Decades later, the memory of my first relapse is as crystalline and sharp as a grain of really good ketamine. It was my junior year of college, and I was in court-ordered rehab. My dad and I were sitting in the industrial gray-hued cafeteria between bouts of group family therapy when, with the bloodhound precision he’s always had for sniffing out my drugs and paraphernalia, he pulled the bucket hat from my head, reached in its tiny cargo pocket (this was a very fashionable hat at the time), and plucked out a half-empty bag of ephedrine. Trucker speed.
“It’s legal,” I said. “You can buy it at gas stations.”
I didn’t consider this a relapse, but I also didn’t consider myself an addict. My rehab counselor saw things differently. She said I had to go to 30 Alcoholics Anonymous meetings in 30 days if I wanted to “graduate” from rehab.
I wish I could say this was my last time relapsing while I was on probation. I did choose better drugs the next time, but my family was over my antics. “I’m sick of your lies, sick of your drugs. I hate you, get out of my house” was the gist… and I did.
Since then, I’ve experienced both sides of relapse—been the user and the wounded loved one staging an intervention. Very recently, a family member relapsed after 10 years of sobriety. I’ve spent a lot of time thinking about relapse and the best ways to support someone who’s using substances in an unhealthy way. (“I hate you” isn’t it.) So I asked addiction and mental health experts how to be there for a loved one if they relapse. This is what they have to say.
Understand the nature of addiction.
To put relapse into context, it’s important to first understand what addiction is and what it isn’t. Addiction is not a moral failing. It’s not being a weak person. It’s not a sin. It’s a “very complex brain disease that has behavioral manifestations. It’s a combination of genetics and external factors,” said Lauren Grawert, an addiction medicine specialist and psychiatrist at Kaiser Permanente.
The American Society of Addiction Medicine defines addiction as a chronic disease, like diabetes or asthma, based on underlying neurology. For a number of reasons, including genetics, life experiences, and environment, the brain of a person with addiction has lower dopamine receptor density (you’ve probably heard of dopamine, a neurotransmitter involved in motivation, emotion, learning and reinforcement—or motivational salience) and therefore a lower “dopamine tone,” according to psychiatrist and addiction specialist Howard Wetsman. That means activities that are rewarding for the average person—charity work, video games—don’t feel as rewarding to people struggling with addiction.
“Addiction is an unwell brain trying to feel normal,” Wetsman said. “The most important thing to understand about someone with addiction is that they aren’t acting that way because they feel the way you feel and are choosing a different way. They choose it because they don’t feel the way you feel, and if you felt the way they felt, you would probably be doing that, too.”
Accept that the whole concept of “relapse” is kind of whack.
John Mendelson, a Bay Area physician specializing in addiction and internal medicine and chief medical officer at Ria Health, thinks we need to change the language around addiction. Being lapsed is a state of not being in grace with God, he pointed out. Mendelson prefers to say “return to harmful drug use”—which, while a little clunkier than “relapse,” at least avoids the judgey overtones.
“Addictions all have these cycles of doing badly and periods of getting better,” Mendelson said. “What we call successful treatment in medicine is when people have longer intervals between periods of doing badly and shorter episodes of doing worse.”
Shaming a person who relapses can actually compel them to use more. As their dopamine-deprived brains flail and grasp for a life preserver, loved ones can mentally reframe relapse as a positive experience, one that can teach people useful things about their addiction.
“[People with addictions] can learn, What do I need to do different moving forward, what were vulnerabilities, what are things I’m going to change in my life so this doesn’t happen again?” Grawert said. In other words—to quote a maxim I often heard at AA meetings—relapse is part of recovery.
Be ready and equipped to help your loved one if there’s an emergency or overdose.
If your loved one has been consuming heavy amounts of benzodiazepines or alcohol, stopping cold turkey could cause seizures or death, and they might require a medically supervised detox, so if you’re helping them stay sober in the immediate, be ready for any emergency trips to the hospital.
It’s important to keep naloxone and fentanyl test strips on hand if your loved one uses opiates. “The safety considerations are really important,” said Pat Aussem, a licensed professional counselor and associate vice president of Partnership to End Addiction. “If someone has relapsed on opioids, it is essential they have naloxone on hand. It can reverse an overdose.”
All major pharmacies, like CVS and Walgreens, carry naloxone over the counter, and it costs $25 to $80 or is free with some kinds of health insurance, and through community health initiatives in some areas. NEXT Distro, a not-for-profit harm reduction agency, offers information on how to administer it and where to buy fentanyl test strips, which aren’t widely available. You can learn how to use fentanyl test strips and naloxone in two VICE guides from earlier this year, too.
Talk about treatment.
OK, so addiction is a brain disease and relapse is part of its course. That’s easy to understand, but possibly a little harder to swallow when your loved one has pawned your amp to buy drugs, or hurled a box of whippit canisters at your face, or overdosed and ended up in the emergency room (again). What’s the right balance to strike between enabling people and scolding them? How does one maintain healthy boundaries—which may involve creating distance—without making a person with addiction feel abandoned?
The first step, Grawert said, is a “courageous conversation”—an empathic, honest talk with your loved one about getting back into treatment (or maybe entering for the first time) for their addiction. A support system could look like a 12-step meeting, addiction therapy, inpatient or outpatient rehab, medication, or any combination of those things.
It’s not an easy conversation to have, especially if your loved one is lying to hide their relapse (that’s part of the disease). But helping that person understand the importance of getting addiction treatment is essential not just for their well-being, but for your own. Otherwise, you may find yourself cast in the role of ersatz therapist. “You can’t serve dual roles as a family member”—or friend—“and pseudo-physician. That leads to fights, burnout and stress on both ends,” Grawert said.
Once your loved one enters treatment, they’ll have a sponsor, peer supporter or therapist to keep them accountable, so family members don’t have to. Plus, professionals have these jobs for a reason. Most people aren’t qualified to do this level of work, and even if they are, acting as a counselor or physician for their own loved one poses serious boundary issues and ethical red flags.
When you do decide to have that talk, it’s best to approach it from a place of concern and curiosity, according to Diana Anzaldua, founder of Austin Trauma Therapy Center and a licensed trauma-informed psychotherapist. “An example might look like: ‘I care about you, Is it OK for me to ask you about your drinking/using?’” Anzaldua said. “If they agree, you can respond with, ‘Is everything OK? I noticed you’re drinking again and thought you were in recovery.’”
If your loved one declines your request to talk about their substance use, then you have to respect that they may not be ready to address their behaviors or change them, Anzaldua said. People with addictions are allowed to have boundaries, too, including some around discussing their usage.
Set boundaries.
If you turn a blind eye to a relapse (maybe you pretend you didn’t find their stash or that you don’t smell them smoking), you risk supporting or reinforcing unhealthy behaviors—also known as enabling. So have that talk about treatment, difficult though it may be, and set some boundaries. Boundaries will help you preserve your mental health, your loved one’s efforts to maintain their sobriety, and maybe even your bank account. It’s possible to set boundaries that encourage healthy behaviors.
Lots of people have boundaries around money and the way they are treated in their home. “Maybe somebody wants money to go into recovery housing,” Aussem said. “A family member may give money directly to the renter of that space as opposed to their loved one who’s struggling with addiction, because money may be a trigger for that person.”
My family felt they were enabling my drug use by allowing me to live at home, but you don’t have to kick your loved one out. Some people create boundaries that require the person with addiction to leave for a night if they use substances, or sleep in the garage. Other people choose not to shield the person with addiction from the consequences of their actions. My parents opted not to bail me out of jail, for example.
“Sometimes life teaches good lessons,” Aussem said. “Life has a way of showing somebody there are consequences for their actions without you getting in the middle of it.”
Avoid triggering settings.
If the person you care about is using again in social settings with other friends, it can be hard to know whether to say something, whether to act like nothing’s happening, or whether even sticking around is enabling. The best way to support someone suffering from a substance use disorder is to avoid exposure to situations that could potentially involve alcohol or substances, Grawert said. “If this situation unintentionally arises, it is best to try to find a way to remove yourself and your loved one from the vulnerable environment as soon as possible,” Grawert said.
If that’s not possible, you can ask whether it would feel supportive to their recovery if you skipped using substances with them. And if they’re already intoxicated, you can hold off, and start a conversation about their substance use from a place of care when you’re both out of the situation.
Take care of yourself.
Addiction is a family disease, and that doesn’t just mean that it has a genetic component—it means that one person with addiction affects everyone close to them. It’s important for you to get help, because otherwise, loving an addict can become an addiction in itself. I learned that at Al-Anon (I’m what members call a “double winner”), a 12-step group for people who are affected by someone’s substance use.
Al-Anon is a great resource for learning about self-care and setting boundaries. It helps you extricate yourself from the roller coaster ride of the addict’s struggle, and paradoxically, by creating distance and working on yourself, you can be a beacon in their recovery.
“Don’t bend over backward trying to fix them,” said Erica Caparelli, a social worker and psychotherapist. “The hope is they will find their way when it’s time. All you can do is support them in their journey.”
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