We’ve all been at a point in our lives where we vowed to combat substance abuse such as smoking, drinking, gambling, over-eating (yes, overeating can be classified as substance abuse); the list really goes on, and for some, this is a rather smooth journey and for others, it’s not. “Monday, I am starting my new diet” sound familiar? And perhaps Monday comes, the diet has started. Two weeks past and the third week Monday comes and it ends with a shameful pizza and a 2-liter bottle of Pepsi. That is what we call a “Relapse” or so it can masquerade as one. I will cover this term more in detail, but first I would delve into what the crux of this article is about.
So we’re at the possible “relapse” point. Now, some people deal with relapses in their own way, and some bounce back quickly and others do not. The severity of the relapse often depends on the substance abuse itself and the person. I can only imagine, a naughty pizza after 3 weeks of swearing of bad food, is no comparison to a heroin addict who’s been clean for 2 months and had a relapse. Now the next step in the process is the bouncing back part, Correct? And this is where this article comes to play. What do we do when we bounce back? Personally, after monitoring myself, I have developed a very sophisticated ritual that I perform after my relapse (or what I would consider a relapse but is actually a slipup of my naughty “not-to-do list” because sometimes throwing things out of proportion is a nifty little skill I have) but nevertheless, this got me thinking. I am sure there are other people out there that have their own rituals. But most importantly, are these rituals healthy and what do they represent? This is what I will be trying to dissect. There are countless articles out there written by professionals and even some experts in their fields in how to deal with the actual relapse, but I am yet to come across an article that covers the post relapse rituals part and whether this part of the process or rituals hold any danger to us. Let’s dig in.
What is the clinical term for a Relapse?
As I commenced my research journey, I was quickly educated on the actual meaning of a Relapse and therefore it’s imperative to point out not all relapses are indeed relapses. Some relapses are actually just what is known as a slip-up.
There is an important distinction to be made between a slip-up and a relapse. The distinction is critical because it influences what actions people take after. A relapse is a sustained return to heavy and frequent substance use that existed prior to treatment or the commitment to change. A slip-up is a short-lived lapse, often accidental, typically reflecting inadequacy of coping strategies in a high-risk situation.
Recounting my earlier “pizza” example, it’s reasonably safe to assume that we’re dealing with a lapse or a slip-up and from here one could assume a bounce back is relatively easy. To some, it will be, if it was just indeed a slip-up, but to some, there’s a completely different mindset at play here. What if the pizza just wasn’t enough? What if it was indeed something more insidious and life-threatening than a pizza?
Let’s play out the scenario where the pizza wasn’t enough and more food or substances are required to scratch that itch and assume that what we’re dealing with is a classic full-blown relapse. This is where the term Abstinence Violation Effect comes in. Say what?
What is the Abstinence Violation Effect?
A book called the “Principles of Addiction” edited by Peter M. Millet describes the Abstinence Violation Effect as the following:
The abstinence violation effect can be defined as a tendency to continue to engage in a prohibited behavior following the violation of a personal goal to abstain. For example, an individual who has successfully abstained from alcohol, after having one beer, may drink an entire case of beer, thinking that since he or she has “fallen off the wagon,” he or she might as well go the whole way. — Extrapolated from Science Direct
So I take it this is where the saying comes from “One beer is too many, and a thousand is too little”- Sadly, you can apply this to any situation.
Now that we’ve delved into some clinical terms, we still haven’t really reached the “Post Relapse Part”. But before we get to that point, there is a significant part to cover first. That is the “Relapse Plan”. Why am I jumping ahead of the game? Well, some might already be thinking, damn, how do I prevent relapsing, and knowing myself, I’d be asking the same thing. This is where the Relapse Plan or also known as the “Relapse Prevention Plan” plan comes along.
What is the Relapse Prevention Plan?
Before I get into it, I must declare, there’s a lot to cover and to understand under the Relapse Prevention Plan umbrella and it truly deserves an article in its own right. So I’ll just provide a short version.
A Relapse Prevention Plan is a plan/tool used to prevent relapsing. Developing this plan often requires professional help. The main goal of the plan is the identifying triggers, cravings, healthy tools, recovery program tools, and damage control tools—all to facilitate in helping to formalize an easy-to-follow Relapse Prevention Plan.
A good relapse prevention plan specifies a person’s triggers for drug use, lists some coping skills to summon up, includes some distractions to engage in, and lists people to call on for immediate support, along with their contact information.
For those that are wondering “what is a trigger?”, check out my previous article where I covered that very topic in detail.
As you can see, the Relapse Prevention Plan isn’t some PDF that you download from the internet, and Bob’s your uncle and your Relapse Prevention Plan is stuck to your fridge with a Tower of Pisa fridge magnet. This process really requires one to do that dreadful internal work with a professional. If you want to look more into Relapse Prevention Plan’s, their function, and how to formulate them, I would recommend the following link from The Recovery Village.
Now, as you can see, we didn’t really jump ahead as we thought we did. In fact, we jumped backward, unfortunately. Because the article is about Post Relapse Rituals, not preventing a relapse.
What is a Post Relapse Ritual? The burning question.
Since I couldn’t find anything similar to this term, I decided to create my own. I tried the “Machine aka Google” to find terms on rituals and addictions, but they’re all referring to the ritual use of substance abuse. For example, Fridays are Beer days? Going to a nightclub is Charlie time?? Something like that. That said, a topic not to be taken lightly and deserved good research.
Coming back to my very own definition of a Post Relapse Ritual or PRR. Drumroll.
A post relapse ritual consists of a set of actions, beliefs, and stages that one follows or goes through, after you have relapsed or even just lapsed, with the pursuit to bounce back and correct or mask the violation to assuage your guilt and shame. For example, A person that fell of the “Diet Wagon”, may go through a cleansing process of throwing out all the unhealthy foods from their kitchen cupboards, set up strict exercise routines and start listening obsessively to meditation tracts etc. — Simon Mouton
Another example could be of a person who engages in extramarital affairs, that goes through the “Cover your Tracks” process of deleting browsing history, blocking all the people who they engaged with, and then attending church and having family times to assuage their guilt and setting them back on the right path.
Having a family member who dealt with addiction from the age of 16 and having observed him for years, their Post Relapse Rituals included a 3-day slumber with the help of pain killers sometimes. Then after having woken up from the 3-day slumber, a refreshed outlook seems to be the state of mind and with that, the cleansing process starts by drinking tons of water to cleanse the body and nourishing the body with food. This gets followed up by the “distraction phase” which consists of watching tons of movies, mostly comedies, and loads of laughter. Most importantly: The Counting of Days! This process involves marking down the days that you have successfully achieved abstinence. This would be then followed up with a daily update of: “it’s Day 3, I’m sober”. “Day 4, I’m sober”. You catch my drift.
These are just droplets of examples in a huge bucket of Post Relapse Rituals or PRR’s examples I am confident enough to say, exists out there.
As you can see, the Post Relapse Ritual can be applied to people with severe addiction problems and to non-addicts that just have other problems in their lives!
Having observed these PRR’s from family members, acquaintances, and myself, the next question that should be posed is, whether these actions are healthy or not? Do they give lasting results or false hope filled with short terms euphorias?
It might also be worth covering the symptoms that one experiences once a full-blown relapse has occurred, as these symptoms can oven-time be the foundation of what sort of Port Relapse Rituals activities in which one might partake.
Further along my journey of research, there are normally two phases after the Relapse. The Detoxification/Withdrawal Phase and then the PAWS or Post Acute Withdrawal Syndrome Phase.
The Detoxification/Withdrawal Phase
The Detoxification Phase is the first phase a person will stop at once they had their relapse and decide to stop using the substance again. The process is much dependant on the substance. An alcoholic that had a week-long drinking binge for a relapse, might need to be checked into a medical facility that is required to handle the process. Similarly for drug users. However, for sex addicts, this might not be the case. They might also need professional help, but perhaps not the same help as a drug user or an alcoholic.
The important thing to take away is that each substance abuse combined with its user will have its own detoxification phase catered to their needs. As for the actual symptoms, one can expect to experience, this again will depend on the substance, the severity of the relapse, and the person.
But I won’t leave you hanging there. Having found the Recover First Treatment Center, they have an extensive article covering the various symptoms of alcohol withdrawal that range from mild to very severe to use as an example.
Example 1: Mild alcohol withdrawal symptoms may include
- Restlessness
- Insomnia
- Decreased appetite
- Irritable mood
- Anxiety
- Impaired thinking and judgment
Example 1: More severe alcohol withdrawal symptoms may include
- Trembling of the arms and hands.
- Sweating.
- Rapid pulse.
- Rapid breathing.
- High fever.
- Increased blood pressure (hypertension).
- Hypersensitivity to noise and light.
- Visual and/or auditory hallucinations.
- Generalized tonic-clonic seizures (rare).
- Delirium tremens (rare).
Let’s turn to the Sex Addict example, what would their withdrawal symptoms look like? Here’s a list from the Novus Mindfulness Institute on what sex addiction withdrawal symptoms:
- Feelings of Ongoing Irritability and Frustration
- Increased Levels of Anxiety
- Symptoms of Depression
- Oversleeping or Insomnia
- Feelings of Hyperactivity
- Hypersensitivity in Daily Interactions
- Increased Anger
- Loss of Interest in Daily Life
- Physical Pain and Discomfort
- Feelings of Exhaustion
- Wild Mood Swings
- An Increase in Irrational or Dangerous Thoughts
- Intense Cravings for Sexual Activity
- Inability to Focus
- Loneliness or Social Isolation
As you can see, the symptoms from alcohol withdrawal aren’t far from the withdrawal symptoms a sex addict may experience.
Now that we have an idea of what the symptoms may be and connecting them with the Post Relapse Rituals, it makes sense that sleeping might be a PRR activity that a person might take part in for instance. Experiencing Physical pain could be a reason for hitting the painkillers as a PRR activity.
It’s a relatively safe assumption to make that the PRR activities are directly related to the symptoms of withdrawal.
Post-Acute Withdrawal Syndrome — PAWS
Here’s the Recovery First Treatment Center’s definition of PAWS:
PAWS is a set of symptoms that occur immediately after a person has detoxed or completed the acute withdrawal stage of drug or alcohol cessation. PAWS symptoms affect a person physically, mentally, emotionally and spiritually and require proper management as they often compel an addict to use again in order to obtain relief. And because PAWS can occur and recur for up to two years or even longer for some people, understanding how to recognize and cope with this condition is the most critical factor for long term recovery success.
Here we can make another connection between PAWS and the Post Relapse Ritual because similarly to the Detoxification/Withdrawal phase, PAWS has its own symptoms. This begs the question, does the Post Relapse Rituals consists of activities exclusively to the Detoxification/Withdrawal phase or the PAWS phase, or perhaps both?
According to the Recovery First Treatment Center, it’s widely accepted by addiction experts that there are six general symptoms of PAWS that fall under the four main categories namely:
Emotional, Physical, Spiritual and Mental
Image from the ©Recovery First Treatment Center website
Looking at the image above and scanning the symptoms, the fast range of Post Relapse Rituals that can be derived from them is huge.
How can we define whether Post Relapse Ritual Activities are healthy or not?
So now that we have an idea of what Post Relapse Rituals are and the possible “how” they come to existence, the next sensible question to ask is whether these PRR’s are healthy or not?
In order to answer the question of whether the PRR activities are healthy or not, we first need to determine whether or not we want to admit that we might have a problem. You see, there’s this thing called “denial” — It’s this magical ability to tell yourself everything is ok and that you’re in control when in reality everything is going to shit!
If denial is the ruling factor, chances are the PRR activities will probably NOT be healthy and activities will most likely consist of actions to mask or cover up the problem and feed the denial.
Example:
A chronic porn user with the goal to abstain from watching any porn, then after having a relapse, deletes their browser history. The PRR of deleting the browser history adds no value to the recovery and all it really does is eliminating the proof of the event itself with the pursuit of assuaging their guilt and shame.
There are too many examples to think of.
However, for the drug-addict that had a near-death experience due to an overdose, and decided, to their life around as they admitted to themselves they have a problem and that they’re not in control, their PRR activities might possibly be more healthy as their journey will be that of recovery and personal growth. This of course is the “happy ending” scenario.
Using these examples with the knowledge of Post Relapse Rituals, I suppose we can ask ourselves?:
“Where am I in life?”
“Am I in denial?”
“Am I living a healthy fulfilling life?”
“Does my actions hurt others and myself? If so, why?”
“Where do most of my time, thoughts, and money go towards?”
“Do my actions support my goals?”
“Are my PRR’s healthy or are they covering up something more sinister?”
It’s strange to believe, but some people really do have a hard time having to admit to themselves they might have a serious problem. Perhaps if you are secretly one of those people, what Post Relapse Rituals do you part-take in, and are they healthy or just a way to distract and mask the bigger problem.
Is there a danger of getting addicted to Post Relapse Ritual activities?
Mmm, Firstly it should be stated again, I am not a professional in the field, so answering this question falls outside my paygrade.
However, I am willing to give you my opinion.
A person can possibly get addicted to anything. Period. I myself have posed this question, thinking that what if a person falls inside a loop or a cycle, where they are so used to the PRR activities, one must Relapse in order to experience the Post Relapse Ritual?
The Post Relapse Ritual can’t live without the “Relapse”, therefore if we become too dependent on the Post Relapse Ritual itself, one will need the “vice” (be it drugs, sex, gambling, alcohol, food) in order to relapse. In that, creating a synergistic effect.
One can derive the conclusion that if the PRR is based on masking the problem though, the more likely one will become addicted to the false sense of security that the PRR’s creates, and as such a vicious synergistic cycle will be created with an escape far out of sight.
However, if the PRR is base on growth, recovery, and most importantly includes professional help, the chances are unlikely that there will be an addiction to the PRR itself.
It’s also worth noting that the road to recovery from the addiction itself is never guaranteed.
I did however reached out to my very old friend and Clinical Psychologist Louis Awerbuck from the Centre For Mental Health in Stellenbosch, South Africa, and here’s his take on it:
“From a behavioural science point of view, I cannot find fault with the paragraph that you quoted in this mail (what I said above). It is an interesting and sensible topic. PRR can become an addiction in itself, like a lot of people do in switching from hardcore substances to cigarettes. In a sense the addiction persists, but for a “greater good”. It is not being addicted that is the problem, but the price way pay for addiction. “Applying” the addiction to create a more appropriate outcome for oneself could therefore be a very clever strategy.”
I hope this sheds some light folks!
N-acetylcysteine and its use in psychiatry
Now, with a slight detour, I don’t want to really go into the medicine part of recovery, but I did come across the following article written by Olivia Dean, Frank Giorlando, and Michael Berk that is currently published in the US National Library of Medicine National Institutes of Health where they discuss N-acetylcysteine and its current therapeutic evidence and potential mechanisms of action in addiction.
What is N-acetylcysteine?
N-acetyl cysteine (NAC) comes from the amino acid L-cysteine. Amino acids are building blocks of proteins. NAC has many uses and is an FDA approved drug. — Taken from Webmd.com
How can it help with addiction?
I’ve extrapolated the following from the article mentioned above:
There is an abundance of literature implicating glutamatergic abnormalities in addiction.47,48 More recently, data are emerging suggesting a role of oxidative stress in the pathophysiology of addiction to drugs of abuse.32,49–51 Research has explored the modulation of glutamatergic pathways by NAC in pre-clinical models.52,53 N-acetylcysteine has been shown to reverse the decline in cystine–glutamate exchange through the cystine–glutamate antiporter and thereby assist in the restoration of glutamatergic pathways in addiction.32,52 These properties have made it a potential prospect for the treatment of addiction. Much of the following literature is based on small clinical trials, nonrandomized cohorts or case reports, but is sufficiently promising to suggest the need for larger well designed studies.
In this article, they’ve covered case studies on various addictions such as marijuana dependence, nicotine addiction, cocaine addiction, pathological gambling, etc, and since I have covered Sex Addiction in this article, I was very curious as to whether their case studies on addiction, for instance, can be applied to sex addiction. So I reached out to Peter.W.Kalivas from the Medical University of South Carolina as his field broadly covers the neurobiology of addiction.
Firstly, for those who are thinking, Sex Addiction — Is that a real thing??
I have come across a PDF that was done by Dr. Stephanie Carnes and she extrapolated a section from the Journal of Psychoactive Drugs that points out the following:
“An orgasm is the primary natural blast of dopamine available to all of us. Accordingly, J.R. Georgiadis (2006) scanned the brains of people having orgasm. He said they resembled scans of heroin rushes. These individuals experienced one of the most addictive substance ever produced: dopamine. Orgasms and addictive substances or behaviors have two things in common. They produce an initial pleasurable experience, and both are followed by neurochemical fluctuations that appear to continue for a week or two (p.137).”
Blum, K., Chen, A., Giordano, J., Borsten, J., Chen, T., Hauser, M., Simpatico, T., Femino, J., Braverman, E. R., & Barh,D. (2012). The addictive brain: All roads lead to dopamine. Journal of Psychoactive Drugs, 44 (2), 134–143. DOI:10.1080/02791072.2012.685407
Based on the work that J.R.Georgiadis (2006) did, I would strongly agree that Sex Addiction is REAL! So here’s how I connected the dots.
After reaching out to Peter.W.Kalivas on the case studies that were performed and whether it can be applied to sex addition, he was gracious enough to respond with the following:
It is certainly safe to say that sex and drugs involve overlapping brain circuits, of which dopamine is one of them as you note below. N-acetylcysteine (NAC) works on a specific drug-induced pathology that contributes to vulnerability to relapse, not specifically on reward. When a person is exposed to drug cues and they start to crave, essentially they begin to place motivation into getting drug rather than other aspects of life that might need attention (family, work, etc). This prepotent attention to drug is normalized by NAC, giving the person greater control over their cravings. The same seems to work with PTSD where thought intrusions of their trauma (rape, combat, etc) come to dominate their thoughts and NAC inhibits these thought intrusions. I suspect it would do the same for sex cravings, but there is zero data I am aware of to support that.
Hopefully, there will be a study on Sex Cravings vs NAC one day!
How does N-acetylcysteine relate to the article?
Well, it does and it doesn’t. It does in the sense that should one consider the therapeutic use of NAC in recovery by the advisement from a professional psychiatrist or psychologist, your Post Relapse Rituals will be affected in some way (for the better it seems) as the NAC will help to avoid the Relapse — therefore in time eliminate the PRR all together.
Remember people, the GOAL is essentially to eliminate the PRR and to remain steady on the road to recovery!
NAC doesn’t relate to this article in general, but since I researched relapses and came across the article, I thought it might be worth sharing.
Conclusions
I started writing this article with a bold conviction to emphasize the meaning of Post Relapse Rituals and with a convinced mind, that it posed a serious threat. I ended up with the truth, and that is not the PRR itself, but on whether we choose denial or a road to recovery.
Some highlights of what I’ve learned on PRR activities:
· PRR’s can be derived from the Detox/Withdrawal or PAWS part of recovery,
· PRR’s can include actions/activities that will lead to a road of recovery, in which case I believe they’re healthy,
· PRR’s can include actions/activities that masks a more insidious problem, in which case I believe they pose more of a threat,
· The PRR can be your friend in recovery or an ally in self-destruction
And most importantly, by shining a light on the Post Relapse Rituals we may partake in, we might get a better view of our own state of well-being.
The PRR can be your friend in recovery or an ally in self-destruction.
References
https://www.naadac.org/assets/2416/stefanie_carnes_neuroscience-trauma_ac16.pdf
https://www.webmd.com/vitamins/ai/ingredientmono-1018/n-acetyl-cysteine-nac
https://recoveryfirst.org/alcohol-abuse/withdrawal-timeline/
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This post was previously published on medium.com.
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