Rehab 4 Addiction

For someone with a substance use disorder (SUD), sobriety is not just about getting clean: it’s about the day-to-day business of staying abstinent. And, while the detox process is certainly challenging, staying sober is no walk in the park.

When you’ve spent a long time using substances, life without substances takes a lot of getting used to. Many of the things you associate with using substances now remind you of a past life you want to move on from.

Staying sober in the long run is about having a set of tools that you can use to deal with challenging situations. Substances often act as a form of coping mechanism; in a life without substances, you need to develop new, healthier coping mechanisms.

Relapse rates

Before we go through our tips for staying sober in the long term, it is worth reminding ourselves of the importance of relapse prevention. According to one major study, the percentage of people with SUDs who relapse in the long term is between 40 and 60%. [1].

In the short term, the figures are even bleaker: only 20% of people make it through the first year without relapsing. Thankfully, those who do make it through the first year are much more likely to stay sober, but relapse rates are still a huge problem which people in recovery must be aware of. [2]

So, how do we help people with SUDs to avoid relapsing, especially over the long run? What techniques have been proven to reduce the chances of a relapse, and how can people put these techniques into action?

Read on for our ten top tips for staying sober over a long period of time.

Tip #1: Stay healthy

Good physical health is one of the cornerstones of good mental health; it is also crucial to long-term abstinence.

Why? Well, we know that there is massive correlation between poor mental health and addiction. 53% of adults admitted to substance use treatment in the UK in 2018/19 had a mental health need. This is much higher than in the general population, where roughly 1 in 4 people say they suffer from mental health issues. [4]

Not only that, but there is strong evidence to link good physical health with good mental health. For example, one study by Dr Felice Jacka looked at the role of diet changes in mental health treatment. The study found that switching to a Mediterranean diet was a very effective way of improving mental health. [5]

There is also good evidence to suggest that exercise can have a positive impact on mental health. Dr Wendy Suzuki has spoken about this at length in her TED Talk, and there have also been several studies on this subject, one of which can be found here.

In summary, then, staying healthy is good for your mental health, and by extension good for staying sober.

Tip #2: Take up a hobby

In relapse prevention, (RP), there is the idea of ‘substitute indulgences’. This is the notion that instead of allowing yourself to engage in substance use, you give yourself different, more positive ‘indulgences’. These indulgences could be hobbies that you enjoy.

William Glasser spoke about a similar thing in his landmark book on ‘positive addictions’. [6] Positive addictions are activities which replace substances as a kind of ‘addiction’.

Examples include running, hiking, swimming, reading or painting. Really anything you like can be a positive addiction, as long as it does not cause any harm to yourself or others.

Broadly speaking, it is important to find something to do with your time when you no longer have substances in your life. Free time presents both a risk and an opportunity. The risk is that you end up using substances due to boredom; however, the opportunity – to take up a hobby, to learn a new skill – is great.

If you want to stay sober in the long term, taking up a new hobby will help you to fill your free time, and provide you with an alternative to substance use when it comes to ‘indulging yourself’.

Tip #3:  Plan ahead for high-risk situations

High-risk situations are one of the biggest threats to long-term sobriety, and learning how to deal with them is crucial to anyone in recovery. Different branches of addiction therapy teach different approaches for dealing with these situations, but one of the simplest and most effective methods comes from relapse prevention (RP).

RP practitioners such as George A. Parks and G. A. Marlatt recommend the ‘avoidance, escape, delay’ method for dealing with high-risk situations. [7]

You can imagine this system like a set of flood defences. There are three lines of defence, such that if one is breached the other two are still there to prevent a flood. This provides an added level of security.

In practice, this method works as follows:

  • If you can, try to avoid high-risk situations. If, for example, you know that people will be drinking alcohol at a party, and you think that might put your sobriety at risk, then just don’t go to the party
  • If you can’t avoid a high-risk situation, come up with a plan of escape. That way, if you fear a lapse may be on the cards, you can still leave the situation without any stress. To continue with the party example, perhaps having an excuse prepared so that you can get away on short notice might be a good idea
  • If you can’t avoid a high-risk situation, and there is no easy way to escape, then delay. Give yourself more time to think before you do something hasty. Imagine you’re still stuck at the party and someone offers you a drink, without knowing you are in recovery. Rather than accepting, you could say ‘Maybe later.’ Hopefully, once the heat of the moment has passed, you will be able to resist the urge to drink and get out of the high-risk situation

Dealing with high-risk situations takes practice, but it can be done, especially with the help of strategies like this one.

Tip #4: Identify your triggers

Another key recipe for long-term sobriety is identifying your triggers:

  1. What is a trigger? A trigger is a ‘stimulus which elicits a reaction.’ [8] In the context of addiction, a trigger could be something like seeing a certain friend or going to a certain place (external trigger) or it could be feeling a particular emotion (internal trigger). ‘External’ triggers come from outside us, whereas ‘internal’ triggers come from within
  2. Why is it important to recognise your triggers? Though a relapse can occur at any time, it is more likely to occur as a result of a trigger or a high-risk situation. Under normal conditions, most people in recovery have defences against substance use which are unlikely to be bypassed easily. However, when you are susceptible to certain triggers – such as, for example, always drinking alcohol around the same friend – those triggers can cause you to slip into old habits. Therefore, even someone who has been abstinent for several weeks or months might find it hard to resist when they encounter a powerful trigger
  3. How do I work out what my triggers are? There are several ways to do so. One is to fill out the Inventory of Drug-Taking Situations (IDTS) questionnaire. [9] This questionnaire, which follows the taxonomy of high-risk situations proposed by G. A. Marlatt, tells the client what their biggest triggers are for substance use. It can be very helpful for those in recovery
  4. How do I avoid triggers? It is impossible to completely avoid every trigger – especially if some of your triggers are emotional, such as feelings of anger or happiness. That being said, knowing what your triggers, and avoiding them as best as you can, will help you to reduce the risk of a relapse

Tip #5: Get a good lifestyle balance

Another helpful idea which comes from relapse prevention therapy is that of ‘lifestyle balance’.

Lifestyle balance refers to the ratio of ‘shoulds’ – activities required by society, external demands – to ‘wants’ – things that the client enjoys and looks forward to. According to RP, if the number of shoulds exceeds the number of wants, that may cause the client to overcompensate by indulging themselves. [10] This can lead to a relapse.

On a slightly broader understanding, lifestyle balance can be understood as the ratio of stressful activities compared to stress-reducing activities in the client’s life. If there are too many stressful activities, that needs to be rectified.

How do I improve my lifestyle balance? Improving one’s lifestyle balance can be a simple as taking up a few more stress-relieving activities, such as meditation, yoga or mindfulness. These activities can help you to unwind and help reduce the risk of a relapse.

Tip #6: Learn how to deal with your cravings

Cravings are a natural part of any recovery. In order to stay abstinent, you need to establish systems for identifying cravings and mitigating their effects.

One danger to be aware of is the association between craving, stress, and relapse. One study looked at the link between stress, cravings and relapse and found that

‘craving and compulsive seeking is strongly manifested in the context of stress exposure, drug-related cues, and drug use itself and can become a potent trigger for relapse’. [11]

Therefore, if you have a craving and notice that your stress levels are high, you need to be aware of the risk of relapse.

One good technique to use for dealing with cravings is the ‘Coping Imagery’ technique from relapse prevention. This technique, suggested by the likes of G. A. Marlatt, involves picturing cravings as a kind of wave. Just like a wave, cravings grow in intensity, reaching a crest, before eventually subsiding.

Knowing that your cravings will subside, and picturing them as a wave, can help some people to resist their cravings. This is known as ‘urge surfing’ and you can find more information about it here.

Tip #7: Create a support network

One of the biggest contributors to addiction and substance use is isolation and loneliness. [12] Loneliness can lead to substance use; those in recovery need to maintain good friendships and relationships with mentors if they are to stay sober.

Why might people in recovery be at risk of loneliness? When you are using substances, you may develop friendships with people who also use substances.

These relationships may be unhealthy, and, after you get sober, it may be a good idea to stop spending time with these people. This is an important step in rebuilding your life and giving yourself the best chance of staying sober.

However, in the short term, it may also lead to loneliness, especially if the majority of your friendships were based around substance use (which is common among long-term substance users). You will need to replace these relationships with less toxic ones, a process which takes time and effort.

Why bother? Support networks – groups of friends and mentors who can help you when you need help – have been proven to have a positive impact on recovery.

This study, for instance, found that support networks led to benefits in the following areas:

  1. Substance use
  2. Treatment engagement
  3. Human immunodeficiency virus/hepatitis C virus risk behaviours
  4. Secondary substance-related behaviours such as craving and self-efficacy [13]

There is therefore a significant advantage to be gained by creating and maintaining a support network.

Tip #8: Make use of aftercare

Aftercare (or ‘continuing care’, as it is sometimes known) refers to care which patients receive after leaving rehab. This can be comprised of several things, such as:

Good aftercare can make the difference between someone relapsing a short time after they leave rehab, and someone staying abstinent for years. Why? One reason is that aftercare helps clients to establish support networks, housing and even jobs.

It can be difficult to re-establish yourself in the world after a period of substance use. Aftercare programmes can help you to do that. Most good rehab programmes include aftercare as standard.

What is the evidence for aftercare? This study found that ‘there is convincing evidence that continuing care can be effective in sustaining the positive effects of the initial phase of care.’ It looked at several other studies and sets of data to draw its conclusions.

Tip #9: Don’t let lapses become relapses

The Recovery Research Institute’s ‘Addictionary’ defines a lapse as

A non-technical term also referred to as a “slip”. It implies a short-term resumption of substance use or heavy/hazardous use (e.g., for a night or a day) that is followed by a return to the original goal of moderate use or abstinence. [15]

A ‘relapse’, by contrast, refers to the ‘recurrence of substance use’.

In relapse prevention, there is the idea of the ‘abstinence violation effect’ (AVE). This is a technical term for the feelings of shame that occur after an initial lapse. RP explains how the AVE contributes towards turning a ‘lapse’ into a 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’ [16]

In other words, the strong emotions triggered by a small lapse (e.g. having a single drink) can lead people in recovery to enter a full-blown relapse. This is a significant risk and needs to be avoided if possible.

One way to do so is by preparing small cards to read which give you advice in case of a lapse. This technique, which comes from RP, can help to take the sting out of a situation, forcing you to calm down and think rationally rather than enter into the chain of events which leads to a full relapse.

Tip #10: Practise mindfulness

In his book, The Craving Mind, Judson Brewer argued that mindfulness was key to preventing addictive habits from forming. [16]

Mindfulness is a technique which incorporates elements of meditation and involves taking a step back from thoughts and feelings in order to view them in a more balanced light. Brewer argues that by ‘witnessing’ your cravings, rather than participating in them in an active way, you can resist them.

This technique can be very effective for some, and provides a slightly different alternative to the relapse prevention strategies which we have discussed in this article. If you’d like to read more about it, there are some links here, here and here.

Thanks for reading, and we hope you have found some of this advice useful.

References

[1] NIDA. 2020, July 10. Treatment and Recovery. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery

[2] Dennis ML, Foss MA, Scott CK. An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Eval Rev. 2007 Dec;31(6):585-612. doi: 10.1177/0193841X07307771. PMID: 17986709.

[3] Gov.uk, ‘Substance Misuse Treatment for Adults Statistics 2018 to 2019’. https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2018-to-2019/adult-substance-misuse-treatment-statistics-2018-to-2019-report

[4] Mind.org.uk, ‘Mental health facts and statistics’. https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/

[5] Dr Felica Jacka et al., ‘A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial)’ https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0791-y

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

[7] 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

[8] American Psychological Association, APA Dictionary of Psychology, ‘trigger’.
https://dictionary.apa.org/trigger

[9] Annis, H.M., Turner, N.E. & Sklar, S.M. (1997). Inventory of Drug-Taking Situations: User’s Guide. Toronto, Canada: Addiction Research Foundation, Centre for Addiction and Mental Health. https://pubs.niaaa.nih.gov/publications/assessingalcohol/InstrumentPDFs/40_IDTS.pdf

[10] 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

[11] Rajita Sinha, ‘Chronic Stress, Drug Use, and Vulnerability to Addiction’, NCBI, 2008/.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732004/

[12] Mohsen Hosseinbor et al., ‘Emotional and Social Loneliness in Individuals With and Without Substance Dependence Disorder’
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295122/

[13] Kathlene Tracy and Samantha P Wallace, ‘Benefits of peer support groups in the treatment of addiction’
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047716/

[14] James R. McKay, ‘Continuing Care: What We’ve Learned and Where We’re Going’.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670779/

[15] Recovery Research Institute, ‘Addictionary’, ‘Lapse’. https://www.recoveryanswers.org/addiction-ary/

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

[17] Brewer, Judson (2017). The Craving Mind. Yale University Press.

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.