Relapse Prevention

Looking at recovery as an ongoing chronic disease that requires continual relapse prevention is a vital part of meaning for addiction treatment.

Some treatments follow the historical model of looking at achieving sobriety as the end of your treatment program. Before people understood what addiction was, those suffering from alcoholism or addiction to other drugs might only have had jail time as a treatment option.

In fact, this historical error can be seen in the 1960 Andy Griffith Show, in which Otis Campbell, the “town drunk” would be locked in the jail overnight to sober up.

However, the running joke was that Otis was so used to frequent relapse that he would lock himself in the cell as procedure would dictate. Even back then, they knew that model didn’t work.

Today, people struggling with addiction may be sent to detox, only to be released when the drug is out of their system, not having addressed any of the underlying causes or potential relapse triggers. The relapse rates for addiction to any drug are high, about as high as other chronic diseases like type 1 diabetes and asthma at 40 to 60 percent. With a coin toss likelihood of relapsing, it’s important to do what you can to bring that number down and relapse prevention strategies can help.

Relapse Prevention Strategies

Many people look at relapse like it’s flipping a switch. You abstain from alcohol, committed to your sobriety, until one day you’ve relapsed. In the blink of an eye, everything you’ve worked for is gone, and you have to start all over again. This is an inaccurate way of looking at it for two reasons:

1. Relapse doesn’t mean that your efforts have failed. It means that treatment should be reinstated and that you should take a closer look at your relapse prevention strategies.
2. Relapse doesn’t occur in an instant. Rather, it occurs in stages that start well before you decide to use an addictive substance again.

Psychologist Gordon Marlatt pioneered the cognitive behavioral relapse prevention model in 1985, and, in his research, he found that high-risk situations are the initial cause of relapse after a period of sobriety. The goal of recovery is for you to make a change in behavior and continue to grow in your mastery of self-control.

In other words, you become better at managing the addiction that used to cause impulsive substance abuse and drug-seeking behavior. However, certain situations, which Marlatt calls high-risk, pose a threat to a person’s control and can potentially lead to relapse.

According to Marlatt, four types of situations can challenge a person’s self-control:

• Negative emotional states that come with depression, anxiety, frustration, and boredom are a significant cause of relapse. Feelings can be triggered by events or by your own perception of life circumstances.
• Triggers that come from another person or a group of people because of conflict, disappointments, heartbreak, etc. More than half of all relapses can be traced back to a high-risk situation involving an interpersonal relationship.
• Direct or indirect social pressure. Direct pressure could be friends urging you to drink at a party and indirect pressure could be co-workers inviting you out for beers after work. In both, the desire not to disappoint other people challenges your resolve to maintain sobriety.
• Positive emotions can also be risky when they are associated with alcohol or another addictive substance, like remembering a good time you had that involved using or passing your favorite bar. Cravings can arise that aren’t caused by a specific stimulus as well.

The moment one of these high-risk situations presents itself is the moment relapse can begin. When you are faced with negative emotions or interpersonal conflict, healthy coping mechanisms can help you safeguard your sobriety.

Coping behaviors are the thoughts and actions you take in response to situational triggers. If you have behavioral or cognitive strategies prepared, you will be more likely to respond with a positive coping mechanism.

Without strategies in place, you may experience feelings of low self-efficacy, or the feeling that you are unable or unwilling to withstand the temptation to lapse.

The moment you begin coping negatively or giving into negative feelings is when your brain starts feeling the effects of negative emotions and goes to work to balance out your emotional state. The disease of addiction leaves its mark on your brain like a bad tool in your brain’s toolbox. When you ineffectively cope with negative emotions, your reward center will start to crave what once made you feel great, not regarding the consequences.

An ineffective coping response leads to a drop in self-efficacy and, with it, your chances for a positive outcome. Then when a lapse (or use of an addictive substance) occurs, you fall under an effect that Marlatt called the abstinence violation effect (AVE), which refers to the negative cognitive effects that come from returning to substance abuse after a period of sobriety. Because the AVE lowers your self-efficacy even further, you’re more likely to relapse again.

Creating a Relapse Prevention Plan

Preventing relapse starts even before developing strategic responses to high-risk situations. Through behavioral therapies, you can identify the high-risk situations in your life; some may be everyday occurrences.

For instance, coming home to an empty apartment after a long day at work may make you feel lonely. Learning about your recurring high-risk situations can help you develop strategies to avoid them. Maybe you could go to the gym after work instead of going straight home.

Of course, you likely won’t be able to avoid all potential high-risk situations. Some may arise because of general stress levels or unknown cognitive factors that are difficult to predict or avoid. Experts call these innate trigger risks covert antecedents. Some behavioral changes can lower your chances of being affected by covert antecedents like lifestyle changes that emphasize positive holistic routines like meditation, exercise, and recreation.

Identifying High-Risk Situations

A therapist can help you determine potential high-risk situations and how to cope with them. High-risk situations often come with warning signs that you can be taught to recognize such as whether your stress levels start to rise or if you start rationalizing a positive outcome for using. Once identified, you may be able to avoid or escape high-risk situations.

Developing High Self-Efficacy

A therapist can help you determine your ability to resist cravings and high-risk situations.

Then, by building up your self-efficacy, you will be able to get through high-risk scenarios with a higher likelihood of success.

Managing Lapses

Even with cognitive and behavioral changes, addiction is still a chronic disease. Lapses are still a possibility. However, a lapse after a period of abstinence doesn’t mean your efforts have failed, it simply means that you need to re-establish and maybe tweak your strategies and resist the abstinence violation effect. That’s the goal of lapse management strategies in therapy. Your therapist can help you create a plan of assessment and response to lapsing after sobriety.

There are a variety of therapies that can help you build up your arsenal of weapons to fight off relapse. However, there is no one-size-fits-all method. A clinician should sit down with you to access your personal needs to create an individualized treatment program for you

Sources

National Institute on Drug Abuse. (2014, July). Drugs, Brains, and Behavior: The Science of Addiction. Retrieved March, 2018 from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery

Larimer, Mary E.,Ph.D., Palmer, Rebekka S., and Marlatt, G. Alan, Ph.D. (199). Relapse Prevention, An Overview of Marlatt’s Cognitive-Behavior Model. Retrieved March, 2018 from https://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

Collins, Susan E. and Witkiewitz, Katie. (2013). Abstinence Violation Effect. Retrieved March, 2018 from https://link.springer.com/referenceworkentry/10.1007%2F978-1-4419-1005-9_623