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EXCLUSIVE ARTICLE |
"A Phenomenological
Exploration of Relapse in the Alcoholic"
By Jesse J. Morris, Ph.D., LPC, MAC Assistant Professor, Psychology (Visiting) University of New England
The purpose of this study is three fold: (1) to contribute to a clearer understanding of the return to alcohol use; (2) to describe how an alcoholic moves from abstinence back to addiction; and (3) to address why the alcoholic has such a difficult time sustaining those characteristics that are meant to maintain abstinence.
An empirical-phenomenological approach was utilized. Data consisted of four subjects’ protocols and taped interviews describing their experience of resuming alcohol use after at least a one-year period of abstinence. The data revealed that the movement from abstinence to resumed alcohol use occurred in phases: (1) Experience of life as meaningless and worthless; (2) Re-metaphorization(s) of alcohol; (3) Interpersonal relationships experienced as empty, void and useless, (4) Self respect, self-esteem not discernible and an alternative to alcohol seemingly non-existent as the alcoholics began drinking again (5) with the end result being a return to treatment.
A Phenomenological Exploration of
Relapse in the Alcoholic
Alcohol is the most widely used drug in the United States (Substance Abuse and Mental Health Services Administration, 2001). According to the DSM-IV (American Psychiatric Association, 1994) approximately 8% of the U.S. population meets the criteria for alcohol dependence. Of this population, when treatment is sought, relapse is a common theme.
Relapse has plagued the alcoholic population and treatment facilities. According to Brownell (1986), current estimates of relapse rates across the various addictive disorders range from 50 to 90 percent.
A more recent study was conducted by Iber (1991). The conclusion drawn from his research was that “almost any patient undertaking consultation for substance abuse who enters treatment will attain some period of sobriety” (p 237). However, of 500 consecutive patients who entered a VA alcoholism program of 5 days, the majority managed to stay abstinent for two weeks. The relapse rate after two weeks was 90%.
Purpose:
The overall purpose of this study was as follows: (1) to enhance the present understanding of relapse by pinpointing specific factors that interfere with the alcoholic’s ability to stay sober; (2) to provide the missing pieces in the understanding of relapse by going directly to the source of the phenomenon under investigation; (3) to possibly provide information that is lacking in the current understanding of relapse by providing information that is helpful in the treatment of relapse and its prevention; and (4) to obtain additional information to be used in the treatment setting, that may provide the alcoholic with increased knowledge about what areas to be cautious of in recovery, which may either eliminate relapses or lengthen the times between each occurrence.
In the past, the traditional view of relapse from a psychoanalytic perspective was related to the relationship between the drug abuse and the libido (Platt & Labate, 1976). A behaviorist may relate the occurrence to the theory of classical conditioning, modeling or learning. Other approaches may explain the phenomenon on the basis of a moral issue or as a disease. The current study was designed with the goal to move beyond these perspectives.
Method:
An existential-phenomenological method was chosen for this study to help the researcher gain a deeper understanding of the participants’ experiences through the use of nondirective interviews (Zakrzewski & Hector, 2004). The overall aim of this approach is to view the phenomena and to accept an individual’s experiences of his/her term terms, unaltered by strategies of analyses, unshaped by theoretical predictions and unhampered by technical verbalizations (Monte, 1999).
Participants:
All subjects were volunteers from a rural substance abuse treatment center. Confidentiality was ensured during interviews and with the maintenance of documentation. A primary diagnosis of alcoholism according to the DSM-IV (1994) was the first requirement to participate in the study. Secondly, subjects had to be able to discuss the time when abstinence was intended and attempted for at least one year but then alcohol use was resumed. Furthermore the cut-off level of one year of sobriety was used based on observations and professional readings that it appears to take approximately one year for the alcoholic to begin to establish successful stable sobriety. The relapse rate for individuals with less than one year seems to be too high to provide appropriate data for the purpose of this study (Friday, 1992; Morris, 1986).
Phenomenological Data Collection:
The researcher began with a written description based of the following reasons: (1) An initial written description helped to promote more organized data of the phenomenon as it is experienced; (2) It provided the researcher with the opportunity to reflect upon the protocol and raise questions concerning the description prior to an interview; (3) It further provided a point of departure for the prospective interview and at the same time it gave focus to the interview. Each subject was asked to respond to the following:
“Please describe in writing as completely and with as much detail as possible a time when you were not using alcohol but then began to use it again after at least one year of sobriety. Discuss what happened prior to, during, and after the time you began using alcohol again. Include in your written description what you were thinking and feeling at that time, discussing any changes that may have occurred within you or within others.”
Data Analysis:
In the next phase of the investigation the researchers analyzed the initial written protocol in order to determine where elaboration on the subject’s experience was needed and to gain a grasp of their individual essence (Jackson, 2006). This initial reflection was needed in order to generate some guidelines for the collaborative interview and for the researcher to focus on the totality of the phenomenon and not simply the details.
After completing the analysis, the researcher met again with the subject for a 45-90 minute taped recorded interview. The taped collaborative interview was used to help clarify, deepen and broaden the written descriptions and issues raised.
The researcher then read and read the elaborated protocol and interview with the intention of grasping and delineating the subject’s experience. As the researcher slowly read over the description, the goal was to perceive transitions or changes in the meaning of the individual’s experiences, referred to as meaning unit. This step demands bracketing where the researchers disengage from all past theories, biases, assumptions or knowledge of the phenomenon being investigated. This allows for the phenomenon to manifest itself (Jackson, 2006). As DeRobertis (1996) states, it is impossible to capture all of ones presuppositions thus in the study additional readers were utilized in an attempt to prevent subjectivity on behalf of the primary investigator. Discrimination of the meaning involved dividing each subjects protocols into smaller, discrete sections whenever researchers discerned a shift in meaning (Jackson 2006). In the next step, the researcher attempted to understand the meaning of each natural meaning unit of the interview and protocol. The specific question that was put to each meaning unit was: “What does this tell me about beginning to drink alcohol again after a period of abstinence?” This became the central theme of each meaning unit.
The central themes comprised the data at this step. The researcher brought together the central themes into a psychologically relevant descriptive statement, which included the concreteness, specifics, and essential meaning of the actual research situation, referred to as a situated structure. Each situated structure summarized and made more explicit what the researchers found to be fundamentally implicit within the phenomenon for each subject individually. This is a written description of the subjects’ personal relapse experience.
The final step was to generate a general structure of the experimental movement from abstinence to relapse and to determine the essential constituents of the experience (Jackson 2006). The researcher dialoged among all situated structures of the phenomenon analyzed in order to discover what, if anything, was essentially common among them.
Results:
Four participants were involved in the study with an average of 7 years of sobriety. In the data analysis it was discovered that there were four general features in the return to alcohol abuse. (1) Experience of life as meaningless and worthless; (2) Remetaphorization(s) of alcohol; (3) Interpersonal relationships experiences as empty, void and useless; (4) Self-respect, self-esteem not discernable and an alternative to alcohol seemed non-existent as the person began drinking again.
Discussion:
“Experience of Life as Meaningless and Worthless”
Each subject’s experience of life prior to the return of alcohol use was marred by feelings of interpersonal purposelessness, meaningless, emptiness, and rejection. Each felt that those who once provided them with acceptance and support were now rejecting them. Subjects reported feeling unloved and un-needed. Self-pity and depression set in along with loneliness and uselessness.
Subject #1 stated, “Well, I just felt useless. You know, all alone.” Subject #2 commented “I was feeling rejected…I was feeling unloved.” Subject #3 stated, “I started feeling lonely and depressed.” Subject #4 commented, “ Things were falling apart.”
“Re-metaphorization(s) of Alcohol Amid the Futility-of-Life-Experience”:
Re-metaphorization of alcohol began to appear as alcohol, which was once interpreted as something to be avoided began to be viewed as something to value. The subjects recalled the positive side of their addiction and began to doubt the value of sobriety. They began to focus on how the alcohol had once provided them with relief from the stress and strains they experienced in life. The individuals considered the value of alcohol in their past lives and how it actually did make them feel better. Subject #1 notes, “ I’ll drink me one or two…it will relax me and make me sleep better.” Subject #2 commented, “It had been so many years since I had drank” , “ I was just so lonely.” Subject #3 stated that “it was after my suicidal thoughts came that I started to drink to get relief…I was just trying to fill the emptiness.” Subject #4 commented that “All the good times I had to have before started to come to mind.”
"Interpersonal Relationships Experienced as Empty, Void, Useless":
The literal return to alcohol use involved a situation in which all subjects experienced a type of emotional discomfort and interpersonal void. Each continued to experience feelings of uselessness, rejection, and loneliness. Subjects reported losing jobs and families and feeling that they had nothing more to offer anyone. Subject #1 stated “…he no longer needed my help. So I no longer felt needed.” Subject #2 commented that “I was feeling rejected.” Subject #3 noted, “ I started feeling lonely.” Subject #4 stated that “Anymore, man doesn’t care about man…”
“Self Respect, Self-Esteem Not Discernable – An Alternative to Alcohol Seemly Non-Existent”:
All subjects were unable to use alcohol only once or casually, or to function adequately in life while drinking. Any attempt to take only one drink led to repeated use and increased consumption. For all subjects there were no inner resources or inner strengths to call upon for support, encouragement, and guidance. Instead a growing self-disgust and self contempt took over. The resumed use of alcohol automatically led to feelings of shame, depression, and disappointment. All realized they were out of control and were afraid of what would happen. Immediately after the drink, the reality of the addiction hit them. Subject #1 stated – “I felt guilty about it, guilt set in and shame.” Subject #2 commented “… I knew I was drowning and it hurt me.” Subject #3 stated – “When I took the first drink it scared me.” Subject #4 stated – “That little glass of wine ended up with another glass of wine.”
“Participants Thoughts About a Return To Treatment”
The return translated into a renewed attempt at abstinence and a clearer understanding of what abstinence meant. Each person discovered his/her limitations and the necessity of avoiding certain people and places. The also discovered how certain thoughts and emotions could trigger problems for them.
The subjects became more open to concentrating on their thoughts, feelings and concerns, as they continuously remain vigilant. Each understands more clearly their strengths and weaknesses when it comes to recovery. They all understand that if they are not constantly focusing on their addiction they can easily return to the same alcoholic lifestyle. All realized areas they need to be consistently aware of: Subject #1 stated – “I’d like to know why a person denies it and keeps denying it". Subject #2 commented – “I feel worthless… know need help.”
Subject #3 commented – "I finally needed to seek help, instead of shying away from people". Subject #4 stated – “…I still get depressed…people.” " I got to get up and go somewhere or do something".
Conclusion:
The following conclusions can be drawn from this data:
The alcoholic experiences an intense struggle beginning with the realization that the possibility of taking a drink exists as a desire to cling to the drinking world reappears and the alcoholic re-metaphoizes alcohol anew. In spite of all the time and effort spent identifying and discussing the signs of relapse and the warning of physical problems related to alcoholism, the alcoholic continues to battle over the issue of returning to alcohol use.
The struggle experienced is ongoing in order to come to terms with the pre-alcohol self, the self that the alcoholic detests and fears. The alcoholic has found in the addiction a new way of transforming self into all they ever hoped to be, a being far superior to the pre-alcohol self.
The struggle with abstinence entails feelings of ambiguity, a discovery of real self before the alcohol, a discovery of the world around the alcoholic, which includes a new discovery of others as the alcoholic’s individuality and personhood come into view more powerfully than before the introduction of the alcohol. The alcoholic sees self before the alcohol as inadequate and weak; those flawed qualities that were attempted to conceal new come into focus. The fears and feelings of rejection, depression, meaningless and hopelessness have their impact as the alcoholic stands alone exposed to the pain of life, a life never accepted to appreciated.
The struggle is also a struggle with what the alcoholic interprets as a demanding, rejecting, cruel world, a world and life experienced as meaningless and purposeless.
The alcoholic experiences severe feelings of uselessness, worthlessness and rejection from those people once utilized for support but also rejects these people and things that once aided in recovery. The rejection is felt both internally and externally. They do not accept who they are nor realize their personal needs or the needs of others.
There is also the fear of offering the self to others as he/she truly is prior to alcohol. The alcoholic internally rejects who he/she is without alcohol and externally rejects those people who could help. The rejection occurs out of fear, fear of who he/she really is and fear of having to look at oneself.
A fundamental change in attitude in regard to personal limitations along with a change in attitude towards the world must occur, which entails a look at the self prior to alcohol and an acceptance of self and personal inadequacies.
Imaginative thinking comes into play in the alcoholic toward an end. Murray (1986) describes this type of thinking as “a work demand made upon the individual who indulges in it” (p.29). At this moment the alcoholic’s life is demanding abstinence, which can be seen as a possibility unlike the time before when they could see no other alternative but alcohols.
The traditional understanding of addiction has been expanded in this study. The desire to drink involves much more than a desire to feel the effects of the alcohol. It is a desire to overcome one’s inadequacies and weaknesses, a desire to have healthy, loving, warm relationships with self and others. However, the alcoholic has concluded that this is only possible with alcohol.
Recommendations:
The conclusions indicate that the return to alcohol after a period of abstinence is a restrictive, limited, manner of existence. This new understanding of the return to alcohol use will require the goals of many treatment programs to be reconsidered.
The alcoholic’s experience of life as rejecting, meaningless and purposeless, which was lived both internally and externally, must be explored in therapy.
A re-metaphorization of recovery and self must also occur in treatment with both being seen as having value and significance and as being possible.
The external struggle, which focused on a fear of rejection of those people and things that once aided the alcoholic in remaining abstinent, must be also explored.
In reference to relationships, belongingness appears an essential theme for the alcoholic. Thus treatment and recovery must consist of efforts to encourage the client to participate in group therapy, AA and so on.
Overall in treatment the client needs to become fully aware of personal limitations and weaknesses with emphasis being placed on the understanding of rejection, how they relate to it, and the responses and reactions to it when it is experienced.
The importance of self and others is imperative, but the willingness to accept one’s limitations must also be explored as well as methods to increase self-respect and self esteem.
Limitations and Recommendations for Future Research:
Subjects were all individuals who had returned to treatment. It may be found that there is a difference between individuals who abstain after going to treatment and begin to drink again versus those people who abstain, begin drinking again but never return to treatment. The factors associated and the struggle involved in the return to alcohol may be found to be very different.
The selection of the subjects was based on individual personal reporting, thus honesty about the length of time actually sober and the factor associated with the relapse is based on truthfulness and integrity.
It may also be found in future studies that the factors associated with abstinence and relapse is different as the number of attempts increase, taking into consideration that alcoholism is a problem plagued by relapse.
An interesting study to consider would be comparison of subjects’ description of relapse and a description completed by family members. All could be asked the same investigative question. This could increase the integrity and honesty but further enhance the treatment of addictions but including family members at a more intense level of treatment.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC; Author.
Brownell, K.D. (1986). Public health approaches to obesity and its management. Annual Review of Public Health, 7, 521-533.
Friday, P.J. (1992). The lived experience of returning to heroine use after a period of abstinence: An empirical phenomenological study. University Microfilms International. (University Microfilm No. 9222344).
Iber, F.L. (1991). Alcohol and Drug Abuse. Boston, MA: CRC Press.
Monte, C.F. (1999). Beneath the mask: An introduction to theories of personality (6th ed). Fort Worth, TX: Harcourt Brace.
Morris, H. (1986). Being-in-control-of-one’s-drinking: An empirical-phenomenological study. University Microfilms International. (University Microfilms No. 8808339).
Murray, E.L. (1986). Imaginative thinking and human existence. Pittsburgh, PA: Dequesne University Press.
Platt, J. J, & Labate, C. (1976). Heroin addiction: Theory, research, and treatment. New York: John Wiley & Sons.
Substance Abuse and Mental Health Services Administration. (2001). Summary of findings from the 2000 National Household Survey on Drug Abuse (National Household Survey on Drug Abuse Series: H-13, DHHS Publication No. SMA 01-3615). Rockville, MD: Author.
Zakrzewski, R.F., & Hector, M.A. (2004). The lived experiences of alcohol addiction: Men of Alcoholics Anonymous. Issues in Mental Health Nursing, 25, 61-77.
I, Jesse J. Morris, confirm the following:
(a) the material above is partially from my dissertation entitled: An empirical Phenomenological Investigation of the Return to Alcohol Use After A Period of Abstinence. It was published by UMI Dissertation Services in 1994.
(b) the paper is not currently being considered for publication elsewhere.
(c) I hold myself completely responsible for the content.
(d) I did not plagiarize any of the work and I maintained strict rules of confidentiality while completing the study and followed all rules related to ethical treatment of the research participants.
Participants were able to review the final results and provided input.
Contact Info: Jesse J. Morris University of New England, University Campus, 11 Hills Beach Rd. Biddeford, ME 04005-9599, (207) 602-2695, Fax(207)602-5956, email: drjesse@netzero.com
