What Is Relapse Prevention?
Relapse prevention is a systematic method of teaching recovering patients to recognize and manage relapse warning signs. Relapse prevention becomes the primary focus for patients who are unable to maintain abstinence from alcohol or drugs despite primary treatment.
Recovery is defined as abstinence plus a full return to bio/psycho/social functioning. As previously noted, relapse is defined as the process of becoming dysfunctional in recovery, which leads to a return to chemical use, physical or emotional collapse, or suicide. Relapse episodes are usually preceded by a series of observable warning signs. Typically, relapse progresses from bio/psycho/social stability through a period of progressively increasing distress that leads to physical or emotional collapse. The symptoms intensify unless the individual turns to the use of alcohol or drugs for relief.
To understand the progression of warning signs, it is important to look at the dynamic interaction between the recovery and relapse processes. Recovery and relapse can be described as related processes that unfold in six stages:
- Abstaining from alcohol and other drugs
- Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery
- Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts
- Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs
- Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors
- Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote irrational thinking.
When people who have had a stable recovery and have done well begin to relapse, they simply reverse this process. In other words, they
- Have a mistaken belief that causes irrational thoughts
- Begin to return to addictive thinking patterns that cause painful feelings
- Engage in compulsive, self-defeating behaviors as a way to avoid the feelings
- Seek out situations involving people who use alcohol and drugs
- Find themselves in more pain, thinking less rationally, and behaving less responsibly
- Find themselves in a situation in which drug or alcohol use seems like a logical escape from their pain, and they use alcohol or drugs.
A number of basic principles and procedures underlie the CENAPS Model of Relapse Prevention Therapy. Each principle forms the basis of specific relapse prevention therapy procedures. Counselors can use the following principles and procedures to develop appropriate treatment plans for relapse-prone patients. Following a description of each principle is the relapse prevention procedure for that principle.
Principle 1: Self-Regulation
The risk of relapse will decrease as a patient's capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases.
Relapse Prevention Procedure 1: Stabilization
An initial treatment plan is established that allows relapse-prone individuals to stabilize physically, psychologically, and socially. The level of stabilization is measured by the ability to perform the basic activities of daily living. Because the symptoms of withdrawal are stress-sensitive, it is important to evaluate the patient's level of stability under both high and low stress. Many people who appear stable in a low-stress environment become unstable when placed in a more stressful environment.
The stabilization process often includes
- Detoxification from alcohol and other drugs
- Solving the immediate crises that threaten sobriety
- Learning skills to identify and manage Post Acute Withdrawal and Addictive Preoccupation
- Establishing a daily structure that includes proper diet, exercise, stress management, and regular contact with treatment personnel and self-help groups.
Because the risk of using alcohol or drugs is highest during the stabilization period, steps must be taken to prevent use during this time. The patient needs to be in a drug-free environment. Any irrational thoughts (thoughts that don't make sense to a healthy person) that are creating immediate justification for relapse need to be identified and discussed. The patient should then be helped to remember the consequences of past chemical use and to develop new coping strategies.
An early relapse intervention plan can be developed by the counselor and patient to decide what action to take if the patient begins to use alcohol or drugs. This early intervention plan motivates the patient to stay sober and provides a safety net should chemical use occur.
Principle 2: Integration
The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increases.
Relapse Prevention Procedure 2: Self-Assessment
Self-assessment first involves a detailed reconstruction of the presenting problems (problems that caused the patient to seek treatment) and the alcohol and drug use history. A careful exploration of the presenting problems identifies critical issues that can trigger relapse. This allows the counselor to design intervention plans that help to solve crises that can be used for relapse justification in the early treatment stages. The next step is a reconstruction of the recovery and relapse history. This helps identify past causes of relapse.
In reconstructing the recovery/relapse history, it is important to identify the recovery tasks that were completed or ignored, and to find the sequence of warning signs that led back to drug or alcohol use. The assessment is most effective if the counselor reconstructs the relapse history using exercises (done as homework assignments), such as making a list of all relapse episodes and identifying the problems that led to relapse. These assignments should be reviewed in group and individual sessions.
Principle 3: Understanding
The risk of relapse will decrease as the understanding of the general factors that cause relapse increases.
Relapse Prevention Procedure 3: Relapse Education
Relapsers need accurate information about what causes relapse and what can be done to prevent it. This is typically provided in structured relapse education sessions and reading assignments, which provide specific information about recovery, relapse, and relapse prevention planning methods. This information should include, but not be limited to
- A bio/psycho/social model of addictive disease
- A DMR
- Common Astuck points" in recovery
- Complicating factors in relapse
- Warning sign identification
- Relapse warning sign management strategies
- Effective recovery planning.
The recommended format for a relapse education session is as follows:
- Introduction and pretest (15 minutes)
- Educational presentationClecture, film, or videotape (30 minutes)
- Educational exercise conducted in dyads or small groups (15 minutes)
- Large group discussion (15 minutes)
- Post-test session and review of correct answers (15 minutes).
It is important to test patients to determine their retention and understanding of the material. Many relapsers have severe memory problems associated with Post Acute Withdrawal that prevent them from comprehending or remembering educational information.
Principle 4: Self-Knowledge
The risk of relapse will decrease as the patient's ability to recognize personal relapse warning signs increases.
Relapse Prevention Procedure 4: Warning Sign Identification
Warning sign identification is the process of teaching patients to identify the sequence of problems that has led from stable recovery to alcohol and drug use in the past and then recognizing how those steps could cause relapse in the future. The process of developing a personal relapse warning sign list is (1) reviewing warning signs, (2) making an initial warning sign list, (3) analyzing warning signs, and (4) making a final warning sign list.
The patient develops his or her own individualized warning sign list by thinking of irrational thoughts, unmanageable feelings, and self-defeating behaviors. Most final warning sign lists identify two different types of warning signs: those related to core psychological issues (problems from childhood) and those related to core addictive issues (problems from the addiction). Warning signs related to core psychological issues create pain and dysfunction, but they do not directly cause a person to relapse into chemical use. When patterns of addictive thinking that justify relapse are reactivated, a return to using alcohol and drugs occurs.
Principle 5: Coping Skills
The risk of relapse will decrease as the ability to manage relapse warning signs increases.
Relapse Prevention Procedure 5: Warning Sign Management
This involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur. The better they are at coping with warning signs, the better their ability will be to stay in recovery.
Warning sign management should focus on three distinct levels. The first is the situational-behavioral level, where patients are taught to avoid situations that trigger warning signs. At this level, they are taught to modify their behavioral responses should these situations arise. The second level is the cognitiveBaffective (thoughts and feelings) level, where patients are taught to challenge their irrational thoughts and deal with their unmanageable feelings that emerge when a warning sign is activated. The third level is the core issue level, where patients are taught to identify the core addictive and psychological issues that initially create the warning signs.
Principle 6: Change
The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases.
Relapse Prevention Procedure 6: Recovery Planning
Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they develop in sobriety. This is done by reviewing each warning sign on the final warning sign list and ensuring that there is a scheduled recovery activity focused on each sign. Each critical warning sign needs to be linked to a specific recovery activity.
Principle 7: Awareness
The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases.
Relapse Prevention Procedure 7: Inventory Training
Inventory training involves teaching relapse-prone patients to complete daily inventories. These inventories monitor compliance with the recovery program and check for the emergence of relapse warning signs. A daily recovery plan sheet is used to plan the day, and an evening inventory sheet is used to review progress and problems that occurred during that day.
A typical morning inventory asks the patient to identify three primary goals for that day, create a to-do list, then schedule time for completion of each task on the to-do list on a daily calendar. During the evening review inventory, the patient should review his or her warning sign list and recovery plan to determine whether he or she completed the required activities and experienced any relapse warning signs.
Whenever possible, these inventories should be reviewed by someone who knows the patient and who can assist him or her in looking for emerging patterns of problems that could cause relapse.
Principle 8: Significant Others
The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases.
Relapse Prevention Procedure 8: Involvement of Others
Relapse-prone individuals cannot recover alone. They need the help of others. Family members, 12-step program sponsors, counselors, and peers are just a few of the many recovery resources available. A counselor should ensure that others are involved in the recovery process whenever possible. The more psychologically and emotionally healthy the significant others are, the more likely they are to help the relapse-prone patient remain abstinent. The more directly the significant others are involved in the relapse prevention planning process, the more likely they are to become productively involved in supporting positive efforts at recovery and intervening on relapse warning signs or initial chemical use.
Principle 9: Maintenance
The risk of relapse decreases if the relapse prevention plan is regularlyupdated during the first 3 years of sobriety.
Relapse Prevention Procedure 9: Relapse Prevention Plan Updating
The patient's relapse prevention plan needs to be updated on a monthly basis for the first 3 months, quarterly for the remainder of the first year, and twice a year for the next 2 years. Once a person has maintained 3 years of uninterrupted sobriety, the relapse prevention plan should be updated on a yearly basis.
Nearly two thirds of all relapses occur during the first 6 months of recovery. Less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase. As a result, ongoing outpatient treatment is necessary for effective relapse prevention. Even the most effective short-term inpatient or primary outpatient programs will fail to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy.
A relapse prevention plan update session involves the following:
- A review of the original assessment, warning sign list, management strategies, and recovery plan.
- An update of the assessment by adding documents that are significant to progress or problems since the previous update.
- A revision of the relapse warning sign list to incorporate new warning signs that have developed since the previous update.
- The development of management strategies for the newly identified warning signs.
- A revision of the recovery program to add recovery activities to address the new warning signs and to eliminate activities that are no longer needed.
Basic Relapse Prevention Techniques
There are a number of techniques that are used when doing relapse prevention counseling.
When you begin a group or an individual session or when you want a patient to calm down and get in touch with thoughts and feelings, you can use a technique called centering. This is basically a relaxation technique. Instruct the patient to do the following:
- Put both feet on the floor, sit up straight and close your eyes.
- Breathe in through your nose and out through your mouth.
- Breathe in deeply, hold it for a second, then breathe out.
- Do this again and feel your lungs fill with air, then empty.
- Slow your breathing to a steady rhythm.
- See if any thoughts are entering your mind.
- Ask yourself if you are feeling any body tensions.
- Open your eyes when you are ready.
Speak slowly as you give the instructions. This will help the patient calm down.
Sentence completion is a technique used to help patients identify thoughts that they have that may not be true. These thoughts are called mistaken beliefs. Many times when a patient is acting in a self-defeating way, it is a result of mistaken beliefs he or she has about the world and himself or herself. When a patient is behaving in a way that hurts himself or herself and others, it is because the patient believes that this is the only choice he or she has. Sentence completion is a way to help a patient identify and correct mistaken beliefs. You do this by doing the following.
- Have the patient form a sentence stem: A sentence stem is the beginning of a sentence that has meaning for the patient. You can form these stems based on topics the patient is talking about. Examples are:
"I know my recovery is in trouble when . . ."
"When I think about drugs, I . . ."
"Right now, I am feeling . . ."
- Have the patient write down the sentence stem.
- Have the patient repeat it out loud and end it differently six to eight times or until he or she cannot think of new endings.
- Have the other group members write down the endings. If you are in an individual session, do this yourself.
- Have the group members read the endings back to the patient as they write them down. Have them use the following form: A(patient's name), I heard you say (sentence stem)(first ending)." Repeat the exercise until all the endings have been read.
- Look for a common theme in the endings. You may form a new sentence stem from the common theme and repeat the exercise, or stop here if the mistaken belief is identified.
- Have the patient identify the mistaken belief if he or she can and write it down.
Sentence repetition is a way for a patient to become conscious of mistaken beliefs and the thoughts, feelings, and actions they cause. Identify the mistaken belief and ask the patient to write it down.
- Ask the patient to repeat it out loud, slowly.
- After each repetition, ask the patient to take a deep breath, let it out, and report any thoughts, feelings, or urges that surfaced.
- Have the patient write down these thoughts, feelings, and urges.
- Ask the patient if he or she can remember who caused this mistaken belief or where it came from.
- Ask the patient if the person could have been wrong.
- Ask the patient if there are other ways to believe that could be true. You may have to ask the group to help.
- Ask the patient to complete the following sentences:
"If I continue to believe this, the best that can happen is . . ."
"The worst that can happen is . . ."
"The most likely to happen is . . ."
"If I change what I believe, the best that can happen is . . ."
"The worst that can happen is . . ."
"The most likely to happen is . . ."
- The probable outcomes can be discussed and a course of action decided by the group. The most important decision is to identify a rational thought that the patient can substitute when the mistaken belief occurs.