In the latest episode of the Addictions Edited podcast, Rob Calder talks to Dr Maike Klein from the University of Bath about her qualitative research into relapse. They discuss how relapse can be perceived as part of recovery or antithetical to it, the connection between overdoses and relapse, and the impact of recurring relapses on the therapeutic relationship.

Dr Klein’s PhD focused on experiences of ‘relapse’, which is the term used to describe someone returning to substance use after a period of non-use.

Asked why relapse is such an important phenomenon to study, Maike explains that people who relapse are at much greater risk of an overdose. When people stop using drugs, they lose tolerance for those drugs quite quickly. If they return to prior levels of consumption, what may previously have given them desirable effects, may now be a fatal or life-threatening dose.

“When an individual abstains from their drug of choice and goes to treatment, their body adjusts to different tolerance levels than they had when they were using. If they then exit treatment or something happens along the way, and they end up using the same amount of drugs that they used to, this can lead to a lot of complications, including an overdose and then potentially even a fatal overdose.”

Participants in Maike’s research demonstrated two very different conceptualisations of relapse. Some people anticipated their relapse, or were not surprised when it happened; they could recognise behaviours and events that led up to their relapse. Others found it quite shocking, and felt that their relapse came ‘out of the blue’.

These different ways of experiencing relapse shaped their views of recovery. The first set of participants were more likely to see their relapse as something they could learn from and grow from, and as part of the recovery process. The second set were more likely to be fearful of relapse, to see it as a threat to their life, and to think, ‘I cannot relapse one more time’.

One of the main themes in her podcast discussion with the SSA’s Rob Calder is the importance of moving away from categorical views of recovery – i.e. of someone either being abstinent or not abstinent, of ‘not using’ or ‘using’. Relapse is a very common experience, she says – particularly among people who use opiates or stimulants, where as many as three quarters of people may relapse. It may therefore be more useful to think of relapse as something that happens during long-term recovery, as opposed to a sign of personal failure and a rejection of recovery.

Rob notes the sense of powerlessness that Maike’s participants described when they had relapsed multiple times, and drew parallels with the language of the 12 steps of Alcoholics Anonymous, where step one is ‘We admit we are powerless over alcohol – that our lives have become unmanageable’. Maike says that the cumulative effect of recurring relapse was not only powerlessness, but a sense of ‘self-mistrust’.

Maike reflects on these findings as a clinician. She says that the dominant models of relapse prevention focus on building self-efficacy, and in particular the ability to navigate risk environments. Her findings, on the other hand, suggested that her participants need help with gaining trust back in themselves when they do engage in risky behaviour, perhaps more so than help building their belief that they can reach their goals and avoid risk altogether.

Rob recalls that several participants described relapse as a ‘place’ or ‘location’. Maike elaborates on this finding, and says that their descriptions evoked a lot of empathy in her, and enabled her to understand how relapse must be isolating, difficult, and challenging, without participants having to explicitly say so.

“One participant, explaining it to me, said it’s like going from a stable familiar place to a chaotic place. So, they understand relapse as something where you can go to or arrive at, and it’s a bit like [the television series] Stranger Things, there’s a sort of a different reality there.”

Maike’s research developed from her own experiences as a therapist in the US, where she was “very frustrated” with the way the treatment system handled people who relapse. Rob asks her whether practitioners experience ‘second-hand trauma’ from working with people who experience relapses. She says ‘yes’, that therapists can be deeply affected by witnessing what their patients are going through, and experience things such as burnout. But she says there’s also a sense of powerlessness that can come from witnessing repeat relapses – mirroring the powerlessness felt by patients – which has the potential to make a therapeutic environment quite untherapeutic over time.

This article is based on a podcast episode available to download or stream here. Quotes have been condensed and edited for clarity.

by Natalie Davies

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