In a previously published article titled, "Coyote in a Bottle" (Fall 1999), I compared the disease of addiction with the trickster figure in Native American coyote myths. I pointed out the trickster's sly, mischievous nature, his tendency to get into trouble, cross boundaries and refuse to reflect on the problems he causes himself and others.
One of the times a therapist will find Coyote is when the alcoholic or addict is on the verge of a relapse. I don't know how many times patients have mentioned their intentions to attend an upcoming social engagement, a wedding or a bachelor party (perhaps in Las Vegas). Sometimes I can almost see Coyote on the couch whispering to my patient, "Go on. You've got it under control. It's only a weekend. Have some fun."
Monitoring relapse risk is essential at any stage of therapy whether a clinician is treating patients struggling to control use, strengthen abstinence or continue sobriety. Assessing relapse risk can be as simple as reflecting on
the status of the individual's sobriety, or it may involve
a thorough evaluation of ten commonsense criteria.
These include Primary Relationships, Family History, Recovery, Drugs of Choice, Patterns of Use, Work History, Dual Diagnosis, Relapse Plan, Lifestyle and Attitude
toward sobriety.
The ten criteria below will help flesh out each concept. Later, I will tell an old Coyote story that illustrates the seductive lure of relapse. The ten criteria for risk assessment are:
1. PRIMARY RELATIONSHIP Is there a long-term relationship? A stable, long-term, primary relationship is a powerful asset for individuals struggling with the task of piecing their lives together from the effects of alcohol and drug dependence. Is the spouse attending AA or Al Anon? A spouse in recovery (whether AA, Al-Anon, counseling, or psychotherapy) is a positive asset. With all the stress in the first year of recovery, having a spouse that supports sobriety is a blessing compared to someone who lives alone or lives with someone who is actively using or drinking.
2. FAMILY Are there long-standing supportive relationships with family members? Having family support can be emotionally and financially beneficial for the recovering alcoholic and addict compared to those who are alone or feel they are alone in the world. Are family members and friends alcoholic, addicted or in recovery? When friends and family members are drinking or using, the newly sober person is vulnerable to forsake abstinence and rejoin the family. Conversely, family members who participate in recovery are better equipped to deal with the alcoholic/addict as well as their own problems with co-dependence and addiction. Are family members and friends available for baby sitting? During the first year of sobriety when the need to participate in counseling and meetings can be demanding, respite care is an asset for the single parent in recovery.
3. RECOVERY Does Recovery include inpatient, outpatient, residential, aftercare, 12-Step Attendance, Working the Steps, Working with a Sponsor, Group or individual psychotherapy? A basic rule-of-thumb to consider is, "The more chronic the disease and the greater the history of relapse, the more structured treatment program is recommended." High bottom alcoholics and addicts who get sober early on in the course of the disease may do well with counseling or psychotherapy and participation in AA. On the other hand, when an individual's life and resources revolved around acquiring, using and selling drugs, it is much harder to develop the emotional, social and financial network to maintain sobriety. The risk of relapse increases when an individual is trying to "white knuckle it" with as little treatment as possible.
4. PATTERN OF USE Is there a history of daily use and/or bingeing? Under the influence, binge users may experience accidents, acute health problems or psychosis. This style of use increases the rate of relapse.
5. WORK Is there a long-term work history? Has work been affected by alcoholism/drug use? Is the work environment supportive of sobriety? If alcohol and drug use interrupts work and there is an environment that is not supportive to recovery, the risk of relapse rises. Conversely, when an individual's work is unaffected and the work environment supports recovery and treatment, the risk of relapse decreases.
6. DRUGS OF CHOICE Is there a history of multi-drug use? Multi-drug users tend to have a more difficult time staying sober than single-drug users. The exceptions include any one of the stimulant class of substances (amphetamines, methamphetamines, cocaine and crack).
7. DUAL DIAGNOSIS Is there a history of psychiatric problems? Within a population of alcoholics and addicts, a varying percentage who suffer from psychiatric problems (including: schizophrenia, depression, bi-polar and anxiety disorders) use a variety of prescription and illicit drugs to self-medicate. Individuals without psychiatric problems present fewer treatment complications and have a lower rate of relapse.
8. RELAPSE PLAN Is there a realistic relapse-prevention plan? Regardless of an individual's drinking or recovery history, having a realistic relapse plan that includes increasing the number of weekly meetings, therapy sessions, re-working the steps and calling 12-Step contacts can be described as "sobriety insurance." Not having a plan is like jumping out of an airplane without a parachute.
9. ASSOCIATION Does the individual associate with people or visit locations identified with using and drinking? Spending time with drinking and using buddies in old haunts such as clubs, bars and liquor stores presents individuals at risk for relapse with overwhelming desire to give in to coercion or psychological triggers that initiate craving.
10. ATTITUDE Does the individual acknowledge a problem with alcohol/drugs, question the importance of sobriety or fantasize about using again? The more subtle indicators of relapse include questioning the need to remain abstinent, minimizing the effects of the disease and fantasizing or dreaming about using. The patient toying with relapse is likely to regress to self-centeredness or an over-confidence in sobriety. This inflation increases the risk for relapse and is a characteristic sign of Coyote's presence. In this state of mind, a patient is likely to think that everything he does will come out right.
Coyote Makes His Way to Zuni
At one time, Coyote was on his way to get married. He was all excited about his new bride, the celebration that was to take place and all the presents the new couple would receive.
After walking for many days in the hot sun and through the dark and cold of the desert nights, Coyote came upon a group of animals gambling around a fire.
Coyote thought, "I'm tired. I think I'll sit by the fire with these nice fellows and rest a bit. Besides, I have plenty of time to get to Zuni."
After a while, someone asked Coyote to join in the game. "Why not," Coyote thought, "I have a little money. When I win, my bride's family will think much more of me." So Coyote started to gamble and he actually won. "This is great," he thought. "Look at all the money I have."
He told his companions he was ready to move on to Zuni. "You can't leave now," they said, "You've got to give us a chance to win just a little of our money back. It's only fair."
And Coyote thought, "Well- if they want to lose more of their money, it's all right with me. If I continue for a short while, I'll be right on time."
But he didn't win. In fact, Coyote started to lose. And as his luck changed he felt sad. He lost all the money he had won and even then some. Then he thought, "I can't stop now. I have to win back the money that I started with."
But he didn't. In fact, he lost all his money. "Oh! This is terrible." Coyote thought. "I've lost all my money and have wasted my time. I'll certainly be late for the wedding now."
"Don't leave now," another animal said. "You can still come out all right. What else do you have to wager?"
Now up to this point, Coyote had the nicest fur of all the animals. It was long and warm in winter and soft and cool in summer. "All I have is my skin," Coyote said, and they accepted his bet. But he lost. So they skinned him alive. But just to show they didn't have hard feelings, they put pitch tar on his body and stuck bits of hair from here and there on him.
And this is why Coyote's fur is so mottled to this day.
Without careful consideration and discussion, the recovering addict and alcoholic, whether inflated or deflated, may rationalize the need or greed to buy a fast car, take a vacation with friends who drink, start a new and exciting relationship or go on a shopping spree.
Flattering a therapist's vulnerable self-image, he might toss in a compliment, "I'm trying to take care of myself as a reward for all the good work we've done." Smiling, binding you to his slippery logic, he (or she) might add, "After all - you've been trying to teach me that I can have fun without alcohol or drugs."
And if you don't hear Coyote, you'll both get taken.
Jacques Rutzky is in private practice in Woodside, California. He is the author of Coyote Speaks: Creative Strategies for Psychotherapists Treating Alcoholics and Addicts (Jason Aronson/1998). He may be contacted at 650/851-8759, by e-mail at jr@minka.batnet.com or by writing to P.O. Box 620923, Woodside, California 94062.
Reference
Rutzky, J. "Coyote in a Bottle." Paradigm, Vol. 4, No. 4, pgs. 4-5, 22, (Fall, 1999).
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