Relapse usually does not occur suddenly, nor do people plan their return to addictive substance use. From the client’s point of view, it just seems to happen. But there are always indictors that trouble is brewing.
Early students of addiction—the members of Alcoholics Anonymous—noticed a paradox: people with substance use disorders often act in ways inconsistent with their conscious intentions. Widely referred to as the “Big Book,” the book Alcoholics Anonymous contains a vignette about Jim, a salesman, who stopped at a restaurant for lunch. Although Jim wasn’t thinking about alcohol or relapse, here’s what happened:
“Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn’t hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the milk on a full stomach” (Alcoholics Anonymous, 3rd ed. New York: Alcoholics Anonymous World Services, 1976:35).
Decades after the Big Book was first published, we now have a better understanding of why people like Jim relapse. Causes include high-risk environmental factors where cues to use substances are present, such as people, places, and things that have been associated with prior drug use. In Jim’s case, for example, relapse occurred in a restaurant that he had visited many times when he was still drinking.
Relapse can also be related to personal factors including substance cravings, negative affect, stress, self-efficacy, and coping skills (see for example Koob GF, Front Psychiatry 2013;4:72). Negative affect refers to problems with mood and anxiety, whereas self-efficacy is often defined as a person’s belief in his or her ability to deal with certain situations.
Here, too, Jim’s case is instructive. He noted that he had eaten at the restaurant many times without drinking (self-efficacy) but earlier in the day had a minor dust-up with his boss (stress) and felt irritated (negative affect).
Nine Steps to Prevent Relapse
One model of relapse prevention therapy (RPT) involves nine steps for learning to recognize, manage, and possibly prevent the early warning signs of relapse. They include:
Warning sign identification and management
Relapse prevention check-ups
For detailed information on the Gorski-CENAPS model of RPT, visit www.cenaps.com or see Gorski TT, The CENAPS Model of Relapse Prevention Therapy. In: Approaches to Drug Abuse Counseling. Bethesda, MD: National Institute on Drug Abuse, 2000:23–38.
Once patients learn to identify relapse warning signs—such as a lack of a firm commitment to abstinence, addiction-related feelings including boredom, stress, anger, or depression, or cravings for alcohol or drugs—they can begin to manage them. (For more about how substance cravings can be a factor in relapse, see “Substance Cravings and Addiction Relapse”)
The effectiveness of relapse prevention therapy (RPT) has been proven for various substance use disorders (see for example Irvin JE et al, J Consult Clin Psychol 1999;67(4):563–570). RPT generally occurs in a group session lasting up to 90 minutes with a standard structure that includes allocated time for interactive exercises and group discussion. The format can be condensed and modified when dealing with individual clients during shorter appointments.
RPT involves first physically, psychologically, and socially stabilizing a patient—by having him move out of an apartment with a drug-abusing roommate, for example. Next, we get to the root of what is making him want to use again, and help him understand and recognize early relapse warning signs.
I might have a client write down his life and addiction history and look at why he relapsed in the past. I will also have him develop a list of signs, such as irrational thoughts and unmanageable feelings, as well as situations, such as hanging around with old drug-using peers, that may lead him back to substance use.
Finally, we put into place strategies for preventing relapse. These include detailed daily planning and personal check-ins to make sure he is keeping with the program. I will have the client write a “recovery plan”—a schedule of activities that he knows will help him stay sober, such as working a 12-step program and attending relapse prevention support groups—and compare it to the list of high-risk situations and early relapse warning signs. What will he do when faced with a high-risk situation? Techniques include mental rehearsal, role-playing, and therapeutic assignments. For example, if he goes into a bar where he used to drink, he will
plan to call his AA sponsor and go to the next available AA meeting.
I recommend that clients start each day by reading something that focuses the mind on sober and responsible living and then planning out the day. I recommend they end the day by confirming that they completed everything on the recovery plan and reflecting on how they dealt with various challenges. If there are issues, the client then decides whether to tap into his support network to talk about the day before going to bed.
There is clear evidence that when families are involved in the process of relapse prevention, clients are more likely to stay sober (Fals-Stewart W et al, J Fam Ther 2009;31(2):115–125). At each step, get family members appropriately involved in treatment.
The pattern of addictive thinking that can cause people to make bad decisions that lead them back to alcohol and other drugs is very strong. Ongoing professional monitoring is needed. Recovery checkups to review and update the relapse prevention plan should occur on a regular schedule. At minimum, I recommend monthly visits for three months, quarterly visits for the next two years, and then annual visits for at least the next five years. A detailed clinical manual, “Recovery Management Check-ups: An Early Re-Intervention Approach,” is available (http://bit.ly/18NlGRi).
Additional Resources on Relapse Prevention
Various books are available on relapse prevention therapy, including the following
For clinicians:Therapist’s Guide to Evidence-Based Relapse Prevention, edited by Katie A. Witkiewitz and G. Alan Marlatt. Burlington, MA: Academic Press, 2007.
For clients: Starting Recovery with Relapse Prevention by Terence T. Gorski. Independence, MO: Herald House, 2012.
For clinicians and clients: Relapse Prevention Workbook by Bradley A. Hedges. Lancaster, OH: Mid-Ohio Psychological Services, 2012 (available as a free online resource at: http://bit.ly/1aM5K4r).