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  • Relapse Prevention (November)
  • Relapse: Why It Occurs and How to Prevent It

Relapse: Why It Occurs and How to Prevent It

The Carlat Addiction Treatment Report, Volume 1, Number 3, November 2013
https://www.thecarlatreport.com/newsletter-issue/catrv1n3/

From The Carlat Addiction Treatment Report, November 2013, Relapse Prevention

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Addiction | Free Articles

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Terence T. Gorski, MA, MAC, NCAC II, Florida CAP

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:
  1. Stabilization
  2. Assessment
  3. Relapse education
  4. Warning sign identification and management
  5. Recovery planning
  6. Inventory training
  7. Family involvement
  8. 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.

Preventing Relapse

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).

Terence T. Gorski, MA, MAC, NCAC II, Florida CAP

Founder and president, The CENAPS Corporation, Spring Hill, FL

Mr. Gorski has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

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  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Benjamin Oldfield, MD, MHS

Dr. Oldfield is a clinical instructor at the Yale School of Medicine, and Chief Medical Officer at Fair Haven Community Health Care where he provides addiction treatment to adults and adolescents. He attended Harvard Medical School and trained in medicine and pediatrics at Johns Hopkins Hospital. He then received advanced training in addiction and health services research at the Yale National Clinician Scholars Program. He is board-certified in internal medicine, pediatrics, and addiction medicine. Dr. Oldfield’s academic interests include addiction treatment among vulnerable populations, including youth and people with HIV.

Full Editorial Information

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