The Revolving Door
Why chronic relapse deserves a different question than “back to treatment again?”
There is a particular kind of failure that the addiction treatment field has become remarkably good at normalizing.
A client completes their fourth, sixth, perhaps tenth round of residential treatment. They know the language. They can practically run the group. They understand triggers, boundaries, trauma, relapse prevention, resentments, attachment, accountability, and the twelve steps. They have done real work, sometimes extraordinary work, and still, eventually, they relapse.
And what do we do? We send them back through the same doors. Another residential stay. Another relapse-prevention plan. Another inventory. Another recommitment to meetings and sponsorship. Another version of a curriculum they may already know by heart.
Sometimes that is exactly what is needed. But eventually, repeated relapse should force us to ask a different clinical question: What if the problem is no longer that the person hasn't done enough of the treatment? What if we have reached the limits of what this particular treatment can do for this particular person? That is a very different question. And I think our field needs to become much more willing to ask it.
What chronic relapse may actually be telling us
Relapse gives us information. Early in recovery, some of that information may concern structure, honesty, readiness, environment, untreated psychiatric conditions, social determinants, medication, relationships, recovery support, or engagement with treatment. Did the person have adequate support? What preceded the relapse? What changed? What was missing? Those questions matter.
But when someone has repeatedly engaged treatment in good faith, when they have done therapy, step work, trauma work, sponsorship, meetings, intensives, relapse prevention, service, and years of recovery, and continues returning to the same destructive pattern, simply asking them to do all of it again may cease to constitute meaningful clinical reassessment.
At some point, repetition is not a treatment plan.
I say this as a clinician who has worked in addiction and recovery for nearly two decades. I also say it as someone who has lived inside this question.
I got clean and remained clean for eleven years within a largely traditional recovery model: meetings, individual therapy, intensives, step work, trauma resolution, sponsorship, community, and service. Those things mattered enormously. They helped save my life.
And eventually, they were no longer sufficient for me.
The answer I repeatedly encountered was some variation of more of the same, harder. Go back. Recommit. Find a better sponsor. Do the steps again. Get more honest. Work harder.
There was truth in some of that counsel. But truth is not the same thing as sufficiency. I needed something the model I knew did not contain.
When the familiar map stops being enough
Addiction is not merely a behavioral problem. It involves learning, reward, attachment, emotion regulation, memory, identity, relationship, environment, physiology, and the nervous system. For many people, it also becomes intertwined with existential questions: Who am I? Why am I here? What makes life worth remaining present for? What do I belong to when the substance is gone?
Traditional addiction treatment can address many of these dimensions, and for millions of people it does so remarkably well. But no treatment model reaches every person. That should not be a controversial statement. It is one of the most ordinary truths in clinical medicine.
And it is here that I believe clinicians need to become more curious about psychedelic-assisted therapies and other carefully screened work with nonordinary states, not as miracle cures, not as replacements for evidence-based addiction treatment, and certainly not as appropriate interventions for everyone, but as emerging possibilities deserving serious clinical attention.
The research is still developing. The evidence is stronger for some medicines, diagnoses, and treatment models than for others. Psilocybin-assisted treatment for alcohol use disorder, for example, has produced encouraging results in controlled research. Other approaches including ibogaine and ayahuasca have generated promising observational findings while carrying significant unanswered questions, limitations, and, in some cases, substantial medical risks.
That distinction matters. Taking these approaches seriously does not require exaggerating what we know. But neither should uncertainty become an excuse for clinicians to remain uninformed about something their clients are increasingly exploring with or without us.
My own experience, offered as experience
My own experience changed the way I understand recovery. Psychiatric medication had helped me manage symptoms at different points in my life. Therapy helped me understand myself. Twelve-step recovery gave me language, structure, accountability, community, and a way of living that sustained me for years.
My experience with earth medicine was different. I experienced access to dimensions of myself…psychological, embodied, relational, and spiritual…that I had not reached in the same way through the approaches I had previously used.
I cannot turn that experience into a universal clinical claim. I would not want to. But I also refuse to pretend it did not profoundly alter the course of my recovery.
What followed mattered just as much as the experience itself. Integration. Community. Practice. Continued psychological work. Relationships. Accountability. Changes in how I lived.
That distinction is essential because psychedelic experience is not the same thing as psychedelic healing. The experience may open something. What happens afterward helps determine what becomes of the opening.
For me, what changed was larger than abstinence. It included clarity where there had been fog, purpose where there had increasingly been maintenance, and a different relationship with myself and with something larger than myself. Call that God. Spirit. Source. Higher Power. Consciousness. Meaning. The terminology matters less to me than the clinical reality that human beings often need more than symptom management to build lives they actually want to remain present for.
What I am asking clinicians to do
I am not arguing against residential treatment. I am not arguing against twelve-step recovery. I am not arguing against psychiatric medication. And I am certainly not arguing that every person who repeatedly relapses should take psychedelics.
I am arguing for something more fundamental: Repeated treatment failure should produce clinical curiosity. If a person has completed the same level of care repeatedly, has demonstrated meaningful engagement, has accumulated substantial insight, and continues returning to the same pattern, the next clinical conversation should involve more than another referral back to the beginning.
What haven't we understood? What hasn't been reached? What has been treated repeatedly without changing? What medical, psychiatric, relational, social, developmental, or existential dimension are we missing? And, where clinically appropriate, should emerging psychedelic-assisted approaches be part of the conversation? Those questions do not require enthusiasm about psychedelics. They require intellectual honesty.
The revolving door
There is also a harder conversation our field needs to have. Repeated admissions generate revenue.
That fact does not mean treatment centers are intentionally keeping people sick, and I would resist that simplistic accusation. Thousands of extraordinary clinicians work inside addiction-treatment systems and care deeply about the people they serve. But financial incentives and clinical incentives are not automatically the same thing.
When someone arrives for a tenth admission, a treatment system should be capable of asking whether providing essentially the same intervention for the tenth time constitutes individualized care. The tenth admission should provoke a different conversation than the first. If it doesn't, something is wrong.
Put another door on the building
The alternative I want is not psychedelics instead of recovery. It is a larger clinical map. For some people, that map may include medication-assisted treatment. For others, trauma treatment, somatic work, psychiatric reassessment, attachment-focused therapy, community, spirituality, changes in environment, or a different level of care. And for carefully selected people, it may increasingly include psychedelic-assisted treatment or other responsibly conducted work with nonordinary states.
Not casually. Not without screening. Not without attention to contraindications, medication interactions, psychiatric vulnerability, medical risk, preparation, setting, legal context, and integration. And not because psychedelics are the newest answer to an ancient human problem.
Because when the intervention we keep prescribing repeatedly fails, good clinical care requires us to become curious about what else might be possible.
Individuals with history of chronic relapse are not treatment failures. They are people for whom the treatment map may be incomplete.
So when someone is sitting across from us after their sixth, eighth, or tenth round of treatment, perhaps the most important question is no longer: How do we get you to do the program better this time? Perhaps it is: What have we not yet understood about what you need? That is the question I wish someone had asked me sooner.
If you work with clients experiencing chronic relapse, or with clients exploring psychedelic and earth-medicine paths in recovery, I offer training and consultation for clinicians learning to navigate this emerging terrain with greater clinical discernment.
Explore trainings, clinical resources, and consultation at https://www.ChristopherShaw.net.
Research & Further Reading
The clinical research on psychedelic-assisted approaches to substance use disorders is promising but still developing. Evidence varies considerably by medicine, substance use disorder, study design, and treatment setting. The following resources offer useful starting points for clinicians who want to examine the emerging evidence directly.
Psilocybin and Alcohol Use Disorder Bogenschutz, M. P., et al. (2022). Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 79(10), 953–962.
This randomized, double-blind clinical trial compared psilocybin-assisted psychotherapy with active placebo plus psychotherapy in adults with alcohol use disorder. Participants receiving psilocybin experienced a significantly lower percentage of heavy-drinking days during the primary follow-up period. The study is among the strongest controlled clinical trials currently supporting investigation of psychedelic-assisted treatment for addiction.
Psychedelic-Assisted Treatment for Substance Use Disorders A growing body of systematic and narrative reviews has examined psilocybin, ketamine, MDMA, ibogaine, ayahuasca, and other psychedelic or psychedelic-adjacent interventions for substance use disorders. Recent reviews generally characterize the field as promising while emphasizing small samples, heterogeneous treatment protocols, limited controlled trials for several medicines, and the need for longer-term safety and efficacy data.
Ibogaine and Substance Use Disorders Observational research has reported reductions in withdrawal symptoms, craving, and substance use following ibogaine treatment, particularly in opioid-dependent populations. However, the evidence remains substantially less established than controlled research on conventional addiction treatments, and ibogaine carries important medical risks, including QT prolongation, cardiac arrhythmias, and reported fatalities. Medical screening and monitoring are therefore particularly important considerations in any discussion of ibogaine.
Ayahuasca and Addiction Observational and naturalistic studies have reported associations between ceremonial ayahuasca use and reductions in problematic substance use, along with changes in psychological well-being and quality of life. These findings are clinically interesting but should not be interpreted as establishing efficacy: controlled research remains limited, and ceremony, community, spirituality, preparation, and integration may themselves contribute to observed outcomes.
A Note for Clinicians
An emerging evidence base is not the same thing as an established standard of care. Psychedelic-assisted approaches differ substantially in evidence, legality, medical risk, contraindications, practitioner training, and regulatory status.
Clinicians do not need to become psychedelic therapists, or advocates for psychedelic use, to become informed about this literature. We do, however, need enough knowledge to discuss these experiences responsibly, assess risk, recognize when specialized consultation or referral is appropriate, and help clients integrate experiences they may already be having.
The clinical task is neither endorsement nor dismissal. It is informed discernment.
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