According to the Center for Substance Abuse Treatment and the transtheoretical model of change, “for most people with substance abuse problems, recurrence of substance use is the rule not the exception” (Enhancing Motivation for Change, 1999, p. xvii). Relapse can and most likely will occur in recovery, and should be recognized as well as anticipated by substance abuse recovery counselors. The significant challenges to counselors are bringing a client successfully and securely through a relapse and eventually preventing relapse from occurring at all. For many, helping a client find faith in a higher power is an essential piece of the puzzle for overcoming addiction.
In research collaborated by Laudet, Morgan and White, there are three stages of recovery for those with the disease of addiction: early recovery, middle recovery and late recovery (2006, p. 36). In early recovery, staying clean is the main focus. Every day thoughts revolve around simply making it through the day without using. This stage, lasting one to three years, can be the most difficult, and is most likely the area when relapse is most frequent as clients find it easier to simply use than to fight the urge.
The second stage that occurs in regaining sobriety is middle recovery. Here, a client may be asking themselves “what do I do now?” It is common for a client to come to seek recovery after hitting rock bottom. This rapid decline often entails homelessness, unemployment, estrangement from family and friends as well as health concerns; very overwhelming realities that may weigh heavy on a client’s mind and may be more of a burden than can be held. Here again is an area that counselors should be aware of relapse. Clients may falter in this stage, as the realization of rebuilding a life from the bottom up can be overpowering. Searching for a home and a job is daunting, ridding oneself of guilt and shame to become capable to approach loved ones is trying, and facing difficult health issues often brought about by their own substance abuse is frightening. These situations trigger great quantities of stress, a common prompt for substance abuse and relapse.
The third and final stage of recovery is known as late recovery, and involves a client finding growth and meaning in life. In this stage, relapse may be less frequent as a sense of purpose is found. As this stage is found only by enduring great challenges, a client may not be as tempted by relapse and the act of back tracking in their recovery may seem tiresome and unworthy of their time. However, though a deep awareness of the consequences of substance abuse is profound, relapse is still possible if an addict forgets that he or she has a disease that is incurable and succumbs to the enticement of “just this one time can’t hurt” or has the thought that “I have been clean for so long. I am cured.” Bill W. stated in his book Alcoholics Anonymous that “This is the baffling feature of alcoholism as we know it-this utter inability to leave it alone, no matter how great the necessity or the wish” (pg. 34). Complete abstinence is the only choice for those with the disease of addiction, and so many recovering addicts forget this simple realization in the late recovery stage.
Hitting rock bottom so to speak is a reason for change commonly heard from those who seek treatment. Mothers who have lost custody of their children, spouses who have become fed up and left, loss of employment due to inability to perform necessary tasks, arrests due to drug and/or alcohol use, homelessness and serious illness are all incentive to desire to be well. Addiction can cost its victims a great amount and in doing so can be the origin of a great turn around in the mindset of an addict.
There are times when motivation is unobtainable, and measures are taken in the form of interventions by loved ones. Or if legal issues are involved, a judicial ruling may strongly speed momentum towards a positive resolution. Often times these recovery arrangements do not acquire the results that are hoped for because a client that is forced to face recovery is not mentally invested in getting well and is simply going through the motions. Treatment in any circumstance is beneficial, however risk of relapse is always looming. The challenge for a substance abuse counselor is breaking this cycle and guiding a client into finding a strong and satisfying life.
Even though there are the benefits of motivators that lead a client to recovery, the situations that caused the motivation still exist after recovery and remain stressful. Stress equals relapse. Relapse equals a greater problem. This equation simply put creates a vicious cycle that seems hopeless. According to Nordfjaern, “relapse could be defined as increased use of substances either after a period of abstinence or a period of lower substance use”. Risk factors found to be of great significance in this study include depression and lack of social support as well as gender, absence of employment, low education levels, diagnosed mental disorders and treatment history (Nordfjaern, 2011, p. 314).
As of 2013, relapse rates amongst men and women are significantly different: men rate at 54.5 percent more likely to relapse as compared to women who are ranked at 71.9 percent more likely to fall into active addiction. Reasons for this discrepancy can be detected in behaviors before treatment (Maehira et al., 2013).
“For men, baseline factors associated with relapse were living with other people who use drugs (PWUDs), living alone, and not having sex with non-commercial partners; whereas for women these were previous history of drug treatment, unstable housing, higher earnings, preferring to smoke heroin and injecting buprenorphine/pethidine” (Maehira et al., 2013, p. 1).
According to Maehira et al., woman also have the stress of selling sex for money, multiple sexual partners, and with lack of condom use had the higher risk of sexually transmitted diseases (Maehira et al., 2013).
With such a variety of stressors, and a diverse cultural society, relapse seems to be virtually inevitable. With a strong recovery program that prepares a client for these ordeals outside of treatment and a solid after care program, clients have a better opportunity to recover quicker from relapse and eventually find relapse absent from their lives.
It is important for substance abuse counselors to understand the developmental aspect of moral and faith development when considering a spiritual, faith based program as a foundation to addiction recovery and relapse prevention as well as to recognize and accept spiritual differences (Weiss & Sias, 2011, p. 85). Lawrence Kohlberg established a sequence of moral reasoning that incorporates three levels: preconventional morality, conventional morality and postconventional morality. Within each level there are two stages, equaling six total stages a person may ascertain in development. As we grow cognitively, our moral thinking changes from a clear black and white moral ground to one that has shades of grey according to society and its views. (Feldman, 2011, p. 320-321) For instance, a child may see stealing as simply wrong and something that he or she should not do (preconventional morality). As development continues, he or she may see moral behavior in a different view that allows thoughts to vary between different areas of correct conduct. For example, touching on the substance abuse theme, ‘if I drink this I am going against my recovery’ or ‘if I do not drink this I have to deal with my issues and may not be a happy person’ (conventional morality). It is not difficult to see how this could increases anxiety and cause sudden relapse. Someone who has advanced to postconventional morality (which is according to Kohlberg, a rarity) may see drinking as a hiccup in their recovery and may attribute not drinking to their misery, however they will ultimately chose to refrain from drinking because in the long run this what is paramount to their living a life that is gratifying and pleasing. Postconventional morality is a level that requires a measured self-assessment to go beyond society’s sense of right and wrong. In this level we find spirituality and faith as prominent in a person’s judgment and when sorting through various decisions, though they may be attracted to choices that are have negative repercussions, in the end their faith in a higher being prevails. This level is one found with experience. In fact, “…not everyone is presumed to reach the highest stages: Kohlberg found that postconventional reasoning is relatively rare” (Feldman, 2011, p. 322).
Fowler takes morality development one step further and explains the growth of faith in a person’s life.
“He described religion as cultural expressions of faith; thus, whereas faith and religion are reciprocal for Fowler, faith is the more encompassing term for him. In this way, his definition of faith lies closer to the definition of spirituality that one finds in some current discussions of the relationship and differences between spirituality and religion. For Fowler, faith, as a universal human activity of meaning making, is grounded in certain structures (inherent in human interactions) that shape how human beings construe and interact with self and world. These structures (e.g., cognitive development, level of moral reasoning, locus of authority, and others described later) are distinguished from the contents of faith. That is, faith is not so much a set of beliefs as a way of knowing, a way of constructing one’s experience of the world. It is the structures, rather than the contents of faith, that determine one’s faith stage” (Parker, 2009, p. 112-113).
In this review, only stages one through five will be identified as counselors are not likely to see stages zero or six. Stage one (intuitive-projective) of Fowler’s theory of faith development begins in Vacation Bible School and stories such as Noah and the Ark and Jonah and the Whale. Like from Aesop’s fables, lessons are learned by imagination and symbolism, wisdom drawn from story time. Fantasy is important in this stage, and when it mixes with a child’s reality it creates instructions for further faith development.
Stage two (mythical-literal) cultivates a cause and effect relationship with life. If good is brought forth, good will happen in return. This is also a time that realization comes that bad does not always receive punishment and good does not always produce positive outcomes. These epiphanies can make for a confusing mindset, and this would be an important time to talk about faith with a child.
In Stage three (synthetic-conventional) of Fowler’s faith development is based on what society views as acceptable. Ones self-worth focuses on how others approve or disprove of certain actions. This is an important stage to recognize as a counselor since this is when an individual will find a relationship with a higher power to be a satisfying or they may find that higher power to be a burden if life is not satisfactory. As a substance abuse counselor, it is essential to make light of strengths a client has, and encourage a positive attitude going forward while building a strong faith foundation so that as a client leads into recovery, relapse temptation has less of an opportunity of following through or is recovered from quickly.
Stage four (Individuative-reflective) is a level that counselors should help their clients attain as this is where one can take responsibility for one’s own decisions and actions and can also begin to take full control over their beliefs and their faith in a higher power. It is here that one can separate themselves from group approval to finding a more individual sense of self, allowing for a more direct path to recovery that is free of binding expectations of others. However, this can also be a time of struggle if a client is in this stage during active addiction. A client may see that their choices and lifestyle are unchangeable, and can be difficult to sway into a more positive mind set. Being able to recognize key stage attributes and their possible transition periods help a counselor best help their client in the road to recovery.
A person who is in stage five (conjunctive) of Fowler’s faith development theory are able to realize that while a task or goal may be difficult or daunting, it is attainable with determination and positive motivation. Faith in a higher power can be solid in this stage. However, when viewing the world a person can become cynical and belief that the world is a good place can become difficult to perceive. This requires a steady devotion to seeking strength and knowledge from faith and a higher power, as well as finding a social group that has similar beliefs (Parker, 2009, p. 114).
Kohlberg and Fowler are thorough in their study of moral and faith development, and while there are criticisms, these two factors have found their way into substance abuse recovery and have been successful in guiding many who have been in active addiction into a life that is fulfilling and faith filled.
While neither researcher mentioned a distinct spiritual basis, Alcoholics Anonymous and the 12-Step program have situated a program that is founded on a relationship with God and a deep spiritual walk with Christ. In the book Alcoholics Anonymous, Bill W. speaks to the atheist or agnostic: “Lack of power, that was our dilemma. We had to find a power by which we could live, and it had to be a Power greater than ourselves” (Wilson & Parkhurst, 1939, p. 45). ‘A power higher than ourselves’ is specified as God by Bill W. and he challenges those in active addiction to give over their dependence to Him (Wilson & Parkhurst, 1939).
Scripture is highlighted throughout each step, and clients are encouraged to either discover Christ as their savior, or to renew their existing spiritual walk with Him. Spirituality is a personal experience. Mason, Deane, Kelly and Crowe differentiated “Spirituality is considered to be a predominantly individual experience, whereas religiosity is often thought to include individual and institutionalized components” (Mason, Deane, Kelly, & Crowe, 2009, p. 1927). Alcoholics Anonymous and the 12-Step Program encourage both a personal relationship (Step 2) and an institutional factor (Step 12).
James 1:12 reminds us that “blessed is the man who endures temptation; for when he has been approved, he will receive the crown of life which the Lord has promised to those who love Him” (NIV). How to endure temptation is key, and there are many avenues science and research has found to treat the disease of addiction. Medications are used to ease the discomforts or lessen the risks of withdrawal, however, without further treatment the majority of clients are in active addiction shortly after treatment. Drugs that treat drug addiction are popular, the most being methadone which tricks the tissue into thinking it has been given opiates as the body has become accustomed to having the drug in the system and has need of its effects (DrugFacts: Treatment Approaches for Drug Addiction, 2009). Antabuse is commonly prescribed for treatment of alcoholism which makes the user ill if a drink is given. While all of these medications may seem viable ‘treatments’ for addiction, a question that could be asked is ‘What if the person with the active addiction decides not to take them?’ In this case, treatment begins at square one.
Behavioral treatment envelopes many areas, including motivational interviewing which helps a human service professional assess the client’s readiness for recovery and further that client’s motivation to do so. Motivational incentives increases the likelihood of recovery by offering incentives for abstinence from drugs or alcohol (DrugFacts: Treatment Approaches for Drug Addiction, 2009).
Cognitive and behavioral therapy offers a client the opportunity to recognize triggers, stressors and motives for addiction and supports a change in thought and behavior to increase the odds of successful treatment and relapse prevention (DrugFacts: Treatment Approaches for Drug Addiction, 2009).. This therapy can be simply cognitive and behavioral, or it can be spiritual and faith based. “Although it is unclear exactly how spirituality operates to predict craving, it is possible that spirituality may improve one’s sense of confidence in a range of situations (self-efficacy) and the capacity of individuals to effectively cope with “cravings” over the course of treatment” (Mason et al., 2009, p. 1928). By helping clients grow in their walk with Christ, and find faith in God and in themselves, it is promising that recovery can last a lifetime.