1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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