Twelve-Step Programs Are Not Enough
The Relapse Warning Sign List As An Additional Recovery Tool
Terence T. Gorski
September 10, 2001
Many treatment professionals believe that the best way for
recovering people to avoid relapse is to regularly attend Twelve Step
Meetings and work the Steps. This
belief is reinforced by the slogan: “It works if you work it!”
If this is true, it means that people relapse because they stop
going to meetings or stop working the steps.
If they’d just keep going to their meetings and working the steps
they wouldn’t relapse.
Unfortunately, many people who diligently work twelve step programs
do relapse. The AA world office in New York City publishes a series of
follow-up studies of their members which indicate that within the first 90
days of attendance at AA, 50% of the members drop out. Of those who maintain sobriety beyond the first 90 days, one
half of them will return to alcohol or drug use within the next nine
months. This means that AA
used as a single, stand-alone intervention has about a 25% abstinence
Follow-up studies of treatment centers that heavily use Twelve Step
programs indicate that when AA is coupled with professional treatment the
average sobriety rates at one year raise from 25% to between 50 and 62% in
high prognosis patients. This still means a lot of people relapse.
For these individuals, Relapse Prevention Therapy is a critical
addition to their recovery program.
At the heart of Relapse Prevention Therapy is the understanding
that relapse is a process not an event.
Relapse begins long before alcohol and drug use.
In essence the relapser moves from a state of stable recovery back
into alcohol and drug use. This
journey is similar for all addicts and the process has been mapped out in
the form of a relapse warning sign list.
This list of warning signs can literally save your sobriety if it
is used correctly. Unfortunately, many people don’t know how to use the
warning sign list as an effective relapse prevention tool.
They make the simple mistake of believing that all they have to do
is read the warning sign list, check the warning signs that apply to them,
and somehow they will magically stay in recovery.
Unfortunately, for most recovering people, this isn’t true.
The relapse warning sign list was never intended to be used as the
exclusive checklist to avoid relapse.
The warning sign list is simply a starting point.
It’s a tool designed to help people to recognize and remember
specific things that have happened to them on their personal journey from
recovery to relapse. Here’s some guidelines about how to use the warning sign
list more effectively:
First, review the list of warning signs.
This is best done by reading the warning sign list out loud in a
recovery group, with a therapist, or a recovery sponser.
The warning sign list and the complete descriptions of each warning
sign are read aloud for a period of ten to fifteen minutes.
Then the group stops reading and each person comments on how he/she
is relating to the warning signs that are read.
After everyone comments, they continue reading again for another
ten to fifteen minutes until the entire warning sign list is read.
Second, ask each member of the group to select three warning signs
that they identify with and rewrite them in their own words.
Each warnig sign should have a personal title consisting of a word
or short phrase that is easy to remember and a personal description that
starts with the words, "I know I am in trouble with my recovery when
...". Each member of the
group reads these three personalized warning signs to the group and tells
the group why they selected these warning signs.
Third, each group member tells the story of a past experience
related to each warning sign they selected.
In the context of telling these stories, hidden warning signs
become apparent. A hidden
warning sign is a problem in recovery that is related to relapse which the
relapser was previously unaware of. Just
as most people do not get a traffic ticket from an officer that they see,
most relapsers do not get drunk over warning signs that they are aware of.
The goal of relapse prevention therapy is to use the initial
warning sign list as a projective device to help people get in touch with
their own unique, personalized list of warning signs that lead them from a
stable recovery back to alcohol and drug use.
Fourth, each group member identifies a time in the near future when
they nmay experience one or more of their warning signs and describe in
detail how they could mismanage that warning sign in a way that could lead
to using alcohol or other drugs.
Fifth, each member of the group listens carefully, asks clarifying
questions, looks for hidden warning signs, and gives the feedback.
Sixth, write each hidden warning sign on a 3x5 card, arrange the
cards in the sequence in which the warning signs tend to occur.
Be sure to eliminate duplication and identify any gaps in the
action where vital warning signs may have been missed.
The end result is a personalized list of relapse warning signs
which clearly shows the sequence of connected problems that lead from
stable recovery to relapse.
Seven, once this list is written and arranged in proper order, the
next step is to identify the three most critical warning signs.
This is done by identifying the warning signs that can recognize
when they occur.
Eight, develop a warningn sign management strategy which describes
his/her old, self-defeating way of coping with that warning sign and
replaces it with a new, more effective coping strategy.
Behavioral research indicates that mental rehearsal techniques,
especially when supplemented with role plays and actual practice exercises
do, in fact, reduce the relapse rate.
Nine, backtrack to the earliest possible indicators that a person
is becoming dysfunctional in recovery.
This is done by looking at the first warning sign on the list and
asking the question: “Did
the process really start here? What
happened before this that caused me to experience this warning sign?
Ten, identify the thoughts, feelings, and action urges that
accompany each warning sign. This
is done by turning each warning sign over and writing down a:
thought statement (“When I experience this warning sign I tend to think
feeling statement (“When I experience this warning sign I tend to feel
urge statement (“When I experience this warning sign I have an urge to
action statement (“When I experience this warning sign what I actually
do is …”),
social reaction statement (“When I experience this warning sign people
around me tend to respond by …”).
Eleven, sort the cards according to thoughts to identify the
primary irrational thoughts that drive the relapse process.
Once you find these thoughts, you can develop ways to challenge
them sober rational ways of thinking.
Twelve, sort the cards according to feelings to identify the
primary feelings and emotions related to relapse.
Research has shown that nearly 70% of all relapses are related to
unmanageable emotions. This
sorting technique is very powerful in identifying the feelings and
emotions that set them up to return to alcohol and drug use.
Once these feelings are identified you can then develop effective
emotional management strategies.
Thirteen, sort the cards to identify the common self-defeating
urges. By recognizing the
self-defeating behaviors that you feel an urge to use, you can figure out
a way to manage those urges.
Fourteen, sort the cards by self-defeating actions and then develop
more constructive things that you can do to stop the relapse process and
get back into recovery.
Fifteen, sort the cards by social reactions.
Tjhis will allow you to see how you are inviting people react to
you in a way that gives you excuses to go back to using alcohol or other
drugs. Then you can
consciously develop ways of inviting people to respond to you in more
The final step of relapse prevention therapy is to develop a list
of high risk situations and a recovery plan to help them counteract those
by either avoiding them or learning how to responsibly cope
The books, Staying Sober:
A Guide For Relapse Prevention, Passages Through Recovery and
the new Staying Sober Workbook
provide a better in-depth idea of how the CENAPS Model of Relapse
Prevention Therapy works.