The following are some reflections on my experience of having run a number of relapse prevention groups in UK prisons.
The Selection Process
In order to run a successful, life-changing, relapse prevention group, it is important to carefully select participants and screen out those for whom general substance misuse awareness and harm reduction work would be more appropriate.
The first thing is for each participant to have identified entire abstinence from drugs and alcohol as their primary purpose. The power and unity of a relapse prevention group will be greatly diluted if a participant openly or secretly plans on having a few drinks or smoking a few joints in the future. There is no point in them attending a group as they are already planning their next relapse. One way of identifying whether or not abstinence is a desirable goal is for everybody to be clear about the consequences of their own using. My goal is to populate my relapse prevention courses with men who without some kind of intervention, will almost certainly return to dependent daily drinking or drug use on their release from prison. If you believe that one day you will be able to choose the terms on which you use drugs, control, modify and ultimately enjoy your drug use – then the relapse prevention course is definitely not for you.
The second thing is to clearly define the following terms: addiction, abstinence, recovery, relapse. The meaning of these terms must be defined, agreed upon – and referred to repeatedly. Ask the participants what these terms mean to them – and then teach them what they actually mean. The group must have a shared vocabulary. I tell a story to illustrate the difference between abstinence and recovery.
Abstinence vs Recovery: A Story
Jake, a heroin addict, is arrested for burglary and sentenced to nine months in prison. This is a wake-up call for Jake – and he is determined to change his life. He quickly detoxes from heroin – and within ninety days is physically abstinent. He gains weight and uses the gym five times a week. He begins working on a personal trainer qualification. He has made a decision to not use drugs again. He is optimistic about the future. He politely declines engagement with the prison DART team as, well, why would he need it? He hasn’t used for over three months, has no intention of doing so – and feels the best he has done in years. He’s serving a relatively short sentence so doesn’t need it from a box ticking point of view for parole or probation. He leaves prison with no intention of using – yet relapses within a few days. Why? Because other than stop using drugs, Jake has done nothing to address his addiction. He is physically abstinent – but he is not in recovery from addiction. We might, in fact, question whether or not the term ‘relapse’ is even appropriate to describe what happened to Jake. Did he relapse? I don’t think so. Not really. He simply hit the pause button on his addiction by practicing abstinence. He wasn’t actually in recovery and therefore couldn’t relapse. Jake using drugs again was as inevitable as the sun rising in the morning. Abstinence is a vital component of recovery – but there is a whole lot more to recovery than simply not taking drugs. Abstinence only addresses part of the physical component of drug addiction.
What is Recovery?
So what is recovery then? Recovery is the overall healing of social, emotional, mental and, yes, physical health. To eliminate confusion, we will now identify the mechanisms of change that are generally present in recovery. They are: (1) acceptance of the self-evident truth that addiction is a chronic, relapsing condition (2) willing and enthusiastic construction of a new social identity, that of a non-user. I would suggest that this new social identity must supersede all previous and current identities (certainly ego-based superficial ones such as ‘one of the lads’, ‘party boy’, ‘gang member’ etc – but also seemingly more healthy, pro-social identities such as ‘son’, ‘father’, ‘worker’ etc. Why is this? Because if your using will result in dereliction of paternal duty and separation from your child – then obviously your primary ‘non-user’ identity is far more important than your secondary ‘dad’ identity. This logic can be applied to all of your secondary identities. The only identity which can really be said to transcend that of ‘non-user’ is that of ‘human being’. The third mechanism of change is that of self-examination and sharing. Assess and confess. Self-examination involves the identification of resentment, fear, self-pity and prideful attitudes and behaviours. The fourth mechanism involves a permanent commitment to inner growth, moral good conduct and always seeking to do ‘the next right thing’. Even if the next right thing might be the opposite of what you want to do! The fifth mechanism, arguably the most important, is that of active, frequent participation in a group or community which will support the aforementioned principles. Whereas abstinence is a solo endeavour, recovery is a team sport. The reason that I say group participation is the most important recovery mechanism is because it will help the addict to accept the seriousness of their situation and strengthen the construction of the new ‘non-user’ identity. Whilst all of the five recovery mechanisms will help to deflate the ego, attendance at recovery groups is perhaps the ultimate act of ego-deflation – as it requires a public admission of the need for continued growth and support. If all of the recovery mechanisms are in continuous activation, and real change and growth has occurred, then it can be said that the addict has progressed from abstinence to recovery.
I find it much easier to work with men who are serving short sentences. Being in relatively close proximity to both the devastation of their last session and the end of their sentence sharpens the mind. Let me provide you with two examples of why it can be difficult to work with men serving longer sentences.
Jimmy is serving a life sentence for murder. He has served ten years and will likely spend at least another eight years in prison. He often used drugs at the beginning of his sentence but soon realised the futility of this and stopped using altogether. Other than occasionally being prescribed medication for anxiety, he has not used for approximately eight years. He no longer thinks about drugs and alcohol – it’s simply not an issue. I met with Jimmy to perform an initial DART screening as I do with each new reception to the prison. Jimmy admitted to having drunk heavily in the past – but was extremely defensive when I attempted to explore this issue, repeatedly claiming ‘I wasn’t some down and out’. I asked Jimmy if he was planning on drinking on his release from prison. ‘I’ll probably have a few cans of beer when I’m back at my mum’s house’ he replied. ‘It’s no big deal’. It might be no big deal. But the last time Jimmy drank alcohol in the community (eight cans of cider), he stabbed an old man many times, killing him in the process. That is a big deal. Jimmy’s crime might not necessarily have been driven by alcohol – but I would want to be pretty damn sure of that fact before drinking again. Jimmy was working as a roofer at the time he committed the offence, something which he believes separates him from the kind of ‘down and outs’ who have real problems with alcohol. But the question is this: can you guarantee your behaviour when you drink alcohol, Jimmy? Jimmy was extremely blasé about the alcohol issue and became hostile as I attempted to explore the true nature of his relationship with alcohol. He began to visibly shake with anger so I calmly thanked him for his time and explained how to refer himself to our service should he wish to do some work around alcohol use in the future. Jimmy appears to believe that his long period of abstinence has qualified him to drink with impunity. Jimmy has not drank or used drugs for approximately eight years – but he is categorically not in recovery.
Here’s another example. Samuel is serving a life sentence for murder. He has been clean and sober for over a decade. He is in his fifties and has had some quite serious health problems. Samuel has been exposed to recovery principles and has attended 12 Step meetings in previous jails. Samuel likes to think of himself as an elder statesman of the relapse prevention group – and whilst he is perhaps further along the road to recovery than other prisoners, he is also a victim of the delusion that the long period of abstinence he has achieved in the custodial environment is an accurate indicator of how he will fare in the community. The fact is that prison (and residential treatment centres, for that matter) provide inmates with a completely false sense of being. Here a recovery worker is faced with the dilemma of how to acknowledge the good work that has been done by the prisoner whilst ensuring that they do not leave jail complacent, defenseless and full of false hope. Here’s what that conversation might look like:
Samuel, I want to acknowledge the good work that you have done to remain drug-free in prison. And whilst I have no wish to disparage that achievement, it would be dereliction of duty on my part were I not to warn you that the hard work starts the moment that you are released from prison.
The challenge for a prisoner like Samuel who has a substantial amount of clean time and knows a little bit about recovery principles – is that he thinks he knows what recovery is all about. But prisons are full of people who know a little about recovery and haven’t used for a year or two. The men I work with are rarely serving their first jail sentence. Scratch below the surface and it is clear that Samuel, whilst putting on a brave and friendly face, is a very angry man. His bitterness and prideful and resentful nature will soon become evident for those who spend more than an hour in his company. He comes out with statements such as this: ‘My mum is coming to visit me in prison and I want her to acknowledge all the pain that she caused me when I was a child’ (Note to people in recovery: if you’re waiting for those who you believe have wronged you to apologise, you might be waiting for a very long time) and: ‘When I get out of prison I can’t wait to see the look on the faces of all those people who said that I would never be able to stay clean’ (An ‘I’ll show you/them’ mentality of this type has been the death of many an addict). For most addicts, ‘proving people wrong’ is a terrible motivator. Why? Because power-driven conquest and ego-driven self-promotion are the antithesis of sane, healthy recovery. Humility and forgiveness are vital ingredients.
The ineffective recovery worker and uninstructed addict love to talk about triggers. That’s because it is the easiest thing in the world to get the flip chart out and write a long list of triggers. It is easy because it is pointless. Why? Because recovery is about a daily commitment to an idea, attitude, way of life – and course of action which results in ascension to a higher level of consciousness which guarantees immunity from relapse.
So we take our pen and dutifully list our alleged triggers: listening to grime music, being invited to a family barbecue, the anniversary of my offence/dad’s death/break-up of my relationship, being in jail at Christmas, experiencing euphoric recall when watching: Glastonbury/Narcos/The Hangover etc. The list can be endless if you want it to be. And whilst the old cliches apply (‘If you go into a barbershop enough times, eventually you’ll get a haircut’ – ‘If you lie down with dogs then you’ll get up with fleas’), ultimately recovery is about so much more than trigger management. Trigger management is an impossible task. But self-management and emotional management allow trigger avoidance to be a thing of the past because a higher state of consciousness will enable trigger neutralization. Now I’m not saying that you play with fire. Clearly an alcoholic that goes into his local pub to sit on his own and sip a diet coke is heading for trouble. Hanging out with your friends whilst they’re playing PlayStation and smoking weed is a profoundly stupid thing to do. A person who behaves in that matter is betraying their new social identity as a non-user. You have to draw a line in the sand.
If you become complacent, cocky or believe that you are cured – you will relapse. Addiction is heavyweight boxing. You can box a perfect fight for eleven and a half rounds and be knocked out with ten seconds remaining on the clock. Complacency kills.
Lapse vs Relapse.
I hate this distinction between lapse and relapse. Let me tell you why. My cousin, a textbook alcoholic, had been abstinent from alcohol for multiple years. There was no recovery work of any kind, he just stopped drinking and led a life of isolation. One evening, a group of his old friends knocked at his house and asked if he fancied going out. My cousin accepted the invitation and ended up literally drinking himself to death. He sat on a chair and died. His body packed up. So, was that a ‘lapse’ or a ‘relapse’? It was, after all, a one-off using episode. My answer to that question is: ‘Do you think his mother could care less about that distinction as her son’s coffin is lowered into the ground?’ My point is this: the next time you drink or use could set in motion a chain of events that will lead to your, or someone else’s death. A lapse sounds nice, doesn’t it? A cheeky little lapse, no harm there, son. But you have no idea what the consequences of your next session will be. It could lead to a five year period of continuous drug use – and what state do you think your life and those of your loved ones will be in after that? I understand the reasoning behind the distinction. Clearly if a person is fortunate enough to get away with one episode of drinking and then resume their recovery journey, then that is something to celebrate. We also don’t want a person who has made good progress to buckle under the weight of a setback. Whilst lapse might be an accurate description of the behaviour, it seems to be yet another way of minimizing negative behaviour on the part of the addict.
A lot of relapse prevention material currently in circulation is not fit for purpose. The worst kind of material infantalises the participants and dances around the edges of addiction. It does not promote reality confrontation. The Hazelden Matrix Model provides some excellent talking points and opportunites for honest reflection.
Nice article but I have managed to control my using and change my habits by embracing the journey. That didn’t work while I was under the control of AA or any other mind who hasn’t done the whole experience till the end. Conscious relapsing is freedom from addiction. I don’t use cause I don’t want but I can if I want.