EXPLORATION OF PRACTITIONERS PERCEPTIONS OF RELAPSE:
AN EXPLORATORY STUDY
Jennifer Elise Coots
B.S.W., California State University Sacramento, 2004
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
EXPLORATION OF PRACTITIONERS PERCEPTIONS OF RELAPSE:
AN EXPLORATORY STUDY
A Project
by
Jennifer Coots
Approved by:
__________________________________, Committee Chair
Andrew Bein, PhD
____________________________
Date
ii
Student: Jennifer Elise Coots
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the Project.
__________________________, Graduate Coordinator
Teiahsha Bankhead, PhD, LCSW
Division of Social Work
iii
________________
Date
Abstract
of
EXPLORATION OF PRACTITIONERS PERCEPTIONS OF RELAPSE:
AN EXPLORATORY STUDY
by
Jennifer Elise Coots
This was an exploratory qualitative study of practitioners’ perceptions of relapse. The
data collected was through voluntary individual interviews of eleven practitioners. The
data was coded and overall themes emerged. The interviewees’ basic definition of
recovery was “getting clean.” They discussed relapse as often, but not always, part of
recovery. Opinions of 12-Step programs varied from viewing it as treatment, a tool, or
support. Humiliation as a form of treatment was frowned upon.
Humiliation was
equated with shame and guilt and interviewees discussed its unintended consequences
and how humiliation may potentially act as a motivator or a barrier to recovery.
Furthermore, based upon the level of credential, there was a perceived difference
regarding how personally or professionally questions were answered.
______________________, Committee Chair
Andrew Bein, PhD
_______________________
Date
iv
ACKNOWLEDGMENTS
I am profoundly thankful to everyone in my network of support. Each and every
one of you has made attaining my goal a reality. Through words and actions, both my
Mom and my Grandma Z have taught me how anything is possible if you put your heart
and your mind to it. Without the two of you, none of this would have been possible.
Ryan, you have been an inspiration to me since the day you were born. Thank you for
your incredibly loving nature and in being amazingly accepting and supportive of the
time I had to give in pursuing this degree. To my Aunt Val and Uncle Jon, thank you for
believing in me.
I am so grateful for the support and encouragement that my friends have given
me. You never let me lose focus of my goal, even if it meant daily reminders. I could
not have done this without you!
To my many coworkers who also encouraged and supported me on this journey, I
thank you. I want to give special thanks to Charles Kidwell and Steve Nassirian. The
two of you made it possible for me to continue working and supporting my family while I
pursued my educational goals. Your simple acts of kindness have greatly affected the
future of my life. The gratitude I have cannot fully be put into words, thank you.
v
TABLE OF CONTENTS
Page
Acknowledgments..........................................................................................................v
Chapter
1. THE PROBLEM ......................................................................................................1
Introduction ....................................................................................................... 1
Problem Background ........................................................................................ 2
Statement of the Research Problem ...................................................................3
Purpose of the Study ......................................................................................... 3
Theoretical Framework ......................................................................................4
Definition of Terms............................................................................................5
Justification ........................................................................................................5
Limitations .........................................................................................................6
2. REVIEW OF THE LITERATURE ........................................................................ 7
Introduction ....................................................................................................... 7
U.S. History with Substance Use .......................................................................7
Addiction..........................................................................................................10
Factors of Use ..................................................................................................11
Treatment .........................................................................................................13
Alcoholics Anonymous ................................................................................... 17
Spirituality........................................................................................................20
Factors of Relapse ............................................................................................21
Summary ..........................................................................................................24
3. METHODOLOGY ............................................................................................... 26
Study Questions ...............................................................................................26
Study Design ....................................................................................................26
Study Population and Sampling Procedures ....................................................27
Data Collection Techniques .............................................................................27
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Confidentiality .................................................................................................27
Data Analysis ...................................................................................................28
Protection of Human Subjects .........................................................................28
4. FINDINGS ............................................................................................................ 29
Introduction ......................................................................................................29
Demographics ..................................................................................................29
Recovery ..........................................................................................................30
Practitioners’ View or Understand of Relapse.................................................31
Concerns and Beliefs about 12-Step Programs ................................................32
Humiliation ......................................................................................................39
Differences Amongst the Interviewees ............................................................46
5. CONCLUSIONS AND RECOMMENDATIONS ................................................48
Appendix A. Interview Questions............................................................................. 52
Appendix B. Consent Form ...................................................................................... 55
References ................................................................................................................... 57
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1
Chapter 1
THE PROBLEM
Introduction
It is a common understanding in the alcohol and other drug (AOD) community
that most people relapse along their recovery path, but relapse does not neatly fit in with
the abstinence only model that dictates the majority of treatment throughout our nation.
The discrepancy that arises between the conceptual model and the reality of recovery’s
curvy path may leave the addict in a place of marginalization. They are not yet a
functioning part of the recovering community, but if the desire is there to abstain, they
are not necessarily a part of the drug-defined community any longer either. Under the
umbrella of abstinence, an act of relapse becomes viewed as a failure rather than a
stepping-stone along the path of recovery. This view sets an addicted person up for
further marginalization as this failure further compounds all other challenges and failings
that they may have experienced throughout their life.
It is a given that every person makes that initial choice to use a substance, but as
Inaba and Cohen (2007) discuss, “addiction is a dysfunction of the mind caused by actual
biochemical changes in the central nervous system” (p. 449). They further discuss how
this causes an arrested development that can be halted, but not necessarily undone. The
chemical changes that result no longer make discontinuance of use as simple as a choice
because addicted persons bodies have actually come to rely on the use of the additional
substance in order to function. When we understand addiction in this way, we can begin
to recognize that it actually becomes a process, not just a decision, for the addict to
2
discontinue use, so the conventional model of abstinence only becomes a difficult goal to
attain.
Problem Background
It is the belief of this researcher that relapse is a common part of the recovery
process. However, it is often looked upon as a failure instead of a step in the progression
of recovery. This particular study will be exploring practitioner’s views on relapse and
its role in recovery. The intention is to increase awareness and knowledge through a
professional’s lens, so the stage can be set for further research into the abstinence only
model that currently dominates the recovery field.
In order to understand the concepts of substance abuse treatment and relapse,
there must first be at least a general understanding of prevalent views that shaped the
ideas around alcohol and drugs. American ideologies have teetered between treatment,
criminalization or a combination of the two. Within the arena of treatment, there are
many variations, from harm-reduction to abstinence only models. All of which have pros
and cons depending on the practitioner and client relationship.
Criminalization rather than treatment is a much more expensive path. Inaba and
Cohen (2007) estimate incarceration to be $20,000-$30,000 opposed to the long-term
residential treatment at $6,800-$15,000. If we take the low estimates of both options, it is
almost three times more expensive to continue to criminalize and incarcerate rather than
treat. Not to mention, if relapse was not an automatic failure of a program, but an
opportunity to reengage, substance abusers would have a better chance at becoming a
contributor rather than a drain in society.
3
Criminalization further bolsters the prison industry; however, the burdens on our
criminal justice system and the negative impacts on the families involved are
immeasurable. Incarceration perpetuates a negative cycle as children of addicts grow up
maladapted without tools for change, which are also difficult to ascertain. Adjusting the
abstinence only model of recovery in treatment programs by supporting rather than
penalizing a relapsing individual who wishes to continue with treatment may enhance
recovery outcomes. Reengaging individuals offers them assurance and support as they
transition from a social liability to a productive, contributing member.
Statement of the Research Problem
This researcher is specifically interested in the areas of relapse and recovery.
Prevention is an important key, but those who have become addicted are at risk of
harming themselves and others and place an enormous financial burden on society as a
whole. Furthermore, it is this author’s belief that those who relapse on their path of
recovery are at a higher risk of continued use and abuse as this set back becomes viewed
as another failure. Understanding the practitioners’ perceptions of relapse and its role in
recovery may contribute to understanding current substance abuse treatment.
Purpose of the Study
This researcher is looking to understand the practices and viewpoints of current
practitioners in the AOD field. Subsequently, information and ideas gained from
professionals working in this area may shed light to alternate forms of practices that may
be more effective than the abstinence only model. When successes are increased and
more individuals are able to sustain their recovery, the multi-level negative effects that
4
result from addiction are minimized. Some of these include a reduction on the burden
that is placed on the criminal justice, welfare and healthcare systems.
Theoretical Framework
The social constructionist perspective will be guiding this research. As a social
worker, it is important to understand the area of interest as it is known to those who live
and/or work in it. When it comes to researching relapse and recovery through the
professional’s perspective, it is important to have a general understanding so guiding
questions can be asked, but ultimately for the interviewees to have their own voice.
The social constructionist perspective, as discussed by Blundo and Greene (2008)
allows a worker to learn about a client through their words and experiences as they relate
them to us, so we can clarify, or breakdown, with them the meanings of what they are
saying. In the interview process of this research, the “worker” is the
researcher/interviewer and the “client” is the interviewee. This approach allows the
researcher to take a not-knowing attitude and ask questions out of natural curiosity. Each
professional will have their unique view, language and meanings around relapse and
recovery. It is up to the researcher to understand and extract overall themes through
analysis of the conversations.
Within the themes that emerge, there may be great variance and this perspective
acknowledges that there are no universal truths. Utilizing this style will thus promote
discussion around these subjective understandings.
5
Definition of Terms
Below is a list of key terms that are used throughout this paper.
Abstinence: Is a voluntary act where a person chooses not to consume any alcohol or
other drug.
Dependence: When referring to alcohol and other drugs, dependence indicates a person’s
need to consume a substance in order to function regardless of the effects or outcomes of
such use.
Recovery: A general term that implies a process by which there will be a return to
normalcy or at least to a prior state of being. For the intents of this paper, it is used to
describe a person or group of people who are not using substances that alter their state of
mind.
Relapse: Is a term used to indicate that a person who is/was in recovery has used a mindaltering substance. However, it does not quantify an amount or duration of use.
Justification
When any population is marginalized, it should be an area of concern for social
workers. Individuals who abuse substances and those who are in recovery do receive
services, and there has been a great deal of research in these areas. However, it is the
group of individuals that relapse in their recovery that this research will be focusing on;
specifically, on the perceptions of the practitioners on relapse and its role in recovery.
Understanding the professionals’ perception of relapse in the recovery process
illuminates areas that need to be further researched and areas that may be considered as
best practices. By being open to alternative viewpoints, this research may be enhancing
6
to the Social Work profession by expanding the knowledge base of current
methodologies. Knowledge can be power and the knowledge gained may identify areas
of needed advocacy and reform in the current policies and procedures.
Limitations
This researcher is targeting the professional’s perspective on the role of relapse in
recovery. The client’s view is not being solicited. Additionally, the sample size is small,
which does not allow generalizations to be inferred.
7
Chapter 2
REVIEW OF THE LITERATURE
Introduction
When looking into the concept of relapse, it is imperative to have a general
understanding of addiction, treatment, and factors of relapse. This literature review will
be arranged around these three main themes and will include subtopics containing factors
of use, Alcoholics Anonymous, and spirituality. After reading about each topic, there
will be a better understanding in which to appreciate the study’s findings.
U.S. History with Substance Use
The sculpting of our current ideologies regarding substance use and abuse was not
straightforward; in fact, there have been many modifications with both attitudes and
legislation. According to Inaba and Cohen (2007), “between 1870 and 1915, one-half to
two-thirds of the U.S. budget came from the liquor tax” (p. 20). Not only was this a
moneymaker for the country, but it also implied at least a general acceptance of alcohol
consumption. However, public displays were not as tolerated; Johnson (2006)
highlighted this point, “drunkenness was viewed as a serious problem, often punishable
by putting a man in stocks for such an offense” (p. 3). The discrepant ideas highlighted
here illustrate the shift that was taking place; an emphasis in moderation was
transforming into the championing of abstinence.
By 1920, the Eighteenth Amendment had been put into effect and Prohibition was
the law of the land. Addictions were seen as immoral, a notion that held strong religious
connotations. Prohibition did not bring to an end to the consumption of alcohol, but as
8
discussed by Inaba and Cohen (2007), it did reduce “alcohol-related diseases,” “public
drunkenness,” and “domestic violence” (p. 21). When the Eighteenth Amendment was
abolished, drinking again began to rise, but another shift in attitudes was coming about.
Van Wormer and Davis (2008) portrayed the emerging viewpoint that “alcoholics were
sick, not sinful” and stated, “there was increased medical awareness of health problems
associated with alcohol misuse,” which brought about “institutions specializing in the
treatment of addiction” (p. 64).
In 1960, E. M. Jellinek wrote a book called The Disease Concept of Alcoholism,
which delineated five separate types. Van Wormer and Davis (2008) discuss the position
that Jellinek became known for which is, “the Gamma variety, which viewed alcoholism
as primary, chronic, progressive, and if untreated, fatal.” This belief has ultimately
shaped the way most substance abuse treatment is conceptualized.
Beginning as far back as 1909 legislation for and about other drugs had also been
established. Anderson (2009) highlighted some of the laws, which began by pinpointing
individual substances, such as the Opium Exclusion Act and the Marijuana Tax Act, then
moved to criminalization with the Boggs Act and later proceeded into the treatment arena
with Community Mental Health Centers Act. The domain of treatment went through a
few legislative changes before entering the War on Drugs, or the Anti Drug Abuse Act of
1986, which brought it back to criminalization. The Personal Responsibility and Work
Reauthorization Act of 1996, better known as welfare reform, instituted restrictions that
directly affected families. Currently, the laws have begun to cycle around to pinpointing
specific drugs as in the Ecstasy Anti-Proliferation Act of 2000. Legislation has cropped
9
up to deal with various drugs and teetering ideologies. Van Wormer and Davis (2008)
pointedly describe how various ideologies led to a rise in both treatment and prisons and
both were moneymakers in their own times.
With the varying ideologies and legislation that surrounds substance use, abuse
and treatment, what happens to the families? As mentioned earlier, prohibition brought
about a reduction in domestic violence. However, it was not until much later that the
private issue of domestic violence became a public concern. There is currently
information that shows how addiction can have profound effects on families, especially
children. SAMHSA (2006) reported that almost one million children are residing with a
parent who needs substance abuse treatment. SAMHSA (2006) also noted that abuse and
neglect occurs at least three times as often to children of substance abusing parents.
These staggering amounts have profound effects beyond the immediate family.
Actually, there is a large cost to society that goes along with substance abuse.
The National Institute on Drug Abuse ([NIDA], 2006) reports that “The economic cost to
society from alcohol and drug abuse was an estimated $246 billion in 1992” (section 1.1).
These costs breakdown into different areas including healthcare, criminal justice and
welfare systems. This cost burden is met largely through higher insurance premiums and
taxes. Although most taxpayers do not want to believe their hard-earned money is
supporting someone abusing substances, in one way or another it is.
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Addiction
The concept of addiction is not new, but it has transformed over the years. In the
early twentieth century, use of alcohol was acceptable as long as public displays of
intoxication did not occur. In this time, moderation was the guiding principle. However,
as the times changed, moderation evolved into abstinence and use/addiction became
correlated with immorality. Immorality and religiosity were intertwined and those who
misused substances became viewed as sinful. After a while, another transformation
transpired and out of it came the notion that addiction was an illness. Once a view of
illness arose, the people inflicted had to be treated. These varying concepts correlate with
how individuals are handled, which teetered between treatment and criminalization.
E. M. Jellinek with his disease concept ultimately shaped most substance abuse
treatment philosophy as “abstinence only.” Over the years, the handling of addicted
persons has wavered between treatment and criminalization or some combination of the
two. Unfortunately with criminalization, there was a high rate of individuals who would
continuously cycle in and out of the criminal justice system since they did not receive
proper and/or adequate treatment. Treatment was often narrowly defined and many could
not prescribe to the abstinence only ideal or to a spiritual component within treatment.
Addiction does not just affect the person who is addicted, but all who are involved
and society as a whole. This point is illuminated by both NIDA (2008) and SAMHSA
(2006) when it comes to parenting. Substance abusers’ likelihood of inflicting child
abuse is increased and addicts create an environment that lend to a predisposition of
second-generation substance use. The area of child abuse, alone, alludes to the greater
11
societal economic impact of substance abuse as child protective services and the criminal
justice system may get involved. If the children are removed from the home, a form of
public assistance may be used to support them. Additionally, the parent(s) may need to
access medical, mental health or treatment services from their healthcare plans, which
may be private or government funded.
When use of a substance continues despite the negative results, this is an indicator
that substance use has become dependence or an addiction. It can be a slippery slope
when individuals are experimenting in substances since there is no specific gauge as to
when each person may cross the line into addiction. Initially use is a choice, but
consuming substances has unique effects on each person at different rates. For some
addiction may occur at first use, where for others addiction it may progress over time.
According to West (2001) and NIDA (2008), there are multiple variables that may
influence the use of substances, but the progression into addiction occurs once an
individual’s ability to make a sound decision is compromised. This may in fact
perpetuate the lack of control over oneself when seeking the initial pleasurable effects of
the substance despite the destructive repercussions.
Factors of Use
The idea of social influences was discussed by Simons-Morton (2007) where he
looked at adolescents, their peers and substance use and discussed how the selection of
friends is generally based on similar interest and the socialization between friends tends
to normalize behaviors. Substance use is often found to be higher amongst friends who
also use. Based on the results of the study, we can see that there are correlations between
12
peer use of alcohol and drugs and personal substance use of an adolescent. In looking at
how these correlations emerge, it was noted that “theoretical explanations have been
offered, including social cognitive, socialization, and social network theory” (p. 681). It
is thought that friends are chosen based on similar ideologies and/or friends are sought
out based on particular interests. Although this study focused on adolescents, a person’s
social networks are a main component that must be worked on in recovery, no matter
what the age of the addict.
Newcomb and Earleywine (1996) do not discount the social factor, but look at
what may encourage substance use and/or abuse, because, as they note, the person who is
indulging in the substance is a “willing host” to the positive or negative repercussions
that manifest. They also indicate that contributing intrapersonal factors may be identified
and possibly prevented under a biopsychosocial framework. Looking at interpersonal
factors in isolation can be a limited observation without the consideration outside
influences, but nonetheless, should not be disregarded. Unfortunately, the interplay of
these factors is not effectively expressed (Newcomb and Earleywine, 1996).
One such intrapersonal factor that needs to be assessed is mental health disorders,
which may not be identifiable until an individual has discontinued use and can be
properly evaluated. There is a correlation between substance use and mental illness, but
not necessarily a clear causal correlation. Sometimes mental health disorders run in
families and although substance use may not cause a mental health disorder to occur, it
may trigger the materialization of it. Also, a person may be living with a mental health
affliction and have not yet been diagnosed, but know that when they take a substance it
13
alleviates symptoms. Alternatively, individuals may not be properly taking their
medication for their known mental health disorders. No matter which way it is looked at,
people’s substance use may in fact be an effort at self-medicating. When both mental
health and substance abuse are presenting problems, individuals are often referred to as
dual-diagnosed. However, treatment of one and not the other, or treatment without cross
consultation may leave an individual more susceptible to relapse since the whole picture
is not being worked on at the same time.
Hofman, Richey, Kashdan, and McKnight (2009) draw attention to dual diagnosis
in relation to anxiety disorders and externalizing problems and found that although both
are known to correlate with substance abuse; those who experience both were less likely
than those who experience one or the other to use substances. This furthers the idea that
an inclusive assessment needs to take place in order to better understand and assist
individuals in a comprehensive manner. It also supports the notion that having a mental
health disorder does not necessarily correlate to substance use even if they are
compounded.
As mentioned above, when we look at the whole picture under a biopsychosocial
framework, we need to consider the whole person, not just a specific aspect. In doing
this, we also cannot focus on a precise time period, but through a lifetime.
Treatment
McIntosh and McKeganey (2001) discuss what motivates individuals to
discontinue use in their article “Identity and Recovery from Dependent Drug Use: The
Addict's Perspective.” They note that there are two factors for successfully ceasing drug
14
use, which include, “(1) a motivation to stop which is based upon a desire to restore a
spoiled identity and (2) a sense of a future that is potentially different from the present”
(Conclusions section. para. 1). They acknowledge that the personal accounts they are
basing this information on may not be applicable to all drug users.
Recovery is a general term that implies a process by which there will be a return
to normalcy or at least to a prior state of being. Considering the factors that may have
brought someone to initiate substance use and perpetuate this use into abuse, there is
usually a need for additional work besides just obtaining sobriety. In the article, “What is
Recovery? A working definition from the Betty Ford Institute,” their Consensus Panel
(2007) created a starting basis for understanding this process as it relates to substance
abuse. It states, “Recovery from substance dependence is a voluntary maintained
lifestyle characterized by sobriety, personal health and citizenship” (p. 222). This
working definition does not prescribe a treatment, but acknowledges that the process is
more than simply abstaining from a substance and includes the concept of positive social
networks.
There are different types of treatment which are necessary since there can be no
one answer to all issues that humans experience. Additionally, treating an individual
with addiction often needs to focus on many aspects of their lives, including but not
limited to medical and/or mental health issues, family, employment and legal concerns.
Some of these concerns may be intertwined and difficult to separate from each other.
15
Regardless of whether the addicts’ motivation to enter treatment was a choice or
mandated, treatment can be effective. However, there may be more initial resistance
when working with a mandated person. Resistance may prompt a therapist to spend a
little more time eliciting motivation for treatment. Joe, Simpson, and Broome (1998)
agree that motivation plays a role in treatment both initially and afterward. One such way
to do this is through motivational interviewing, which NIDA (2008) describes as a quick
way to stimulate an individual’s driving force.
Detoxification is another piece of the treatment puzzle, which is generally timelimited, three to five days, and a stepping stone into the recovery process. Historically,
under the idea of criminalization individuals who were under the influence generally
suffered through withdrawals at the jails. This withdrawal period is where many side
effects can manifest and may result in death if not properly handled. Conversely, when
ideas shifted towards the disease concept, medical interventions assisted in this process
and as more advances were made, pharmacological assistance has also eased the ill
effects of withdrawal symptoms. As important as this step is, it is not enough to merely
rid the body of substances for recovery to occur. However, detoxification is often a
requirement for admittance to in-patient treatment services.
In-patient treatment may be short or long-term, lasting anywhere from one day to
a couple of years, with an average of about twenty-eight days. These programs are
supervised and often incorporate a range of services to treat individuals in a holistic
manner. They often start out more restrictive and lessen as the skills of recovery begin to
be mastered. There is often a stipulation of abstinence in these facilities. This is not only
16
being promoted for the well-being of the individual, but also the others that reside in the
same facility. Treatment often occurs in a group setting. Group work offers
opportunities to learn from others, fosters a family-type environment, and creates
learning of newly acquired skills in a safe environment. In some settings, individuals
also receive case management, pharmacotherapy, individual therapy, and are encouraged
and/or mandated to participate in a 12-Step program and obtain a sponsor. The vision of
12-Step affiliations is to have a tool to continue the therapeutic care once the individual
has graduated the program. This tool will be discussed further.
Out-patient services are many and varied. They range from day treatment, where
individuals attend a structured program but continue to reside at home, to intensive outpatient, which includes a prescribed number of hours that is less than day treatment, but
is similar in services. Within these, and sometimes on their own, are services that include
group therapy, individual therapy, pharmacotherapy, and 12-Step program.
There are also different types of practices that are utilized including faith based
interventions, motivational interviewing, cognitive behavioral therapy, aversion therapy,
rational recovery, harm reduction models, educational groups, peer-run groups, self-help
groups, etc. One main theme that is common throughout most practices is relapse
prevention (Van Wormer and Davis, 2008; Inaba and Cohen, 2007).
With all the variations available, it is important to try to appropriately match an
individual with the right treatment. This practice not only assists with meeting an
individual’s needs, but also with retention rates. In–patient treatment can be difficult to
access since the need is greater than the availability. Whatever services are available, the
17
interaction between the therapist or primary service provider and client is extremely
important. Knight, Broome, Simpson, and Flynn (2008) discuss both the internal and
external factors that play a role in the effectiveness of treatment with key items including
caseload proportions, clients, and coaching and preservation of staff.
Alcoholics Anonymous
For many, recovery is synonymous with Alcoholics Anonymous (AA), or other
12-Step programs, all of which utilize the same manual for recovery, the Big Book. This
is but one tool, but many other programs recommend it as part of an overall recovery
program. It has become a worldwide program that has well over one hundred thousand
groups. Although there is no fee and the only requirement for AA and similar groups is a
desire to quit, success is measured in days of abstinence. These days are announced and
rewarded at what is called birthday meetings. These celebratory meetings can be
supportive and encouraging for those who are able to maintain sobriety; however, for
someone who relapses this practice may contribute to a sense of failure not only
personally, but also publically if they return and announce their lower number of days of
abstinence.
Overall, this program is embraced worldwide and its effectiveness, either
scientific or through compelling anecdotes, is discussed by many including Vaillant
(2005) and Inaba and Cohen (2007). It is such a celebrated intervention that at minimum,
its guiding principles have been integrated into many programs. Given that not all
treatment is for everyone, there is uncertainty around this program as well. Some
question its effectiveness and others describe it to being cult-like. The program’s
18
spirituality may be a barrier for some individuals.
Some of the key elements to recovery are also tied in with preventing relapse and
are noted by Inaba and Cohen (2007) to include accessibility, accountability, and a
holistic approach. These are woven into the make-up of AA along with the essential
component of relapse prevention. As mentioned above AA is worldwide, so no matter
where someone is, it is accessible. Working through the steps provides personal
accountability, but allows for a sense of release for that which is out of a person’s control.
There is also accountability to others by announcing length of abstinence to the group,
making amends, and working with others on their personal recovery. When individuals
first start AA, they are encouraged to work with a sponsor and build relationships with
others who are in the program. This aspect starts building positive social networks with
others who have been through similar experiences. It also allows for opportunities of
social development and interaction as individuals learn how to live substance free. The
program may not be designed to address all facets of a person’s life, but it has a focus
that transcends simply becoming abstinent. It addresses recovery, spirituality, giving
back and fosters relapse prevention through social networks, self-care, and
conscientiousness (AA, 2010).
Below are the twelve steps that AA and all anonymous programs are guided by:
1. We admitted we were powerless over alcohol—that our lives had become
unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we
19
understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of
our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends
to them all.
9. Made direct amends to such people wherever possible, except when to do so
would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly
admitted it.
11. Sought through prayer and meditation to improve our conscious contact with
God, as we understood Him, praying only for knowledge of His will for us and
the power to carry that out.
12. Having had a spiritual awakening as the result of these Steps, we tried to carry
this message to alcoholics, and to practice these principles in all our affairs.
(Alcoholics Anonymous, p. 59).
A main theme throughout the steps is the relationship with God. There is not a
need to subscribe to a particular religion, but is encouraged to come to their own
understanding through the steps. The emphasis on God or a “higher power” is also the
component that many struggle with.
20
Spirituality
In the area of addiction and recovery, spirituality is a concept that is used loosely.
Cook (2004) found that there was no specific definition of spirituality in the addiction
field. However, professionals who work within this field continue to view spirituality as
a potentially positive aspect for recovering individuals.
Those who have a higher sense of spirituality seem to stay in recovery longer than
those who do not. An individual’s exact definition of spirituality does not have to be
clarified, just that they have an increased sense of spirituality. It also seems that
inclusion of this facet in the recovery process reduces the likelihood of relapse and
increases the maintainability of abstinence (Jarusiewicz, 2000; Tonigan 2007).
Generally when people talk about going into recovery, the first thing that comes
to mind is AA, or one of the various 12-Step derivative groups, all of which are
spiritually based. The spirituality of AA and NA often brings up strong feelings, whether
positive or negative. Since there is a positive correlation between spirituality and
continued recovery, this is an aspect that should be addressed between doctors and their
patients so they can point them in the right direction for out-patient services (Zylstra,
2006). With all the personal questions that physicians ask in order to appropriately
diagnose, spiritually should also be taken in to account as part of a holistic approach for
appropriate referrals. Brown, Whitney, Schneider and Vega (2006) point out that there
are three main types of out-patient treatment that include nonreligious, spiritual and
religious based and each is suitable for some, but not all.
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Factors of Relapse
There is no specific trigger that sets a person in recovery to relapse. There are
however, some significant general areas that need to be addressed that commonly trigger
individuals to relapse, which include treatment length, social context, and intrapersonal
capacities. Additionally, Moos, Moos, and Timko (2006) along with Grella, Scott, Foss,
and Dennis (2008) have argued that gender may play a role. Specifically, men may
relapse more often than women.
It has been shown that the longer an individual is in treatment, the better the
outcome (Moos, Moos, and Timko, 2006). This is not looking at which treatment works
the best, i.e. in-patient, out-patient, or self-help, but rather the duration of the chosen
treatment. This finding is similar with detoxification. While individuals are in treatment,
it is likely to give them time to adjust to their new life in recovery, which includes the
social context and interpersonal capacities (Moos, Moos, and Timko, 2006).
There are several pieces to the social context that may have an impact on a
person’s life, including social networks, isolation, boredom, social wherewithal, and
friends. As discussed earlier, people tend to gravitate to others who have similar
interests. Often times individuals who are misusing substances are involved with others
who are doing the same. Their friendships and activities may be wrapped up in this drug
culture that effectively creates a complicated lifestyle in which to break away from. It
becomes very important for the person in treatment to include people in their social circle
who are also in recovery (Matto, Miller, and Spera, 2007).
22
LePage and Garcia-Rea (2008) and Corvinelli (2005) maintain that boredom is
another factor that enhances the probability of relapse. Boredom is basically a lack of
excitement. When a person goes from a lifestyle that was consumed with obtaining and
misusing substances to one of recovery, it is an immense adjustment that may bring forth
boredom. There is a need to have activities to alleviate this boredom that are supportive
of recovery.
Social isolation is another factor that may stimulate relapse and is interconnected
with friendships and social networks, especially for women. For both sexes, recovery
efforts are enhanced if not done in seclusion. Socialization may be of particular
importance to women since they tend to relate through bonding with other women in
similar situations and take advantage of each other’s experiences (Moos, Moos, and
Timko, 2006; LePage and Garcia-Rea, 2008).
As supportive friendships are formed and positive social networks expand,
isolation becomes mitigated and stability through recovery enhances stable social
wherewithal. This does not imply that an individual’s social status necessarily changes,
but that they learn how to access and employ the resources that are available to them
(Moos, Moos, and Timko, 2006).
Another substantial factor of relapse is that of intrapersonal capacities. Specific
capacities vary greatly from person to person, but a key area that seems to help in
preventing relapse is coping mechanisms, which may include beliefs, conflicts, and
boredom. The development of coping skills is lacking in many people and in particular
those who misuse substances. When a situation arises that induces tension or worry and
23
individuals do not perceive themselves as adequately prepared to handle the situation, the
tendency is to turn to that which is comforting or takes the stress away. When an
individual’s coping mechanisms are enhanced, he/she is better able to handle a situation
confidently, or at least minimize the self-doubt, and utilize positive resources rather than
substances (LePage and Garcia-Rea, 2008; Moos, Moos, and Timko, 2006; and Grella,
Scott, Foss, and Dennis, 2008).
Matto, Miller and Spera (2007) stress the notion that an individual’s beliefs play a
crucial role in their recovery. They believe that it is fundamental for recovering
substance misusers to acknowledge and accept their recovery so that they can envision a
better way of life. This concept is furthered through weakening the way of thinking that
drugs and/or alcohol will bring good to their lives and enhancing the positive results of
this new way of life. By building on the successes, an individual’s self-worth is
enhanced (Matto, Miller and Spera, 2007).
Many people who reach the point of needing recovery have often wronged others
and burned bridges. However, as individuals begin to shift their beliefs and enhance their
coping mechanisms, they are better prepared to moderate conflict. Conflict management
is seen as another area that when improved, can actually reduce the likelihood of
relapsing (Moos, Moos, and Timko, 2006).
Ultimately, clients need to find satisfaction in daily activities (Corvinelli, 2005).
This is noteworthy, as it is within the mundane that boredom tends to develop, which
may conjure up triggers that result in relapse. If people are taught how to redefine
monotony and utilize their social resources and coping skills, relapsing may be prevented.
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Summary
Both political and personal views towards substance use and misuse have
undergone various changes throughout the years. Along with that, the treatment of those
who misuse has also fluctuated. The effects of substance abuse are societal, not just
individual.
There are many factors that increase the probability of initiating use and once
someone starts there is no predicting a timeframe regarding progress toward addiction.
Biologically, an individual who misuses substances may have chemically altered their
being and thus cannot easily make and then follow through with the decision to
discontinue use. They may experience withdrawals as their body no longer receives the
substance that it has become addicted to. Understanding the diffuse effects that addiction
has on individual’s lives is important when exploring treatment options. Amongst others,
Vaillant (2005) and Hubbard, Simpson, and Woody (2009) agree that better outcomes
arise from longer treatment.
Recovery is not something that people achieve and then move on, it is generally
worked on across a lifetime, so realistic goals in a supportive atmosphere is
indispensable. Thus, a holistic approach is imperative so addicted persons can create a
balance that affords an opportunity to continually generate a lifestyle that is conducive to
their goals.
Part of the recovery process is to diminish the effect of potential triggers through
relapse prevention. There are many areas that need to be taken into consideration
including treatment length, social context, and intrapersonal capacities.
25
Social networks can be both positive and negative, since human beings tend to be
around others who share similar interest. When an individual is misusing substances,
their network of people is generally comprised of those who are also misusing. Once
someone enters recovery, it is crucial to build and enhance supportive social networks.
These help with issues directly and indirectly related to recovery.
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Chapter 3
METHODOLOGY
Study Questions
The guiding research questions will be addressed through the narratives of the
professionals being interviewed and are as follows:
1. What views on relapse and recovery do practitioners share?
2. How do practitioners view the connection between relapse and recovery?
In this particular study, there are no clearly identifiable independent or dependent
variables.
Study Design
This is an exploratory study on the practitioner’s view on relapse in the recovery
process. Their views will be ascertained through direct interviewing and the data will be
qualitative in nature. The participants to be interviewed will be selected through
convenience and snowball sampling.
Although the primary design is exploratory, there may be a bit of descriptive
research as well. As mentioned by Kreuger and Neumann (2006), these two designs are
alike and may “blur together in practice” (p. 22). Specifically, in looking to understand
the practitioner’s views on the connection between relapse and recovery, there may be a
description of conflicting models that are used throughout the recovery field (e.g.,
abstinence only versus harm-reduction).
27
Study Population and Sampling Procedures
The study population will be professionals in the field of alcohol and drugs. At
least one local agency will be contacted with a request for authorization to interview their
practitioners. Once this is obtained, a request for volunteers to participate in this study
will be done according to agency procedure. It is up to any practitioner interested to
voluntarily contact this researcher. When contact has been made, the content of the
informed consent will be covered, which also states that participation is voluntary. The
informed consent must be agreed to and signed before the interview process transpires.
The sample of participants will be obtained through snowball and nonprobability
convenience sampling, since it is the content that is of concern. The sample size will be
limited to, at least ten practitioners. It is understandable that this small size will not allow
for generalization, but will highlight specific themes that may be studied further.
Data Collection Techniques
This researcher will be doing direct interviewing at a location of the participants
choosing. The design of the interview is to start with broad questions and end with a few
demographic ones. The initial questions are to be conversation provoking, meaning
semi-structured interviews with open-ended questions. The demographics will be asked
at the end instead of the beginning so the interview does not develop through short
answer questions. Interviews will be taped for credibility, with participant approval.
Confidentiality
This researcher will maintain confidentiality to the extent possible. In order to
protect confidentiality, all information collected from for this project will be kept in a
28
locked cabinet that can only be accessed by this researcher. Whether the interview is
tape-recorded and transcribed later or notes are taken during the interview, it will be
identified by a number rather than by name. Consent forms will be kept separately from
the interview and transcription or notes from the interview and will not be linked to the
information provided. This researcher will transcribe all tape-recordings. No individual
identifiable information will be used in any reports in this research project. All data will
be destroyed no later than July 2010.
Data Analysis
The content will be analyzed and coded and this researcher will look for emerging
themes. Potential themes will first be identified in this researchers debriefing meeting
with her project advisor. It is under the themes and umbrella ideas that the significance
of this research will materialize.
Protection of Human Subjects
The Protection of Human Subjects application was submitted to California State
University, Sacramento the Division of Social Work. The Committee for the Protection
of Human Subjects from the Division of Social Work approved the application for this
study as minimal risk on December 11, 2009. The human subjects approval number is
09-10-073.
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Chapter 4
FINDINGS
Introduction
The results of this study offer insights into a variety of areas within the alcohol
and other drug (AOD) field. This researcher will first discuss the demographics of the
interviewees. Next, the practitioner’s concept of recovery will be discussed to set the
foundation for the emerging themes. There were four significant themes that arose
including the practitioners’ view or understanding of relapse; concerns and beliefs about
12-Step programs; humiliation; and differences amongst the interviewees.
Demographics
This section represents the results of interviews with eleven different practitioners
in the AOD field. The interviewees consisted of three males and eight females. Their
diversity in terms of credentials vary from one CADC; one masters in counseling, CADC
II; three marriage and family counseling (MFT); one master of science counseling, MFT
intern third year; one masters in social work (MSW) first year intern; one MSW second
year intern; one MSW; one MSW, licensed clinical social worker (LCSW); one MSW,
LCSW, Substance Abuse Prevention (SAP). Their duration of experience in this arena
also varies from seven months to thirty-eight years. Additionally, the age of the
interviewees according to a range is two 30-39, two 40-49, six 50-59, and one 60-69.
30
Recovery
In the simplest terms recovery meant “getting clean” to all eleven interviewees. A
couple emphasized that there needed to be a period of complete abstinence in order to
clear the mind and make rational decisions about whether or not it would be appropriate
to have some alcoholic beverages if those were not the abused substance. This notion
was discussed through the concept of harm-reduction. Four of them specifically
discussed that recovery meant abstinence only with one stating that it is the “pristine
goal.” One of these four believes that abstinence only does not apply to all clients and
when discussing long-term alcoholics stated, “it’s primarily harm-reduction because
abstinence only is both physically and mentally impossible for them.”
Four of the interviewees discussed a “complete change of lifestyle,” equating
recovery to a “new birth,” and a “rediscovery and reconnectedness” to the prior or new
self. One of the interviewees, who is also in recovery, stated that recovery is “a feeling of
peace and happiness in life. Being able to work, pay your bills…umm...a lot more to do
with everything other than not using.” This concept resonated with a few other
interviewees including the notion that recovery does not just pertain to alcohol and drugs
and incorporates “increasing awareness.” One of them summed up this perspective of
recovery stating that it is “a lifelong process whereby a person improves their overall
function and across many life domains by eliminating behaviors and habits that
undermine their own goals, not only in substance abuse, but other things too.”
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Practitioners’ View or Understanding of Relapse
All eleven interviewees discussed relapse as a part of recovery, but stated that it
did not have to be a part of everybody’s recovery. One practitioner was very adamant
with her feelings on this topic explaining:
I despise the term that relapse is a part of recovery. Many addicts will use
it to justify what you call chipping, occasional use. I absolutely despise
that term. I think if they are going to say anything with that, what they
need to say is that relapse can be a part of recovery, not that it is. With the
way they [addicts] already distort reality anyways and their denial systems
when you give them something like that that they can distort into their
belief. It’s supposed to be used to take away the guilt if a relapse or slip
occurs, but addicts will distort it to justify using. Is, is an absolute; it can
be (on the other hand), it’s (relapse) not an is.
A contrary belief held by another practitioner is that:
Relapse is part of recovery. Relapse happens way before a person picks
up the pipe again or starts to smoke again or so forth. They can get into
relapse mode before they start using again. In the program it says be aware
of your people, places and things. And if they start getting to cocky, if
they stop going to meetings, if they go back to old ways they’re in
relapse…it’s just their state of mind. Stinkin thinkin, we call it, they’re
going back to the negative thought process.
32
Even with these discrepant terminology beliefs, there was still an understanding that
relapse occurs. The terminology highlights a reference point of where relapse begins and
thus a difficulty in obtaining a consensus on the definition. One practitioner even stated,
“That’s a pretty controversial issue.” There are also variances of the term relapse,
including “chipping,” “oopsies,” “slips,” “blip,” and “learning experiences.”
Some of the practitioners interviewed discussed relapse as a “fine edge” where the
client either does not return or as an opportunity, or “learning experience.” One
discussed relapse in an alternative view, “The ones that don’t relapse are the ones that
scare me after a while because of the rigidity. This is a wonderful opportunity because
they are telling you right then and there what needs to be worked on.” Most talked about
relapse in terms of an opportunity to work on triggers so it does not occur again. The
overall sense from the interviewees was that with honesty on the part of the client in
combination with a willingness to move forward, relapse could be “a step forward.”
Concerns and Beliefs About 12-Step Programs
When it comes to 12-Step programs, views and opinions vary greatly.
Nonetheless, there was a consensus that 12-Step programs work for some people. One
interviewee said, “When one changes one’s life and they change their place in life,
there’s a transitional phase that can be very, very lonely and AA and NA and those 12
Step programs help fill that gap while you’re changing your place in life.” A few of the
interviewees noted that not all programs are for all people, so people should try out a few
before they decide if 12-Step programs are right for them or not. Furthermore, once
people begin attending meetings, they need to understand that just showing up is not
33
necessarily going to make them clean and sober. As one practitioner stated, “What
people fail to realize is that the individual is only going to get out of Alcoholics
Anonymous…or narcotics anonymous; you are only going to get out of them what you
put in.” Conversely, another commented on the professional structure stating, “It’s
ridiculous the unprofessionalism that can happen there and there’s no checks and balance
with that.” Specifically, three interviewees said it was treatment, one said it was a tool
and the rest; either directly or indirectly, said it was support.
The majority of interviewees believed that 12-Step programs are a “Great support
system, not treatment.” That said there were many variances. Even for some that do not
see 12-Step Programs as treatment, they understand that it is all that is available to some.
This point was discussed by one, “I think because of budget constraints, it’s becoming
more of a treatment, but I see huge issues with that.” The issues that many referred to
centered on the 12-Step lack of professional capabilities.
One practitioner explained, “12-Steps aren’t treatment, they’re support. They’ve
never been meant to be treatment. In the twelve by twelve it even says it’s not treatment,
its addicts helping addicts for support, so it should never be used as treatment.” An
important point made was about the availability of support through those relationships.
When professionals go home for the evenings, weekends, or holidays, they are not
available; “So it’s a good support they can have around the clock that they are not going
to get from a business.”
Another common thread was that even if the practitioners felt as though 12-Steps
were helpful to some degree, they are not for everyone. Unfortunately, some programs
34
mandate a specified number of 12-Step meetings per week. One practitioner stated, “I
see it as an adjunct to treatment, a support and that millions of people have been helped
for many, many years by 12-Step and other self-help programs and I think it can be very
reinforcing.”
A few concerns that were mentioned include, “I’ve had problems with 12-Step
people trying to run my clients out of treatment because they felt they just needed 12Steps,” and “12-Steps are nothing but people reiterating their problems.” It was also
mentioned that, “I think that for most people I don’t think it’s a complete treatment
program because they really haven’t worked on their issues, they’ve been clean and sober
and they’ve worked the steps, but there’s still other issues that need to be worked out and
sometimes don’t get worked out.” Even though the concerns varied, the general thought
was that it was beneficial to have a professional to come back to.
One of the interviewees was very neutral when elaborating on the support versus
treatment concept and as mentioned earlier stated, “you are only going to get out of them
what you put in.” “The treatment success rate is going to be the same as is individual
therapy. If the individual is willing to work on the issue, and does the work on the issue,
the therapy will be successful, the same thing with 12 Step programs.”
There are many different 12-Step meetings and each has an individual style. As
mentioned earlier, this leads many practitioners to recommend trying out multiple
meetings before making a decision about them. Several interviewees also commented
about who seemed to benefit the most from 12-Step meeting work. Some of the
35
determining factors of success were stated to include personal characteristics, gender, and
spirituality.
Clients who have anxiety issues were said to have different responses depending
on their anxiety. One practitioner explained how having a fear of groups prevented some
from going to 12-Step meetings. As a result, those clients will meet individually to work
through their anxiety with the goal of attending groups later on. Another practitioner
explained the following:
The clients who have a history of being institutionalized, whether it be in
residential facilities as kids or anything like that, they need more of the
structured steps; they need things to be a little bit more black and white
because they don’t trust themselves in those areas of gray that they’re
going to be able to make those better choices. So people who tend to have
a lot of anxiety do really well in a 12-Step program because it is very clear
what it is that you are supposed to be doing to your path of recovery.
Sometimes when you are able to give your power over to somebody else
and realize that it is not yours, that’s almost relieving to people who have
anxiety. I think that the 12 Step programs work really well.
Gender also came up as a factor related to 12-Step success. It was not implied that
all women have issues with 12-Step programs, but some do for a mixture of reasons, and
this dynamic is a concern if their sobriety becomes at risk. Some of the concerns raised
included, “…if it’s mostly men, women are probably not going to relate as well,” and
“women tend to feel very alienated in those kind of settings because of the gender roles
36
that have been socially constructed in our culture. Men feel they have more of a right to
sort of dominate a conversation.” Additionally, “…women tend to be more nurturers.
It’s important that they don’t get distracted from taking care of themselves and it’s very
easy for that to happen in co-ed groups.” It was not suggested that women not partake in
12-Step programs, but that they find ones that they feel comfortable with and to be aware
of the options available including all women’s meetings. “People who are new to
recovery in general are not really good at setting boundaries and things like that, so until
that is a strength for them I encourage them to be protective of their space.”
The topic of spirituality raises many concerns vis-à-vis 12-Step programs. Five of
the interviewees discussed the “higher power” as being both positive and negative for
clients. Some indicated that the “higher power…doesn’t necessarily mean GOD… if you
want to chose the door knob can be you’re higher power. And I’ve seen people get upset
because GOD is not a door knob.” Some people prefer to rely more on their church or
religion, where others are “offended by the references to GOD or higher power.” Still
others “have no belief in GOD at all or higher power and have a little trouble with it. But
if they stick around long enough, they can understand the spirituality portion of it.”
For some it is not about a belief in GOD or higher power, but a deeper feeling of
distrust. As explained by one practitioner:
The other problem is folks that grew up with long term trauma in the home
and did a lot of praying to GOD to make the beatings stop and the
molestation stop and it never stopped and now to tell them to release it to a
higher power, they have too many anger issues with higher power/GOD
37
images to ask them to do that. So for certain populations, I am reluctant to
send them to 12 Steps.
Spirituality was also discussed in general with one interviewee stating, “Getting
reengaged in our spirituality will help people from relapsing. Using is really seeking
spirituality, but they try to back door it and it doesn’t work. You got to go through a
process to achieve spirituality.” Another mentioned how important it is “because there
are some things in life that there’s just no rhyme or reason for… and you can pick apart
and you can dwell on and it can wreck your day real quick, but having a faith in
something else just having a faith in something else, helps.”
Many people present many issues and not all people fit neatly into the traditional
12-Step meetings and out of that, adaptations have arisen. As one practitioner discussed:
I also like that we have a lot of 12 Step programs that are specifically
based for whatever chemical. We’ve got Cocaine Anonymous, Marijuana
Anonymous, Methadone Anonymous because when sometimes when a
client is on methadone and they go to NA, they’re told that they’re not
clean and sober and some of our clients need methadone.
Twelve-Step programs are encouraged for support to recovery, “Plus it can give
people a new community to relate to that is very vital for them, especially when they’ve
had to give up some old associations that weren’t too healthy for them.” As one
interviewee put it, “…12-Steps is not only the meeting, it’s also the social. A lot of
clients do not know how to have fun clean and sober.” By attending meetings, and
working the program, 12-Step programs assist in creating the space that used to be filled
38
with substance preoccupation, use and/or abuse. Twelve-Step meetings “…help get
people thinking, they reduce isolation, they get people together that have a common
denominator.” As an interviewee and former substance abuser, this point was illustrated
when she said, “we need to feel loved and cared about and I got that there. People loved
me there because I was an alcoholic. I was the same, I fit in, I found a place where I
could feel wanted and needed.”
It is also a handy resource, as one practitioner stated, “you can do this ten years
from now if you have a bad day and a lot of other things like that. And you know ten
years from now you probably aren’t going to call me up.” Even though 12-Steps
meetings are viewed as supportive and offer avenues for participants to learn how to
socialize while in sobriety, not all feel as though it is necessarily needed for the client’s
entire life, “The whole idea is to outgrow it. A wonderful place to go back and revisit,
maybe, but no, the process is to get beyond that.”
The addiction to 12-Step meetings was only brought up by one practitioner, but it
was nonetheless noteworthy. People go to 12-Step programs to gain support and or
treatment in hopes of maintaining sobriety from their addiction(s). Considering the
support that is gained and the lifestyle that is created, one noted that 12-Step programs
also have “a down side… it can become a religion and another addiction.”
As mentioned above, not all meetings are for all people, even if ultimately people
are all working on substance abuse issues. “It’s funny because in the United States we
have such a binary way of thinking and we have so much of an us or them kind of
attitude that I have heard people say in AA meetings, ‘We don’t want those druggies in
39
here’ and it’s kind of like, wait a minute. And I’m sure it’s vice versa, I haven’t heard it,
but I’m sure it is.” That concept reverberated in a few other interviews. Another
practitioner explained: “I’ve had them [12-Step people] stand over and watch my clients
and make them flush their psychotropics when they were bi-polar or schizophrenic and
these were indigent people that can’t out of their pocket pay for them to be replaced, that
means they go without.” Taking psychotropic’s and or being on methadone is not viewed
by all as being clean and sober, even if these are managing other issues under a doctor’s
care. Dual Recovery Anonymous (DRA) is one of the 12-Step programs specifically
created for people who do not fit within the traditional paradigm. One practitioner stated,
“I like the idea that we have DRA now. In the past if a person with a mental health issue
went to a 12-Step meeting, they were told that they aren’t clean and sober because they’re
taking psychotropic medications, so I think that it’s really important that we have DRA.”
Humiliation
When this researcher posed a question about humiliation, the responses were
interesting; ten of the eleven interviewees answered the question as though the inquiry
was about whether it should be used by a therapist as a form of treatment. This was not
the intent of the question, so after they initially answered, a follow up question was posed
with the focus on the unintended role of humiliation for the client.
Every person interviewed acknowledged humiliation in some form on behalf of
the client, explaining both positive and negative elements. There was a consensus that
“Shame, guilt and humiliation, are all kind of woven together” and clients put themselves
40
through it, so no contribution is needed from a professional. One noted that it “is a part
of relapse.”
Four of the eleven practitioners described how humiliation can work as a
motivator to get into treatment or return to treatment. This can be illuminated by one
comment, “It’s a huge role on why people may want to recover, because they’re
embarrassed, because they’re sick and tired, because their kids are going to see them
throw up, because they’re going to lose their job…” There may be many factors that
cause the humiliation, but that personal feeling is what is being described as the catalyst.
Another noted, “If there is no humiliation on their part of the person…they’re not that
one step closer where they need to be.”
A few others described it as not just a motivator, but also a state of being that can
be viewed and or utilized as a stepping-stone; “Okay yes, you do have these feelings and
these feelings are real, but from that you gotta look at what occurred in your life and how
you can rise above those feelings.” Another furthered this point when stating:
I think that like any unwanted feeling or mental state when people feel
humiliated that they’ve failed or haven’t met their goal, that can be a
wakeup call, but I don’t think it’s healthy to stay there or dwell in it or
punctuate it for people. You really have to go the other direction of okay
now you need to get up again rather than wallow and feel terrible and feel
ashamed of yourself. I think some shame helps people realize how
vulnerable they are and in that sense it’s useful.
41
Four other practitioners described humiliation as a barrier on a macro, mezzo, and
micro level. On a macro level, humiliation was discussed systemically:
I think that clients do feel humiliated in the system. In whatever system
we are working in, most of our clients are lower income. There’s a lot of
humiliation associated with assistance of any sort that comes from the
government and it’s created to be sort of like a negative system, so people
don’t want to go and abuse it, but at the same time it creates a catch
twenty two where people who really do need assistance or some sort of
help, they don’t want to pursue it. So I think clients that have AOD issues,
they create their own scenarios where they feel degraded and humiliated in
their personal life and then to go and reach out for help in the county or
the state systems is also humiliating and degrading. So I think it’s a huge
part of what’s wrong with our system.
Once a client is in a system of treatment, whether it is government or not, there
are still concerns as to whether or not a client will return if they have relapsed. When
looking specifically at 12-Step meetings, participants celebrate their recovery based on
days of sobriety and at specific “birthday” meetings. These “birthday” meetings are
supportive and encouraging of sobriety for those that maintain it, but a concern was
expressed about the humiliation of an individual that relapses and returns to the
practitioner for encouragement to return to meetings:
They can feel humiliated, especially during the 12 steps if they had a lot of
time clean, to go back. Especially if they were considered one of the
42
grandfathers and now they’ve relapsed it can be very, very humiliating for
them to go back and helping them build back up their self-confidence to
be able to return.
This concern was echoed in a general statement about any treatment, “I think if
they are too humiliated they won’t come back.”
At a very personal level, one interviewee explained humiliation as a
justification and stemming from a place of familiarity and comfort:
I think humiliation is the basis of why they try to justify their relapse.
They see themselves as failures, as losers, they messed up and you have to
consider where is the addiction coming from, what part has humiliation
played in the start of the addiction in the first place? It certainly takes
them back to a place where they are comfortable.
When the interviewees understood the question as humiliation by the practitioner,
there was an across the board answer of no humiliation is not a desirable consequence of
relapse. There were variations in the explanation, but all can be summed up with the
words of one:
I don’t think it’s okay for any clinician to use humiliation with a client
because they are going to walk in the door already feeling humiliated and
the guilt and the shame. It’s important for us to create a space for them to
be okay sharing any of that stuff that comes up for them. And just give
them a safe place that they are not going to feel judged and that the
43
emotions are going to pass and are only temporary and really kind of walk
through some of those feelings that they are walking in there dealing with.
Even though all the interviewees agreed with this train of thought, some discussed
how humiliation is or was used as a form of treatment, but often likened it to an
“old school” perspective.
Two of the interviewees called this “old school” perspective confrontation therapy
and they talked about this being used back in the 1970’s-80’s. When explaining, one
practitioner stated, “Confrontation therapy is partially about humiliation. It would work
with a select group of clients, but I would not advocate its use for the general
population.” The other discussed how she was trained under confrontational therapy and
worked in a “treatment program run by addicts who were ex-cons and everybody shaved
their head, they sat on the bench, they were put on the hot seat and yelled at and so forth.”
Another interviewee explained confrontation therapy as, “kind of like the military,
where you break them down and build them back up.” This orientation may have benefit
with select individuals: “I’ve seen it work, I’ve seen it work with really hard core vets,
long-term military people who are used to that being part of their lifestyle.” This same
practitioner also explained how “it tends to have reverse consequences if the basis for
your alcoholism is that you’ve been humiliated as a child.”
Another practitioner explained how humiliation is used by some through shame
and guilt, but how it may not be intentional:
A lot of counselors use humiliation; you know shaking their finger at
them. That comes from a lack of understanding from your own process,
44
your own issues. If you don’t take care of your own issues, you put it on
your clients. A lot of counter transference I see in our offices and a lack
of understanding. So we need to work on ourselves so we don’t shame
our clients when they do mess up, that way we don’t take it on; I messed
up that’s why you messed up. If I had been a better counselor, maybe you
wouldn’t relapse. We need to understand that it’s not about us, that’s why
counselors do shame. Maybe they have family members that they have
personal experience with drugs and alcohol. We got to deal with
ourselves. So we need to know ourselves before we can help our clients.
We don’t shame ourselves; we don’t shame our clients.
As mentioned above, the overwhelming response to humiliating a client was that
there is no place. One practitioner stated, “I don’t believe in humiliation in any kind of
situation. I think it devalues the person, I think it takes away their power. If they are
devalued and have no power, why on earth would they think that they could ever
overcome drug use.” All interviewees were asked about how they reengage with
individuals that relapse and, for those that work with clients that test positive for
substances, what they thought that process was like for the clients.
For the most part, practitioners had similar responses about reengagement stating,
“it’s an opportunity;” “I really talk about the benefits of relapse;” “don’t make it a big
deal;” “with support and kind of a positive outlook;” and “I let them know from day one
that no matter what happens, give me a call and we’re gonna work through it.”
Additional comments included not being judgmental, and understanding what was going
45
on with the clients. These approaches were in-line with some of the modalities of
treatments that were utilized and discussed by the practitioners, including motivational
and client centered.
When talking about dirty tests, relapsing and reengagement, there were some
different answers. Most were similar to the following:
Well, I think that there’s a lot of power struggles around this issue, it’s like
I know that you tested dirty…you did…you used. I don’t think that that
kind of approach, that in your face confrontation necessarily works. So
what I like to do when I work with clients is preemptive. If I create a
scenario where they can talk about relapse, then they’re not going to deny
it. Maybe I have a client that has obviously relapsed or is using, maybe
not talk about this specific instance but talk about, well what’s been going
on? What’s been happening? Where are they at? And trying to see
what’s going on from that perspective. So I feel like immediate
confrontation of an issue isn’t necessarily going to get you anywhere, but
if you let the person talk about their story, they’re eventually going to at
least identify things that you can talk about. Maybe they won’t say that
they relapsed, but they’ll talk about being in a place where there were
drugs being used around them and that can be a starting point of a
conversation. Well, what were you doing in that place? Who was there
that you needed to see? Let’s bring it back to a support network that we
talked about you developing. Do you feel like you are being supported?
46
What’s happening? What are your triggers? That’s a more productive
conversation than confronting someone about a dirty test. I know that
there is a place for that in the system, but as far as my work with clients, I
don’t feel like that’s very productive because we can argue all day whether
or not they used; obviously they did, but how’s that actually going to
benefit anyone? Getting them to a place where they want to talk to you is
the important place because then that’s when you can start moving
forward with a plan, what happens next?
Conversely, some of the interviewees talked about “you only find out if in fact
they’ve tested dirty and then you have to kind of confront them.” This was even after
explaining how humiliation has no place. Another said, “if they weren’t admitting to it,
I’d just be able to hand them a piece of paper that would be kind of simple.” The
interconnected shame, guilt and humiliation may not be intended modalities of practice,
but a side effect in the way services are delivered. This author is not making an
assumption, but noting a discrepancy of intention versus unintentional consequences.
Differences Amongst Interviewees
One interesting theme that emerged was the difference in how questions were
answered. The interviewee that has a CADC spoke from personal experiences. For
example, “It worked for me,” “I know I felt…,” “I mean, for me…” “I have to put my
recovery…,” everything was explained through an I statement. Additionally, this
interviewee explained, “I always try to ALWAYS, always, I use my personal experience.
I think that it helps to be able to say I was in this situation and this is what I did.” The
47
first year MSW intern related examples to personal situations through a family member,
but not as often as the CADAC individual. This interviewee was still very unsure of how
to respond to some questions and had difficulty expressing beliefs about recovery models
(i.e. abstinence only versus harm-reduction).
As far as the MFT’s, only one related a personal thought stating, “But I do think
that from a personal perspective, which is important for counter-transference, it’s hard for
me to see how people can sustain their recovery without some type of higher power in
their life.” This was an illustrating point about watching counter-transference, not
specifically relating a personal story. One of the LCSW’s discussed counter-transference
as well, but in an aspect of a general situation, not personally revealing; “A lot of
counselors use humiliation, you know shaking their finger at them. That comes from a
lack of understanding from your own process, your own issues. If you don’t take care of
your own issues, you put it on your clients.”
48
Chapter 5
CONCLUSIONS AND RECOMMENDATIONS
This study was done to explore the ways that relapse is viewed as a part of the
recovery process. The particular focus of the study was to view treatment provider
perceptions within the context of abstinence only modalities. The practitioners
interviewed came from non-residential settings and had varied credentials and length of
time working in this field. Their insights shed light on the areas of relapse and recovery,
along with some unexpected themes.
What emerged from the interviews was supportive of the information written
about in the literature review. Addiction to substances was seen as a way of life rather
than as a choice: “People become addicts because of genetics, because of environment
and their surroundings, so people cope the best they know how.” Moving from addiction
to recovery is viewed as a process, not something that is obtained by discontinuing use
and moving on. As one interviewee stated, “It’s the ongoing process of increasing
awareness of the person’s awareness of self - what was going on, what they want, what
path they were on, how they’re going to get their needs and wants met without the
addiction. So development of coping skills, all of that is in there.”
Finally, there was talk about relearning how to live without relying on a substance
through a whole life change. Changing one’s life requires a holistic approach in order to
meet all areas of need and continually move forward to meet individuals and their goals.
One interviewee explained:
49
They actually have to do kind of a thorough self-appraisal on how they are
handling lots of areas of their lives, particularly relationships, priorities,
goals, things like that. So, while they are working on recovery, they really
have to be working on themselves in kind of a holistic way. They have to
work on investing in their health, they have to work on investing in their
mental health, they have to work on investing in ridding themselves of
certain behaviors and learning new and more functional ones, so it’s pretty
holistic.
In doing this, there is no one size fits all approach and as all eleven interviewees
indicated treatment needs to be “individually tailored to that individuals needs.”
An unexpected theme was around the concept of humiliation as a form of
treatment. Although there was a resounding answer from the interviewees that there was
no place for humiliation to be an intentional part of treatment, the researcher actually
meant to investigate how humiliation affected clients who end up relapsing.
When this research began, this researcher was not intending on looking at the way
in which education and training affected the way in which interviewees responded to
questions. Since the sampling pool was small, there was no way to determine if the
observations would be similar on a larger scale, but nonetheless differences were noticed.
Various levels of education, not necessarily representative of years in the field, reflected
answers that were based on personal experience for CADAC workers. Less personal for a
MSW first year intern, but still familial. An MFT discussed a personal opinion in light of
counter-transference. Whereas an LCSW discussed counter-transference in terms of
50
what professionals need to watch for. This may be an area for further research into the
effectiveness of treatment by various credentials.
Furthermore, all of the interviewees viewed relapse as, at minimum, a possibility
in recovery. This was not a response that this researcher was expecting to receive across
the board. Looking back at the interview pool, these results may have been skewed since
there were no interviewees from residential settings.
The questions that were used in this research study were utilized by a supervisor
in a training session with her staff. She had determined that the nature of the particular
questions generated for this study were highly valuable for her staff to investigate and
discuss as a group. Questions regarding relapse, humiliation, and personal orientations to
treatment as well as personal thoughts regarding 12-Step work are valuable for delivering
effective, consistent, and unbiased services. Although the results of this group discussion
were not reported in this study, the compelling nature of these kinds of discussions
persists for the substance abuse treatment community.
51
APPENDICES
52
APPENDIX A
Interview Questions
Exploration of Practitioners Perceptions of Relapse: An Exploratory Study
In this particular study, there are no clearly identifiable independent or dependent
variables. The guiding questions will be answered through the narratives of the
professionals being interviewed and are as follows:
1.
What views on relapse and recovery do practitioners share?
2. How do practitioners view the connection between relapse and recovery?
Specific questions that will be asked are as follows:
1. What model guides your practice when working with individuals in recovery and
why?
a. i.e. abstinence only, harm reduction, etc.
2. What are your thoughts on recovery?
3. What are your thoughts on the role of relapse in recovery?
4. What do you find is the best way to work with individuals in recovery?
5. How do you think the work with triggers helps individuals in preventing relapse?
6. How do you reengage with individuals who do relapse?
53
7. What kind of role does humiliation play for individuals who relapse?
8. What is the difference in how you work with a client that has relapsed and
willingly admits to it opposed to one that test dirty and does or does not admit to
it after the dirty test?
9. What are your thoughts about Alcoholics Anonymous?
10. What do you think is the best way to sustain sobriety?
11. What does the ideal treatment look like to you?
12. When an individual relapses, whether they reengage or not, how does that feel as
the helping professional?
13. If there is a sense of personal disappointment or failure, how do you deal with
that?
At the conclusion of the interview, a few demographic questions will be asked and they
are as follows:
1. What are you credentials?
2. How long have you worked in this field?
3. What is your gender?
4. What is your age group?
o 20-29____
54
o 30-39____
o 40-49____
o 50-59____
o 60-69____
55
APPENDIX B
Informed Consent to Participate as a Research Subject
Title: Exploration of Practitioners Perceptions of Relapse: An Exploratory Study
I hereby agree to participate in research which will be conducted by Jennifer Coots, an
MSW II student at California State University, Sacramento. She is working under the
direction of Dr. Andrew Bein, Associate Professor as his thesis advisor.
The purpose of this research is to:
The purpose of this study is to delve into practitioner’s perceptions on relapse and how that fits
into recovery.
Procedure:
This researcher will be conducting one-on-one interviews in which a few general
questions will be asked in order to provoke a conversation regarding the practitioner’s
perceptions of relapse. A few demographic questions will be asked at the close of the
interview. The interview will last for approximately one hour and will be held in a private
location of the participant’s choosing. This researcher will be tape recording each
interview. Participants may request that the recording be discontinued at any point
during the interview. At the end of this study, all forms of data will be destroyed.
Risks:
Participants are being asked to discuss their professional perceptions on relapse. No
personal experiences are being elicited and participation in this interview is clearly
defined as voluntary and may be terminated at any point without recourse. However, if
this interview triggers any unforeseen response, the following services can be accessed:
Capital Christian Center Counseling Center
9470 Micron Ave.
Sacramento, Ca, 95827
(916) 856-5955
University Psychological Associates
425 University Avenue, Suite 110
Sacramento, CA, 95825
(916) 290-3994
Sutter Counseling Center
855 Howe Ave #1
Sacramento, CA, 95825
(916) 929-0808
56
I understand that this research may have the following benefits:
The purpose of this study is to delve into practitioner’s perceptions on relapse and how that fits
into recovery. The information acquired may emphasize the need for further exploration into the
way the current mode of mainstream recovery is applied.
Alternatives/Rights to Refuse or Withdraw:
Any participation in this research is strictly voluntary. If you decide to participate, you
may, at any point, terminate your participation without consequence.
Confidentiality:
All participants of this study will remain anonymous. No identifiable information will be used
and data will be stored under an alias. All tape recordings, transcripts and data will be stored in a
secure location at this researcher’s house to assure confidentially. At the end of this study, all
forms of data will be destroyed.
Compensation:
No compensation will be provided for participation in this study.
Contact Information:
If you have any further questions regarding this research project or its results, you may
contact Jennifer Coots at (916) 267-3050 or by email at cootsj@hotmail.com. This
researcher’s thesis advisor, Dr. Andrew Bein, may also be contacted via email at
abein@csus.edu.
I understand that my participation in this research is entirely voluntary. I may decline to
participate at any time without risk.
Your signature below indicates that you have read, understand and agree to participate in
the research project.
__________________________________
Signature
_____________________________
Date
57
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