Rehab 4 Addiction

Relapse prevention is an evidence-based cognitive-behavioural approach to addiction treatment. It uses a range of strategies to help service users minimise the risk of relapse. These include dealing with high-risk situations, avoiding ‘abstinence violation effect’ (AVE) and coping with cravings.

Many scientists now understand addiction as a ‘chronic relapsing illness’. [1] This understanding takes into account the very high rates of relapse that exist among the section of the population who suffer from substance use disorders (SUDs).

Relapse prevention (RP) does not completely inoculate people with SUDs against relapse; rather, it provides a useful framework in which to develop towards a state of sustained recovery. [2]

In this post we will go through some of the key ideas in relapse prevention (RP), and then discuss some of the strategies it proposes for avoiding relapses.

In this section we take a look at some of the key concepts in RP, beginning with a metaphor for recovery.

Understanding relapse: recovery as a journey

Relapse prevention therapy conceptualises recovery from addiction as a kind of journey. In this metaphor, quitting substances is the act of departure, and is only the first step in a long and difficult journey.

The relapse itself is seen as a natural part of the habit change process, rather than a failure. Habit change is cyclical and is rarely successful at the first time of asking.

‘RPT is designed to teach clients not to be demoralized or to view relapse as a failure, but to re-ignite their motivation and commitment to change and to risk beginning the journey again.’ [3]

Through the metaphor of the journey, RPT, therefore, puts forward the idea of recovery as an ongoing process which requires courage and willpower.

Lapses, relapses and the ‘abstinence violation effect’

Alan Marlatt, one of the creators of the relapse prevention school of therapy, outlined the difference between a lapse and a relapse. This is a useful distinction which crops up a lot in RP.

According to Marlatt, a lapse is the first time someone uses substances after having stopped using. Often, this initial lapse may be relatively minor; it is the full-blown ‘relapse’ which entails a heavy binge on substances.

This is not to say that a lapse is any less serious than a relapse. What is important is how the person in recovery reacts to the initial lapse. If they blame themselves and give in to the ‘abstinence violation effect’ (another useful term which we will define in a second) then they are much more likely to ‘relapse’.

‘When a lapse occurs there is often an abstinence violation effect, composed of guilty feelings and a sense of inherent powerlessness, which can interact with these other factors and trigger a relapse’. [4]

The abstinence violation effect, then, is the feeling that someone in recovery gets after using substances for the first time during a period of abstinence.

As the quote above implies, this feeling can include emotions like guilt and powerlessness, combined with the perceived effects of the substance (e.g. the slight buzz from drinking a beer or taking a drug).

Where does relapse prevention come into all this? Well, RP has several strategies which are intended to stop lapses from occurring, and several strategies which are intended to stop a lapse from turning into an all-out relapse. We discuss them below.

Relapse prevention strategies vs relapse management strategies

RP provides us with another distinction: between relapse prevention strategies and relapse management strategies. Both of these kinds of strategy are useful for encouraging habit change. So what is the difference between the two?

According to RPT, relapse prevention strategies help the person in recovery to cope with high-risk situations, in which there is a danger of relapse. Relapse management strategies, on the other hand, are used after a slip or a lapse to prevent it from becoming a full relapse.

Through a combination of these two kinds of strategies, RP hopes to provide two layers of defence against relapses. The first comes in the form of relapse prevention strategies, which help people with SUDs to navigate difficult situations without using substances.

The second line of defence, relapse management strategies, attempts to combat the abstinence violation effect (AVE) and prevent a lapse from turning into a relapse.

High-risk situations and interpersonal vs intrapersonal determinants

When someone goes through addiction treatment, they will often feel a heightened sense of self-control. As the period of abstinence continues, this sense of self-control will become even greater.

However, high-risk situations threaten to undermine this self-control by causing the person with a SUD to relapse. According to George A. Parks, a high-risk situation is one which

‘poses a threat to the individual’s sense of perceived control or ability to cope with the immediate situation or its subjective consequences (e.g. elicitation of negative emotions).’ [5]

Key factors in high-risk situations include negative emotional states, social pressure and interpersonal conflict. When one or more of these factors is combined, it makes for a very challenging situation for someone in recovery.

Factors in high-risk situations can loosely be classed into interpersonal and intrapersonal determinants. Intrapersonal determinants refer to things going on inside your head, such as negative emotions, urges to use substances and so on.

Interpersonal determinants refer to things that happen between you and other people, such as conflict and peer pressure.

Self-efficacy and its role in the relapse process

Another useful concept in RP is that of self-efficacy. Self-efficacy refers to:

‘an individual’s expectation concerning his/her capacity to cope effectively with a specific situation or a particular task.’ [6]

In other words, self-efficacy is all about a person’s confidence in their own abilities to deal with challenging situations.

Self-efficacy is at the heart of RP’s understanding of the relapse cycle.

If someone with a SUD deals well with a high-risk situation, that leads to an increase in self-efficacy. In other words, the person feels that they handled the situation well, so they become more confident in their ability to stay abstinent. This means they are less likely to relapse in the short-term.

If someone with a SUD deals poorly with a high-risk situation, as a result of an ineffective coping mechanism, that can lead to a decrease in self-efficacy. Then the person may be more likely to have a lapse, especially as ‘Positive Outcome Expectancies’ come into play. (Positive Outcome Expectancies refer to the feelings of excitement and anticipation which precede a lapse).

After a lapse, the person may experience Abstinence Violation Effect (AVE), as well as the effects of the substance. This may lead to a full relapse.

Self-efficacy, therefore, can play a huge part in either continued sobriety or a relapse. It needs to be managed carefully in order for people with SUDs to stay abstinent.

Relapse set-ups

One final concept in RP that is worth discussing is the idea of a ‘relapse set-up’. This refers to the way in which someone with a SUD may, without knowing it, ‘set themselves up’ for a relapse.

It is a strange idea, but a very useful one for understanding (and preventing) relapses.

Why is it a strange idea? Because most people in recovery actively want to stay abstinent. Someone who is seeking treatment, and has been abstinent for a period of time already, is unlikely to want (on a conscious level, at least) to relapse into an addiction they have only recently escaped.

And yet, there are many things pulling them towards substances. They may be tempted by the freedom from responsibility which comes with drinking, or the instant gratification of the drink itself.

There may also be certain ‘cognitive distortions’, such as denial and rationalization, which allow the person with a SUD to get past the defences they have erected against substance use.

Life-style imbalances, such as an overabundance of ‘shoulds’ – duties – compared with ‘wants’ – desires, things you find enjoyable – may also contribute towards the relapse set-up.

One of the aims of RP is to teach service users how to spot the signs of a relapse set-up and prevent it from turning into a relapse.

Relapse prevention techniques

We now turn to some RP techniques for avoiding relapse. RP intervention strategies fall into two main camps: specific and global intervention strategies. Specific intervention strategies centre on how to avoid lapses and how to deal with high-risk situations.

Global intervention strategies, on the other hand, focus on modifying the service user’s lifestyle and identifying the determinants of a relapse, such as relapse set-ups and cognitive distortions.

There are many examples of both specific and global intervention strategies, so we’re picked out five or six examples of each.

Specific relapse prevention strategies

Below, we list four specific relapse prevention strategies which come highly recommended for people in recovery:

1. Autobiographies

At an early stage of RP treatment, service users write short autobiographies in which they detail their relationship with substances, and how it has changed over the years. They are asked to focus on things like: substance use among members of their family, first time using substances, factors that cause them to drink or use drugs in greater quantities, and self-image as a drinker or substance user.

The aim of this exercise is to work out what triggers the service user has that cause them to use substances, and what high-risk situations they may be especially susceptible to. Using this information, treatment can then be tailored to the individual so as to help them cope with these specific things.

2. Stimulus Control

Stimulus control is a form of coping skill which helps people to handle high-risk situations. It is a three-part system, based on the principles of avoidance, escape and delay. It is especially useful at the beginning of a period of abstinence, when situational cues – such as old friends associated with substance use – are rife.

The three stimulus control techniques of avoidance, escape and delay act as safeguards. The first of these, avoidance, comes into play when the person in recovery sees a high-risk situation on the horizon and is able to avoid it. This may not always be possible, which is why the other two safeguards are useful.

The second – escape – should be pursued if avoidance is not an option. In other words, if one finds oneself in a high-risk situation, simply escaping will help to prevent a lapse. If the person has a plan in place for escaping these situations that will make it easier.

Finally, if escape is impossible, then delay can help the person with a SUD to buy time before they eventually manage to escape.

3. Relapse rehearsal

Similar to another RP strategy, ‘relapse fantasy’, relapse rehearsal involves practising coping skills with the therapist through imagery and roleplay.

The therapist will walk their patient through a high-risk situation – preferably one which is specific to the client – and then ask the client to practise their responses.

Also known as covert modelling, this technique can be a good way of preparing for high-risk situations and practising coping skills in a hands-on fashion.

4. Stress Management

Another strategy for helping clients deal with high-risk situations is to teach them how to deal with stress. Stress adds another layer of difficulty to high-risk situations; when it is removed, or reduced, it can help people in recovery to make better decisions.

Stress management techniques include meditation, exercise, muscle relaxation and breathing exercises. These techniques, when applied during a high-risk situation, can lower the chances of a lapse or relapse.

5. Challenging Positive Outcome Expectancies

In the immediate lead-up to a lapse or relapse, a person with a SUD will often experience so-called Positive Outcome Expectancies – which refer to the anticipation of pleasure gained from substance use.

In order to help people with SUDs to identify and ignore these POEs, therapists talk about the ‘Problem of Immediate Gratification’ – or PIG. Clients are told to envision their desires for alcohol or drugs as a hungry pig.

This metaphor helps to underline the irrational, destructive nature of these desires.

As well as the PIG metaphor, a decision matrix is also recommended by therapists as a means of combatting POEs. A decision matrix helps service users to work out the pros and cons of decisions, rather than acting in the heat of the moment. Doing so should reduce the chances of a hasty, ill-judged decision.

6. Coping with lapses and the Abstinence Violation Effect

A lapse, in the words of George A. Parks, is a ‘moment of crisis which combines both danger and opportunity’. [7]

In order to deal with lapses, it may be useful for service users to have a reminder card, with certain bits of advice on it. The aim of this card should be to prevent a lapse from becoming a relapse.

Advice for dealing with lapses should include:

  • Stay calm. Accept the feelings of guilt and shame which come with a lapse, and them allow them to dissipate. Move on
  • Stop, look and listen. A lapse indicates that you are in a dangerous situation. What do your senses tell you? Should you be in this situation? Can you extricate yourself, or seek help?
  • Stay motivated. Remember why you stopped using substances. Don’t give up hope
  • Think about what causes the lapse. Can you avoid this happening again? What were the warning signs?
  • You should have a plan in place for lapses. Stick to the plan. Get rid of any substances on your person and remove yourself from temptation
  • Get help. There are always people to talk to. If you have sponsor, call them. If you have therapist, call them. If you have a friend or loved one who you trust, speak to them

General relapse prevention strategies

1. Assessment of Lifestyle Balance

According to RP, lifestyle balance plays a major role in a person’s desire for gratification; it, therefore, has a significant impact on someone’s ability to stay abstinent.

How do you measure whether someone has a balanced lifestyle? You can look at things like:

  • Mental health conditions
  • Physical health
  • Exercise, diet and sleep
  • Relationships with family and friends
  • Social support
  • Money
  • Spiritual beliefs
  • Employment status

All of these things play into someone’s lifestyle balance. An excess of ‘shoulds’, or duties, can lead to an imbalance. This will need to be rectified.

2. Increasing Lifestyle Balance

In order to increase lifestyle balance, a range of strategies can be pursued. These should attempt to improve someone’s mental, physical, and spiritual wellbeing.

Some typical exercises for improving lifestyle balance include:

  • Massages to reduce stress
  • Exercise
  • Meditation
  • Social activities

These exercises can be tailored to the individual’s needs. For instance, someone who is very physically unwell will need more exercise and diet tips than someone who is physically healthy.

3. Substitute Indulgences

Since not all lifestyle imbalances can be corrected instantly, and lifestyle imbalances often lead to the desire for indulgences, it might be useful to suggest some substitute indulgences for patients who are at risk of using substances due to an excess of ‘shoulds’.

Substitute indulgences should be ‘positive addictions’, to use Glasser’s phrase. [8] These might include things like running, swimming or other hobbies. They should not include things like food, or screen time, which can become more negative addictions.

The good thing about positive addictions is that they replace the desire for substances with a constructive, healthy want. In the long run, this should help people with SUDs to stay away from substances and lead a happier, healthier life.

4. Coping Imagery

People with SUDs, especially those who are relatively new to abstinence, may have the mistaken belief that cravings for substances get stronger and stronger until the sufferer eventually gives in.

In fact, most people with SUDs experience cravings as something more like a wave, with a ‘peak’ or ‘crest’ that eventually subsides. Using imagery like that of the wave can help service users to visualise their cravings in a way which reminds them of the temporary nature of cravings.

5. Craving Cards

Similar to reminder cards, which are used to help with the response to a lapse, craving cards are used to help with cravings. They should feature general and specific tips for dealing with cravings. They might include:

  • Tips on how to distract yourself during a craving
  • How to escape from high-risk situations
  • Positive statements about oneself
  • How to recognise cravings

Final thoughts

Relapse prevention’s analysis of lapses, relapses, and the process by which people with SUDs end up relapsing is very perceptive. RP also has several useful strategies to offer people with SUDs, some of which we have looked at in this article. For more information on relapse prevention strategies, we have included some useful resources below:

Useful resources

‘Relapse Prevention and the Five Rules of Recovery’ – NCBI. This article talks about some of the key ideas in relapse prevention.

References

[1] Dimeff LA, Marlatt GA. Relapse prevention. In: Hester R, Miller W, eds. Handbook of alcoholism treatment approaches, 2nd ed. Boston, MA: Allyn& Bacon, 1995:176–194.

[2] Dr Richard K. Ries, ed. The ASAM Principles of Addiction Medicine, 5th ed. (2014, Lippincott Williams and Wilkins).

[3] George A. Parks, ‘Relapse Prevention Therapy’, The Essential Handbook of Treatment and Prevention of Alcohol Problems. Sussex, England: John Wiley & Sons, Ltd. (pp.575-592)Edition: 1stChapter: 29Publisher: John Wiley and Sons, LtD.Editors: N. Heather, and T. Stockwell
https://www.researchgate.net/publication/236171060_Relapse_Prevention_Therapy

[4] George A. Parks, ‘Relapse Prevention Therapy’
https://www.researchgate.net/publication/236171060_Relapse_Prevention_Therapy

[5] George A. Parks, ‘Relapse Prevention Therapy’
https://www.researchgate.net/publication/236171060_Relapse_Prevention_Therapy

[6] George A. Parks, ‘Relapse Prevention Therapy’
https://www.researchgate.net/publication/236171060_Relapse_Prevention_Therapy

[7] George A. Parks, ‘Relapse Prevention Therapy’
https://www.researchgate.net/publication/236171060_Relapse_Prevention_Therapy

[8] Glasser, W. (1974). Positive Addictions. New York: Harper and Row.

boris

Boris is our editor-in-chief at Rehab 4 Addiction. Boris is an addiction expert with more than 20 years in the field.  His expertise covers a broad of topics relating to addiction, rehab and recovery. Boris is an addiction therapist and assists in the alcohol detox and rehab process. Boris has been featured on a variety of websites, including the BBC, Verywell Mind and Healthline.