What’s the Trendline?
The word “relapse” in both Mental Health (MH) and Substance Use Disorder (SUD) most simply means that symptoms have returned. In other words, a return to behaviors or thought processes that existed prior to treatment intervention. It doesn’t mean failure. This cycle of ups and downs exists in almost every major systemic disease – so why do we think differently about MH and SUD?
Same but Treated Differently
I use the comparison of Type II Diabetes often since it’s such a prevalent disease in modern America – but also because it most closely relates to the two factors of MH and SUD: behavioral and physiologic causes. Type II Diabetes is caused by (1) a person’s behavior: poor eating habits and sedentary lifestyle which leads to (2) a physiologic effect: the pancreas produces less (or no) insulin. Spoiler alert – the treatment consists of the same two factors: behavioral (diet and lifestyle changes) and physiologic (insulin / medication therapy).
MH and SUD are markedly similar in treatment: behavioral modification and medication support. So how is it acceptable that a person with Diabetes on insulin treatment can talk about having a “cheat day” where they just use more insulin so they can indulge in unhealthy eating habits? But someone who has an anxiety attack or depressive episode, or gets drunk on a Saturday night is a treatment failure and socially condemned? Or to be even more blunt, what about someone that is on erection disfunction (ED) treatment and doesn’t get it up one night? Is that a treatment failure or relapse? Diabetes and ED elicit empathy even though they are just as behavioral and physiologic in nature as MH and SUD issues.
Stocks and Trendlines
So let’s talk about stocks – as in the stock market. Over time the market goes up and down. Day traders chase these highs and lows to make (or lose) a quick buck – but the smart players look into the long-term investments. This is how most retirement plans work. We put money in over time and that money grows from interest earned on market returns. But then the market dips – oh my god I’m losing everything! The financial managers say to relax and that we’re investing in the long term. Don’t pay attention to these “dips” or “market corrections”. What matters more is the long-term trendlines.
It’s important to understand the trendline in MH and SUD treatment. Like any other disease, treatment takes time to develop visible changes in outcome. An obese person with Type II Diabetes may get their physiologic insulin levels under control, but still has a long way to go with behavioral changes in diet and lifestyle before visible changes are perceptible. The same philosophy applies to treatment of MH and SUD. Initial detox and medication management is a key starting point, but visible changes to behaviors may not occur for quite some time.
It’s not a Market Reset
Too many times I’ve seen folks back in formal SUD treatment after a weekend binge. Like they need to start over. This is often times called “reintensification”. This really, really disturbs me. How about we lock up smokers after they puff a cigarette or we send folks off to fat camp after they have dessert? That sounds as silly as it really is. Why do we treat folks differently in MH and SUD then?
In Diabetes a cheat day is not considered a relapse or treatment failure. It’s considered unhealthy behavior. The problem with MH and SUD treatment preconceptions is that they are based on an absolute. What other disease treatment is based on a 100% all-or-nothing approach to wellness? If someone slips into depression or uses again – now all of a sudden, we’re back into the infantile stage of treatment and starting over?
Mania and Relativity
I once bought a 30-foot twin diesel boat during what I (anyone) would consider a manic phase when I was stationed in Hawaii. A five-figure purchase of something that I didn’t even have time to use because I was on a sea tour and deployed 280 days a year. Made sense right? Fast forward a decade or so and with behavioral modifications and medication management my manic phases consist of binge buying old 1980 sci-fi movies from Amazon at (sometimes) two-digit expenses. So even though that could be considered a relapse of manic behavior, what is my trendline indicating?
SUD for me has been absolute – I was self-medicating and definitely got to the self-destructive phase of my drinking. I can not afford to return to that even for a night. But I have been successful in my SUD sobriety because of my focus on my MH trendline. I have had many ups and downs in my MH treatment even while I stayed sober. But if I stay sane, I stay sober. Last year we added Lithium and I dare say that was a game changer for me. It’s taken me four years of chasing medication combinations while going to therapy every two weeks to get to a point where I think I’m pretty dang stable. And I have no intention to stop doing any of that. For me, how I address these cycles matter. The mental pull of ups and downs can be overcome if I learn to focus on the overall trendline. If I pull back to the top-level view, I can see I’m doing fine and going the right direction.
Focus on the Trendline
Just like sitting down with a financial advisor to talk about the market corrections is a good idea, sitting down with a MH or SUD professional is a good idea when these things occur. But not if the MH and SUD professional essentially considers your poor investing as behavioral failures that require more intensive financial education. I ask you, would you keep going back to that advisor if they kept telling you that your efforts weren’t good enough and you need to start over with the basics? Maybe. But I think most of us would get tired of that rather quickly and move on or just pull our money out and go somewhere else.
How about we go with the inviting approach. What direction is the behavior going? Someone in MH that recognizes they are slipping into anxiety, depression, or mania and makes steps to correct that is a positive thing. Someone who drinks from a high stress situation and recognizes that if they keep doing that it will only end one way is a positive thing. Neither of these is a “relapse” as both indicate a positive trendline. See, it’s really important how we characterize these events. MH and SUD have heavy stigmas and a social morality connotation that we need to understand. How we approach this is critical.
Please understand that I’m not advocating for acceptable “cheat days” on SUD or saying that MH downturns are not fraught with risk. Both can be extremely risky to the individual and those around them. What I’m asking is that we seek to understand what direction the trendline is going. A setback is not necessarily a downward spiral. Neither should a visible downward spiral be discounted as merely a setback. The question rather should be: is it a relapse (market crash) or a market correction that deserves closer monitoring?