CHAPTER 7: Relapse Prevention in the Treatment of Substance Abuse and Addiction Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

Introduction One of the main goals of all substance abuse counseling is preventing the return to problematic use, or relapse Relapse is a common aspect of recovery and high percentage of clients return to using at some point during the recovery process Relapse prevention is not a theory, but a variety of models grounded in theory The purpose of this chapter is to enhance understanding of what constitutes relapse, discuss how relapse fits into the recovery process, describe models of relapse, and explain relapse in terms of diversity and using a case study

What is Relapse? Slip Generally, the one-time return to drug usage after a period of abstinence. Lapse Breaking abstinence but not returning to pretreatment levels of use Relapse A period of uncontrolled drinking or drug use following a period of abstinence Prolapse Mistakes that clients can learn from to improve the chance of success

What is Relapse? (Continued) Clients should be prepared to manage slips in abstinence and it is important to normalize slips There is some controversy between harm reduction and abstinence models regarding whether lapses constitute relapses Slips and lapses can lead to relapse Abstinence Violation Effect (AVE)-an experience of shame, guilt, and other difficult emotions when a slip occurs. This mindset can lead to a “I blew it so I might as well go all out” mentality

Recovery and Its Relation to Relapse is a period of deliberate and intentional non-use of substances includes abstinence and behaviors that promote a healthy lifestyle can be a lifelong process, that is not necessarily linear involves finding a positive purpose in life Models of Relapse Prevention Most popular is Alcoholics Anonymous and other 12 step groups Many models are cognitive behavioral in nature

CENAPS Model of Relapse Prevention Integrates developmental theory, the disease model of addiction, and cognitive-behavioral elements in each stage to enhance responsibility and awareness of relapse triggers and offer alternative coping skills Six developmental stages of recovery 1. Transition 2. Stabilization 3. Early Recovery 4. Middle Recovery 5. Late Recovery 6. Maintenance

Marlatt and Gordon’s Relapse Prevention Model Based on cognitive behavioral theory and social learning theory 1. Addiction is an over-learned, maladaptive habit 2. Behavioral-modification principles have an impact on addictive behavior 3. Bad habits and the difficulty in ceasing them is understandable 4. Escape from addiction requires changing habits Relapse Taxonomy Immediate determinants Covert antecedents

Marlatt and Gordon’s Relapse Prevention Model Continued Any combinations of determinants can lead to relapse The key is to help clients view lapses as mistakes and provide tools to manage high risk situations Effective coping skills can increase self-efficacy which promotes abstinence Ineffective coping skills can decrease self-efficacy which can lead to AVE and a higher likelihood of relapse

The Dynamic Model of Relapse Revised relapse prevention (RP) model that highlights the complex nature of relapse Key Components 1. Distal risks 2. Cognitive processes 3. Coping behavior 4. Tonic responses 5. Phasic responses 6. Perceived effects High risk situations are at the core of this model

REBT and Relapse REBT assumes the client has made the decision to stop using substances When a client experiences high-risk situations, the desire to use can increase The decision to NOT use leads to irrational beliefs (e.g I cannot stand not drinking) Irrational beliefs lead to anxiety, leading to the decision to dispute irrational beliefs or succumb to use Interventions to prevent relapse Assess and avoid high-risk situations Practice disputing irrational beliefs Assist in developing healthy coping skills to manage anxiety

Application of Relapse Prevention in the Treatment of Substance Use Relapse prevention can be used as a standalone intervention, or in conjunction with other interventions Content areas Psycho-education Identification of high-risk situations Development of coping skills Development of new and balanced lifestyle behaviors Enhanced confidence Avoiding AVE Drug and alcohol monitoring Establishing support systems

Specific and Global Relapse Prevention Strategies Encourage a nonconfrontational stance and incorporation of client’s perspective in the relapse plan Specific intervention strategies include focusing on cognitive distortion, high-risk situations, and negative reactions to the environment Global intervention strategies include establishing lifestyle balance, identifying and handling early warning signs, and managing AVE

Specific and Global Relapse Prevention Strategies Continued Lifestyle modification and balance: Developing an appropriate balance between “shoulds” and “wants” Stimulus control: Taking control of one’s environment by avoiding, escaping, and delaying Urge/craving management: Managing cravings with strategies such as urge surfing, relaxation, and breathing exercises Relapse road maps and apparently irrelevant decisions (AIDs): An analysis of high-risk situations, available choices, and consequences that help identify seemingly innocent choices that can lead to relapse

Relapse Management Helping clients to manage a lapse so it does not lead to relapse Goal is to minimize the degree of setback and help clients get back on track General relapse management strategies Help put lapses into perspective so clients do not experience AVE Teach clients that lapses can be attributed to external events Remind clients that abstinence is only a moment away

Relapse Management Continued Specific relapse management strategies Stop, look, and listen Make an immediate plan for recovery Stay calm Renew commitment Review the situation leading up to the slip Use support network Work through/process guilt and other negative emotions related to the AVE

Behavioral Chain Analysis: Breaking Down What Happened A DBT strategy that functions to determine the nature of the problem, what is influencing the target behavior, what is getting in the way of more adaptive behavior, and what resources the client has/lacks to handle the problem Six steps 1. Identify the target behavior 2. Identify prompting events 3. Identify vulnerability factors 4. Link the chain of events 5. Identify consequences of substance abuse 6. Generate hypotheses

Emerging Relapse Prevention Strategies Mindfulness-Based Relapse Prevention (MBRP) combines traditional RP strategies and mindfulness techniques Mindfulness techniques can: increase awareness of triggers and promote cognitive mechanisms to observe cravings without reaction induce feelings of well-being and relaxation help clients focus on increasing acceptance and tolerance, decreasing the need to release negative emotions through substance use help clients process reactions to situational cues

Relapse Prevention in the Treatment of Diverse Populations Some concern exists as to whether RP strategies are applicable to multicultural populations Exploration of cultural and social norms to develop RP plans that are compatible with the client’s cultural background is essential High-risk situations may look different amongst different populations AA may not be culturally sensitive toward women and minority populations

Running Case Study: Michael Despite his sobriety of several months, Michael continues to experience risk factors for relapse To address these triggers, the clinician provides education about relapse, focuses on cravings and triggers, assesses high-risk situations, assists in developing healthy coping strategies for these situations, discusses the importance of lifestyle balance, and reinforces social support Note Michael’s collaboration with the clinician throughout the relapse prevention plan

Strengths, Limitations, and Ethical Issues Related to Relapse Prevention Strengths Can be used independently or in conjunction with other interventions Incorporates the language of addiction Empirically supported Suggests a broadening of the influence of contextual factors in relapse which can improve delivery of services to diverse populations Straightforward to understand and implement

Strengths, Limitations, and Ethical Issues Related to Relapse Prevention Cont. Limitations Because they rely on CBT concepts, limitations of CBT can apply Controversy as to whether slips/lapses are different from relapse Educational component may not be preferred by clients Do not address fundamental disorders of personality Ethical issues Proponents of the disease model may refute the idea of viewing slips as mistakes because it can place clients at risk