The Relapse Clock
Original Article 2023
I am a practising psychotherapist specialising in addictions and I volunteer every Friday at a local rehabilitation centre, where I lead sessions for the clients on understanding and developing relapse prevention plans.
Relapse of substance abuse and problematic behaviour after a period of abstinence or recovery is common. More than two thirds of clients return to using within months of exiting treatment. (McLellan, Lewis, O’Brien, &; Kleber, 2000; Paliwal, Hyman, &; Sinha, 2008). Relapsing can be frustrating and discouraging for individuals who are trying to overcome addiction or other problematic behaviours and there is more to be learnt on how to empower clients in their own recovery and help them safeguard against relapse.
This article is the story of how a group of clients within the rehabilitation centre and I co-designed an adaptation of a ‘relapse clock’ with input from one particular client, Michelle, on its development and implementation to treatment.
By bringing together the ‘cycle of addiction’ into a user-friendly ‘relapse clock’ a cohort of clients from the rehabilitation centre over a period of two months explored how they could learn and understand their personal cycle of relapse of substance or alcohol misuse, including the triggers, and the ongoing journey and process of recovering.
The development of the Relapse Clock started with a blank clockface but was underpinned by the Cycle of Change Model suggested by James Prochaska and Carlo DiClemente, Norcross, J.C. (1992. In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114).
Their model was developed in the 1980’s and was based on the idea that behaviour change is a process involving several stages, each with its own unique challenges and opportunities, highlighting a transtheoretical model. 12 noon was the start, which was labelled, ‘Point of Relapse’ and added the cycle of change stages of, ‘Pre-contemplation’, ‘Contemplation' and ‘Planning' at 9, 10 and 11 o’clock (see image attached) with 6 o’clock labelled as the ideal place to be.
Once 12 o’clock was identified as the ‘Point of Relapse', 1 o’clock represented a ‘Time of Guilt & Shame'. As Michelle described it: ‘it’s a time of waking up [a] ..crucial point to ask for help as at this point we are in the danger zone [of] denial, the fear of asking for help…feeling complete despair and isolating ourselves from everything”.
For clients to continue around the clock, they recognised that they would need to step forward into 2 o’clock and ‘Ask for Help’. 3 o’clock continued to be a crucial yet challenging time for being able to ‘Get Help,’ and achieve support for oneself. Michelle writes ‘[the] hours between 2 and 3 o’clock are a crucial moment … and can determine our chances of recovery. If we can get to 3 o’clock we can start recovery with [a] support network, family rehabilitation, therapy and the twelve-step programme. Together we realised that the hour between 2 and 3 o’clock represents a tough journey and takes time which for many addicts can take them beyond the period they want to recover and end up straight back to 9 o’clock - the ‘Precontemplation Stage’.
Continuing around the clock, it was decided that 3 to 5 o’clock would represent the rehabilitation phase, but the clients’ feedback was that the label didn’t account for all the other methods of recovery which may be called upon. These hours were then labelled as ‘Controlled Recovery’ with arrows added. In fact, we added arrows on each of the quarter segments of the clock, indicating clients could travel in both directions, e.g, you can slip back from 2 o’clock to ‘Relapse' or from 11 o’clock, ‘Planning', back to a ’Secure Place’.
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As clients enter rehabilitation their world changes and for some it is the first time they feel safe, with the chaos of living in addiction behind them. Michelle reflects “[at] 3 o’clock our core beliefs can really impact decisions at this time, am I good enough? Am I worth it? Others can talk down to us [and] can ruin our self-belief and self-worth, affecting our recovery. Once we reach 4 o’clock, our ‘Cognition Returns' and we can start to make good decisions and [begin to] use new coping skills to maintain recovery”.
As we spent time together exploring the impact of being sober or clean; how that felt and the journey the group had embarked upon, I noticed the changes in the clients’ physical appearance, their attitude and their behaviour.
We continued around the clock and concluded that at 5 o’clock clients are ‘Becoming Accountable', learning more coping skills, understanding some of the roots of their substance/alcohol abuse and, crucially, preparing to return home. Some of the group were beginning to extend their time in the rehabilitation programme, looking to do some further work on what is called ‘Stage Two’ (an additional twelve weeks of recovery) located at another site.
We spent time together looking at the transition from the controlled world of a rehabilitation centre to the independent ‘outside’ and subsequently decided that 6 o’clock is only possible with outside support from family, friends, groups and key-workers/social worker. Michelle writes, “to stay at the good point and to maintain it can be an amazing transition time, it’s what we do and how we focus during this crucial time…asking for help. Planning is essential to regain control, there has to be a way to stop the relapse clock”.
We then began to think beyond 6 o’clock and we tried to imagine what might be the influences that would cause us to become less stable or able to cope. Michelle continues, “the stresses and strains of life, work and family will move us further round to 7 o’clock, where we begin to become less accountable and are starting to deny the impact of life; wanting to appear as though all is well. [she adds that] 8 to 9 o’clock is an extremely vulnerable place, where we might ask the question, ‘was it all worth it? Changes can feel pointless, helpless and hopeless and sub-consciously we are
giving up”.
By the time we discussed 9 o’clock there was a sense that, although we had assigned 9, 10 and 11 o’clock, frequently the time from ‘Precontemplation', ‘Contemplation' and ‘Planning' happens much faster and often feels like an out of control roller-coaster. Michelle writes that, “9 o’clock is the stage we begin to blame [ourselves], substance availability, denial, and subconsciously we are unaware and desperately think things will be ok. Becoming aware things are not right, heightened awareness of despair, [a] sense of why is this hard. We then hit the self-destruct button, moving onto 10 o’clock - and before we realise we are at 12 o’clock”.
As we worked on though the weeks we became aware that the times 10 to 12 o’clock and 12 to 2 o’clock are crucial and so we created the Red Zone, which went right across the clock. Some of the group recalled that in the height of addiction they would swing between ‘Relapse', (12 o’clock), seeking help (2 o’clock) and straight back to planning the next fix, (11 o’clock). Likewise, 8 to 10 o’clock and 2 to 4 o’clock were a real challenge and a very vulnerable place to be. The group acknowledged that, similar to the Danger Zone, there were challenges from seeking help (2 o’clock), entering controlled recovery (4 o’clock) and across the clock at 8 o’clock as stresses begin to materialise (8 to 10 o’clock). We therefore inserted an Amber Zone. The times from 4 to 6 o’clock and 6 to 8 o’clock were the best place to be, therefore they become the Green Zone.
During our discussions a client remarked that although they were in rehab (3 to 5 o’clock), a relatively secure and safe place, she still felt that she wanted to relapse. We therefore decided to add the minute and hour hands, labelling the minute hand, ‘Emotional’, what we are feeling and the hour hand, ‘Actual’, meaning where we actually are.
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Michelle in her notes writes, “the recovery relapse prevention clock keeps on swinging like a pendulum between Recovery and Precontemplation. The hands of the clock can go in either direction: a clock of many emotions and feelings. The emotions are stronger to manage and we have to be aware of the internal emotional and external awareness in recovery. The two should be in line together”. Michelle adds, “we don’t move around like a clock-face. We change daily, depending on emotions and needs; asking for help and learning coping and managing skills. Our
physical and emotional needs can affect our progress and be overwhelming. [We then begin to ask ourselves several questions]. Are we ready to be sober…have the purpose to live and exist…wondering if life is worth it? Being validated in life, being wanted and not judged…is there a point of no return of being at relapse? We need a mindset and focus and reason to stay in recovery. Learning to deal with emotions. Sober is a journey and getting back a sense of
independence from addiction. If you look at the Relapse Prevention clockface, the hours are a crucial part of recovery. With the right help, support and [encouraging a feeling of] self-worth it is a powerful twelve hours that can change our lives, prevent relapse and keep us in a good place to live in the Green Zone”.
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During the period of our time together, with some of the clients leaving the programme, we had to acknowledge that for some people, they are either not ready to start the journey of recovery or cannot find the focus to continue. We inserted, just outside of the clock face, what we called the ‘F’ it! button. This represented those clients who leave in the middle of controlled recovery, sometimes with no real understanding as to why this has happened.
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Summary
The group and I began our sessions, described as, ‘Relapse Awareness’, which looked at the various factors that affect the possibility of relapse. We wanted to explore the process of their addictions and give them a way to explain simply where they were, where they wanted to be and to think about the life journey on which they were about to embark. I began with a flip-chart and we proceeded to map out what would later become the Relapse Clock. Of the eight clients in the group, three were asked to leave during our time together, (one of whom had sadly sinced passed away), three have moved on to stage two and are continuing their recovery and two have returned to their homes.
Looking at the Relapse Clock from a CBT perspective, the idea of asking the question, ‘what time is it for you’ allows us to extract two important pieces of information: where they think they are and how they are feeling. The Relapse Clock gives them a visual example of reference, enabling both key-workers and others to understand at what stage they are. I asked Michelle to give me her summary and here are her words:
“…I have found [the Relapse Clock] helpful and the work we did has enabled a way to express how addiction feels, as sometimes it is hard to put into words. Understanding…[at] what stages we need more support and at what time we relapse without a good clear plan in place. The fact that the hands represent emotional and actual I relate to so well and [I realise] that to remain in the amber to green zone is vital for my recovery. I have thoroughly enjoyed working on
this [for] the last eight weeks and definitely will be keeping the Recovery [Relapse] Clock with me on my recovery journey and strongly believe it would help anyone else to be able to relate to their addiction cycle.”