If an alcoholic or drug addict manages to become clean and sober for a certain length of time, there are smiles of admiration and encouragement all round.

If, however, that person suddenly starts drinking again, or using, there are howls of "I told you so -- he didn't really want to get better,'' and an air of injured disappointment, or even outraged frustration prevails.

Relapse, as it is known in the field of chemical dependency, is not uncommon.

People can, and often do, pick up a drink or that insidious twist of white powder for no apparent reason after they have sobered up, and after they have made a real commitment to their recovery. This recovery might, and usually does, include some sort of supervised treatment followed up by attendance at a self-help group such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).

"Relapse'' is a word that strikes a chill in the hearts of addicts and their loved ones. With Bermuda facing a drug and alcohol problem of crisis proportions, most of us have at least heard of someone who goes off each year to "rehab'' almost as regularly as some go off on holiday, or know someone who "can't even stay off the booze for a week!'' Visiting Bermuda this past week was Mr. John Michael Kelley, who has some of the answers to the greatly misunderstood and under-treated problem of relapse.

Behavioural Recovery Services, run by Maria and Michael Picard, who also specialise in the treatment of relapse, invited Mr. Kelley to present an introductory seminar at the Bermuda College on Training in Stabilisation and Relapse Prevention, for professionals working here in the treatment of addiction.

His system teaches counsellors (and addicts), through a programme of stabilisation techniques, to recognise and treat the symptoms of relapse, before the relapse itself occurs.

Mr. Kelley points out the US has spent "billions'' on treatment and comments, "I hope Bermuda will learn from our mistakes!'' During his visit Mr. Kelley, who has pioneered new techniques and is the author of several books on the subject, talked to The Royal Gazette .

"I qualified in 1975 with a Masters in traditional psychotherapy and counselling. My knowledge of addiction -- like most of us at that time -- was extremely limited. That all changed in 1983 when I had to come face to face with the fact that I, myself, was an alcoholic and drug addict (marijuana). As I recovered, I tried to learn everything I could about addiction for myself and for my work.'' He discovered that there was not a lot of information available on the process of recovery itself, apart from that offered by the self-help groups.

Noting that the "abstinence'' philosophy taught by the Minnesota Model and developed by the premier treatment facility, Hazelden, in the US, quotes a very high success rate, Mr. Kelley began to investigate those figures. He found that these results pertained primarily to the upper-class white male, who is well educated, and still has a job and family. "We're talking about quite a small group, here,'' says Mr. Kelley.

While 60 percent of these patients maintained sobriety for a year or more, he found that for non-high prognosis groups, the figure plunged to zero to 20 percent. Of the former 60 percent, he says, only ten percent managed to stay sober for five years.

Some of the policies and attitudes he encountered during his own treatment, he says, "appalled'' him.

"After my own recovery, I worked in an out-patients treatment centre at one point and I was appalled by the way we were taught to treat patients! I kept asking these embarrassing questions, like: `Why throw people out of the treatment programme if they're discovered using?' I would bring this sort of thing up at staff meetings and was told that I didn't understand alcoholics and drug addicts. That was pretty ironic, considering I was one!'' In desperation, Mr. Kelley sought out Terence Gorski, whom he considers to have been the leading expert on relapse in the US at that time. He had devised a programme that would assist patients who relapsed after one year of sobriety.

"This was an important step forward because up until then, the primary traditional method of treating addiction was 28 days in a rehab facility, and then into self-help. But with Terry's method, you had to have a year or more of solid recovery before you could learn how to use the model he had developed to avoid relapse.'' For three years, he worked as a consultant for Mr. Gorski, but became increasingly concerned about the person who is unable to get sober in the first place.

"I felt we had to teach addicts that they have a disease. They can make a complete recovery through abstinence but they have to learn how to recognise symptoms before they result in drinking.'' Pointing out that relapse -- the point when people actually start drinking or using again -- is the end result of an inability to control behaviour, Mr.

Kelley says that some people may not actually get back to drinking or drugging.

"They might collapse with the strain and unhappiness of it all. Or commit suicide. Then people will say, `Well, at least he died sober!' What use is that?'' He began to study a group of people who had never had any success in treatment. "I realised that the traditional method ignores the fact that people are not stable when they begin treatment. Prolonged substance abuse causes temporary brain dysfunction which affects the ability to think rationally, logically and distorts emotions. So the addict's ability to grasp cause and effect is destroyed. Yet we tend to treat people who are newly abstinent as if they're okay.'' Mr. Kelley has devised a method whereby the stability of the patient is maintained as he teaches them, initially in an in-patient setting, about their diagnosis and setting out the barriers that they will encounter in recovery.

He likes to start working with patients as soon as they have been detoxed "or, better still, while they're still in detox!'' His approach, which he believes empowers patients to take an active role in their own recovery, has been adopted in the States of Texas, Tennessee, Idaho, and in treatment centres around the US (including the Betty Ford Centre which recently sought his help as a consultant) and Canada. It was while he was in Ottawa that he met Michael Picard who, in turn, has implemented his treatment methods in Bermuda.

Training counsellors in San Antonio's prison system, Mr. Kelley found them complaining of the lack of motivation in their patients. "They had been trained in traditional methods and were sceptical of me, but I asked them to just try it. Within one month these prisoners had been transformed from being `hopeless' to being well motivated.'' His programme for the Tennessee public system of counsellors on substance abuse has also been successful.

"In one new day programme for people in the late stages of alcoholism, eight out of ten have maintained complete abstinence for six months. Two relapsed, but only for one day, and they came straight back and had already figured out what had gone wrong and caused them to pick up a drink -- and how to avoid doing that again.'' Visiting counsellor takes aim at relapse From Page 19 "I treat people as if they have a terminal disease which, if it's not treated, it is. Treatment of addiction is still in its infancy, but we do know that if you follow certain recommendations, your chances of complete recovery are greatly increased.'' Using a checklist of events or emotions experienced in the lead-up to a relapse, he has assembled a 26-point symptoms list which the patient uses as a referral and safety valve in recovery. He emphasises that these symptoms are normal.

"There are many indicators that threaten stabilisation in the early days of recovery. Just before a person relapses, he is often totally overwhelmed by feelings of resentment which can lead to quitting treatment and AA programmes, as fear, loneliness, frustration, anger and tension will guide his footsteps to the nearest bar.'' One of the most important elements is what he calls `Trigger Events' and may only become apparent to an experienced therapist. He tells the story of one of his patients who, feeling tense and stressed out, would keep going to the fridge and just stand there, looking inside. He couldn't understand why he was doing this. It turned out he had alcoholic parents who used go off on `benders' and leave him, the eldest child, to look after the others. He, of course, could tell when a `bender' was imminent so he would keep going to the fridge to make sure there was enough food for the kids while they were gone.'' Mr. Kelley works closely with AA and believes that organisation to be the best bet for most people in recovery. He feels, moreover, that his system of a more individualised treatment is more consistent with AA principles than traditional treatment. "Nowhere in AA does it say that you should work through the first five steps of AA's 12-Steps to Recovery in the first 28 days, which you do with the Minnesota Model. There's not much sense in that when the brain is still fogged up. What we do is to introduce the principles of AA so that people can then use them as a tool for recovery.'' Mr. Kelley believes there has to be a fundamental change in attitude towards "relapsers,'' to remove the sense of shame and failure.

"We're talking out of both sides of our mouths when we dismiss someone by saying, `Oh, he didn't want it badly enough.' He is convinced that what is seen as psychological `denial' by an addict is, in fact, physiological. "We have to rehabilitate the brain just as doctors treat head injuries or strokes.'' Mr. Kelley, who is based in Austin, Texas, has authored many papers for professional journals, including the National Institute on Drug Abuse. He is also the author of "Out of the Fog'' and "The Out of the Fog Workbook,'' and co-author with Father Jim Swarthout of "Perfectly Human, Perfectly Divine.'' A complete training seminar for Certified Assessment and Stabilisation Specialists will be presented by Mr. Kelley at the end of January.

Says Mr. Picard of Behavioural Recovery Services, sponsors of the Seminar, "This first, overall workshop was a great success, because people working in the field here could understand that there is an easier way of facilitating treatment, which is also very cost-effective. You can't put all your money into in-patient treatment. It's just as important to have out-patient continuing care and follow-up. With John's system, a patient is not going to be in therapy for ten years! People learn to rely on their own abilities, to become aware of their own self-value and self-worth -- and then the therapist's job is over!'' For further details on the January Seminar, telephone 295-6413.

HOPE FOR ADDICTS -- Mr. John Michael Kelley, who is conducting a series of seminars on the prevention of relapse in alcoholics and drug addicts.