We started listening to him, and as we went around the table we began to introduce ourselves as John's friends instead of case manager, doctor, advocate, and so on. It changed the way we did our work. John continued to resist our ideas and had a few of his own.
We followed his lead even though we didn't really appreciate the process. It didn't seem efficient. If we could just make him do what we wanted, he'd get better faster, and we wouldn't have to put as much effort into it. We wouldn't have to sit around and listen to him search for words, thoughts, and a direction that felt right to him. We wouldn't have to share in the agony he was experiencing over the things he had to give up to move forward.
Yet what seems efficient at the time usually is not the fastest route to recovery. In fact, in this case, insisting on our “efficiency plans” would have slowed the progress because we would have robbed John of the opportunity he desperately needed to step forward in his own life and take the lead in making plans that appealed to him.
In the nick of time we realized that while it would have helped us to have a plan that inspired us, John was the one who needed to be inspired to gain enough momentum to move ahead. John now is getting much better—faster than some of us thought he would. He did things his way, and we helped. There were holes in his plan that he wasn't able to come to grips with until he fell into them, but when he did he was able to come up with ways to pull himself out, and we helped.
While the process was sometimes painful and frustrating for us to watch, the outcomes were worth it. John developed more confidence in his direction and stuck to the plans he developed. He's back in school, has a good plan for long-term housing, and has been making new friends. He also has stopped using.
Best of all, John gets to own the successes of his good work. He hasn't had to pretend to agree with us just to get our meetings over faster. We haven't had to pretend that he was involved in developing and carrying out the plan because he took the lead. He did good work and in the process taught the rest of us a lot about how to walk the talk.
A Recovery Formula
From our experience with John, we learned more about how to be a good partner. We were able to recover from the brink of relapsing into taking over, managing, and making all the decisions. John pulled out of the relapse. We all got the results we wanted and feel good about the outcomes. Thanks, John!
Here's a recovery formula for handling relapse:
Avoid seeing the relapse as solely the person's problem. See it as a problem to share among all the partners involved.
Be sure to involve the person in decision making. We're talking about person-directed, not just person-centered, decision making and planning.
Agree on what all partners will do to create a solution.
Identify the corrections that the system can make to better serve its constituents.
Try not to be bogged down in the problem—stay focused on a solution.
Avoid looking for someone to blame, or telling long stories about the past that contributed to the problem. Again, stay focused on the solution.
Focus your collective strength and energy on maintaining momentum without giving in to hopelessness, guilt, and shame.
Remember that people in recovery who relapse usually do not start all over again.
Remember that efficiency in the short run often does not translate into effectiveness in the long run.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.