Relapse Prevention Treatment

Relapse Prevention is an essential element of any treatment episode.

Many addicts and alcoholics were first introduced to the topic of relapse prevention with the book, “staying sober” by Terrance Gorski. Much has been added to the field of relapse prevention since those early days.

It can be easy for an addict or alcoholic to see relapse as something that “just happens” without appreciating the high-risk factors contributing to it. Despite how it seems, relapse doesn’t just happen. A relapse is one event in a long series of related events, sometimes stretching back for months. However, to the addict or alcoholic who experiences a relapse, it seems to “just happen.”

Some relapse prevention theories posit that relapse happens in a series of stages, starting with emotional relapse, followed by mental relapse, and finally ending in physical relapse. At each stage, feelings, thoughts, and actions propel the individual forward into relapse.

There are many internal factors involved in relapse, which is why it is said to be multi-determined. Some of the internal factors contributing too, or protecting from relapse include self-efficacy, outcome expectancies, craving, motivation, interpersonal factors, emotional states, and coping mechanism availability.

According to research on the subject: “In particular, high self-efficacy, negative outcome expectancies, potent availability of coping skills following treatment, positive affect, and functional social support are expected to predict positive outcome.” Interestingly, cravings have not historically been shown to serve as a strong predictor of relapse.”

Know the Stages of Relapse

Knowing the stages of relapse is imperative to being able to stop the relapse process.

1. Emotional Relapse

Unhealthy emotions and behaviors are building up for a possible relapse in the future. The key here is not the experience of unhealthy emotions and behaviors, but because they are building up without being resolved or dealt with, they contribute to relapse. Emotions should come and go, but when they stick around for a long time or cause severe disruption to your daily life or personal relationships, you may be headed toward a relapse. Some of the negative emotions you might feel during this phase include:

Anxiety
Anger or intolerance
Defensiveness
Mood swings
Isolation
Not asking for help
Poor eating and sleeping habits

2. Mental Relapse

This phase of relapse starts with idly thinking about using, but the thoughts grow more and more serious. Essentially, what happens is the addict or alcoholic begins to have thoughts of using. They keep these thoughts to themselves, where they turn into fantasies. At this point, an obsession results, and thoughts of using become harder and harder to shake off. During a mental relapse, you might notice

Glamorizing the past use
Lying
Hanging out with old using friends
Fantasizing about using
Planning how to avoid being caught

3. Physical Relapse

The most challenging stage to stop, in a physical relapse, the substances are actively sought after. Behaviors involved in a physical relapse include

Going to places where alcohol/drugs will be readily available
Driving to the liquor store or to meet a drug dealer
Possessing alcohol, drugs, or drug paraphernalia

The Relapse Prevention (RP) model developed by Marlatt and Gordon in 1985 is based on social cognitive psychology. One crucial difference between earlier models is how RP views relapse as an isolated event and an interrelated process. A process begins before the drug or drink is picked up and continues after the initial use.

As you can see from the model below, the relapse prevention model puts emphasis beyond the immediate high-risk situation to consider the individual’s coping response. If a patient were to overcome a high-risk situation with an effective coping response, they would be better able to overcome the next high-risk situation with similar behavior.

A core tenet of RP is that relapse is not an “end” state, and thus a “slip” does not have to cause a relapse. In fact, researchers noted how a relapse is more like a fork in the road, and if used as a warning to re-engage with treatment, can be considered a “prolapse.” A prolapse was defined as: “the problem behavior is corrected and the desired behavior re-instantiated,” in the research paper, “Relapse prevention for addictive behaviors.” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163190/)

Relapse prevention therapy: an overview of the principles of relapse prevention

Relapse prevention therapy can be overviewed with the following nine principles:

Self-regulation- this includes self-regulation of thoughts and behaviors as well as memories and feeling.
Developing an understanding and integration of the factors that led to prior relapses- a counselor might help the patient discover what they wanted the substance to do for them and what it actually did for them.
Understanding of the general factors that cause relapse, generally in the form of relapse education.
Developing self-knowledge of relapse signs so they can be self-managed
Coping skill development and client efficacy improvement- it’s essential that the client believes they are able to avoid relapse. The more they internalize coping skills to help overcome relapse, the better their sense of self-efficacy.
Change via recovery planning, self-care education, and post-treatment scheduling.
Building awareness with morning and evening reviews. In the morning, the patient should spend a few moments reading some motivating literature and planning out their day. During the evening review, the client examines their day and reflects on how they dealt with the various challenges they faced.
Involving the significant people in a client’s life is important because research has been shown to be a protective factor that improves clinical outcomes.
On-going professional treatment in the form of outpatient treatment visits will lessen over time. Still, the following is recommended at a minimum: monthly visits for three months, four visits per year over the next two years, followed by annual visits for five years.

Relapse Prevention Program Delivery

Relapse prevention treatment usually occurs in a group setting in a relapse prevention group. A typically structured relapse prevention therapy might include a short introduction phase, followed by an educational presentation facilitated by the counselor. The group would then be broken down into small groups for interactive exercises before joining the large group once again for processing.

Relapse Prevention Strategies and Avoiding Relapse

There are 4 main ideas in relapse prevention: (From Relapse Prevention and the Five Rules of Recovery- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553654/