Webster’s Dictionary defines a relapse as a recurrence of symptoms of a disease after a
period of improvement. This definition can apply to medical, mental health, or addictive
diseases or disorders. Alan Marlatt, a widely published author who wrote the first book on
relapse prevention (RP), defined relapse as a breakdown or setback in an attempt to change
an addictive behavior such as alcohol or drug use. A lapse is the initial episode of substance
use after a period of recovery, and it may or may not result in a full-blown episode of relapse,
in which substance use is out of control.
Research shows a 40% to 60% relapse rate among individuals receiving treatment for
addiction. Similar relapse rates are found with other chronic medical health disorders such as
hypertension, asthma, and diabetes and with mental health disorders such as bipolar
disorders or major depression. Most relapses to addiction occur in the first year, with the
majority occurring in the first 90 days. It takes a year of abstinence before less than half the
addicted individuals relapse. After achieving 5 years of abstinence from alcohol or drugs, only
14% relapse.
No one factor determines if a relapse will occur, but there are often warning signs or behavior
changes that indicate an increased risk of substance use. These changes may be evident in
the person’s attitudes, thoughts, emotions, behaviors, or a combination and can happen
gradually or suddenly. Relapse may begin in a dynamic that reactivates patterns of denial,
isolation, elevated stress, and impaired judgment. If recognized early in a relapse cycle, the
individual with addiction or a supportive person (e.g., clinician, sponsor, mentor, peer in
recovery, family member, or significant other) may be able to intervene to reduce the risk or
severity of relapse. This entry examines the causes and effects of relapse and describes
several strategies for RP.
Causes of Relapse
Many factors contribute to a relapse. Understanding these helps professionals, individuals
with addiction, and families gain insight into early identification and ways to develop RP
strategies.
According to the work of Marlatt, relapse factors usually fall into two categories: (1)
interpersonal or (2) interpersonal. These often overlap for a given individual, as several factors
may work together to contribute to a relapse. Dennis Daley and Antoine Douaihy identified the following eight factors that contribute to relapse, all of which fall under Marlatt’s determinants of relapse.
Affective (feelings, emotions, moods, stress): Negative emotional states such as anger, anxiety, boredom, depression, and loneliness represent the most common category of relapse factors. However, it is not the emotional state but whether the individual uses coping skills to manage the emotions that determines whether a relapse occurs. In a few instances, relapse can occur after experiencing a positive emotional state.
Behavioral: Failure to use problem-solving, stress management, and leisure or time management skills increases the risk of relapse. Not having enough productive activities to engage in may contribute to boredom or depression, which can raise the risk of relapse.
Cognitive: The individual’s beliefs about addiction, recovery, relapse, and his or her coping abilities influence the decision to use or not use substances in specific situations.
Environmental and interpersonal: Inability to use coping skills to resist direct or indirect social pressures to use substances is the second most common relapse factor. Social networks involving others with active addictions or who do not support recovery, conflicts with a family member or significant other, and lack of recovery supports also increase the risk of relapse if coping skills are not used.
Physical: Strong cravings, pain, and other medical symptoms increase the desire to use substances and influence relapse for some addicted individuals.
Psychological or psychiatric: A decrease in the motivation to change, internal conflict over a past trauma, or an untreated mental health disorder can have an impact on relapse.
Spiritual: Feelings of guilt or shame, not feeling connected to others, or struggling with a lack of direction or meaning in life can affect the relapse process.
Treatment: Poor adherence to treatment or not receiving appropriate treatment influences relapse. For example, individuals with chronic alcoholism who have relapsed multiple times can benefit from medication-assisted treatment for alcoholism. However, not all treatment programs or clinicians promote the use of medications for individuals with alcohol dependence.
Effects of Relapse
The effects of a relapse vary from therapeutic to mild, moderate, severe, or fatal, depending
on the individual and the circumstance of the relapse. The individual who relapses may feel
disappointment, shame, and guilt, or may judge himself or herself as a failure rather than
view the relapse as a mistake that needs to be corrected. The individual may experience a
loss of control in that his or her alcohol or drug use spirals out of control. Sometimes,
individuals lose control of substance use slowly once a relapse starts; at other times, the loss
of control is rapid. The individual begins using as often and as much as before or, in some
cases, uses more of the substance. In many instances, a relapse is a learning experience in
which the person reviews the warning signs and high-risk factors and develops strategies to
manage these should they occur again.
Strategies to Reduce Relapse Risk
Relapse cannot always be prevented, so it is important to think about ways to reduce relapse
risk. Poor adherence to treatment or recovery activities is a major factor in relapse. Many
studies show that individuals who are adherent to treatment have better outcomes and lower
rates of relapse than those who do not adhere to treatment, miss sessions, or leave against
medical advice. An effective strategy to improve adherence is increasing an individual’s
motivation and addressing dips in motivation. In addiction treatment, it is normal for an
individual to feel ambivalent about treatment or changing substance use behaviors.
Motivational interviewing and motivational incentives are two approaches that have a positive
impact on adherence to treatment.
RP counseling and other therapy models address relapse by focusing on key elements of
Marlatt’s model: identifying and managing high-risk factors, developing cognitive and
behavioral skills to manage these, making lifestyle changes, and intervening early in the
relapse process. Numerous clinical trials and meta-analyses examining the efficacy and
effectiveness of Marlatt’s model have led to RP being identified as an evidence-based practice in the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-Based Programs and Practices. The interventions presented in this section incorporate the work of Marlatt as well as others, including Daley and Douaihy.
Identify and Manage Early Warning Signs
High-risk factors may be interpersonal (internal thoughts or feelings) or interpersonal
(relationships and interactions with others) situations in which the individual feels vulnerable
to using substances. Relapse is more likely to happen as a result of not using coping skills
than from the high-risk situation itself. An individual in recovery can identify the high-risk
factors and develop coping skills or problem-solving skills to manage these. There are many
clinical tools to help this process, such as reviewing a list of common relapse factors.
Manage Negative Emotions
Research shows that more than one third of relapses occur in response to a negative emotional state or mood, such as anger, anxiety, boredom, depression, or loneliness. Mutual-support programs such as AA or NA use the acronym HALT (hungry, angry, lonely, tired) to emphasize the significance that negative emotions can have on a person’s recovery or
relapse. Helping individuals learn emotional coping skills can decrease the likelihood of a
relapse. For example, there are many cognitive and behavioral strategies that are effective in
managing anxiety and depression. Leisure counseling can help an individual with an addiction
reduce boredom and build structure in daily life.
Refuse Social Pressures to Use Substances
Social pressures may be direct, such as having someone offer alcohol or drugs, or indirect,
such as being at an event (e.g., wedding, party, concert, ballgame) where alcohol or other
drugs are available. An important part of an RP plan is recognizing social pressures (people,
places, events) and how these influence thoughts such as “I want to be able to drink and fit in
with my friends; why can’t I have a few drinks?” Learning how these influence emotions and
behaviors is also important in developing a plan to refuse pressures to use substances. Some
individuals also need to avoid high-risk people, places, and events, especially in the early
phases of recovery. Practicing saying no in behavioral rehearsals or role plays is one way to
help a person learn to refuse social pressures.
Change Addictive or Negative Thinking
Cognitive distortions, faulty thinking, or negative thoughts (e.g., “I need a drink/drug”; “I can
control my use”; “A few can’t hurt”; “How can I have fun if I’m not using with friends?”;
“Sobriety is boring”; “I need some action”; “I had a rough day/week”; “I need a drink/drug to
relax”) can lead to relapse or cause negative emotional states. AA and NA refer to this process as “stinking thinking” and encourage individuals in recovery to challenge and change how they think in order to reduce their relapse risk. Cognitive behavioral therapy (and other
therapies) helps individuals identify and change beliefs and specific thoughts that can
sabotage recovery and contribute to personal distress.
Build a Recovery Support System
Positive social supports can enhance recovery from an addiction. Individuals benefit from
active involvement in twelve-step mutual-support programs (e.g., AA, NA) and non-twelve-step
programs such as Rational Recovery or Women for Sobriety. Sponsors and peers in recovery
can provide ongoing support. Other social supports include family members, friends,
coworkers, and others who the person feels can be trusted. Some individuals have a hard
time asking for help or support due to feelings of embarrassment, shame, or guilt, or a fear
that others will not help them, and they may benefit from practicing how to ask for help from
others.
Involve the Family or Significant Other
Many studies show that family involvement in treatment has many positive benefits, including
improved adherence to treatment, less substance use, and improved functioning for both the
individual with the addiction and his or her family. For adolescents, family involvement also
leads to improvement in academics and interpersonal behaviors. Families experience less
conflict and improvement in communication, and family members feel less of an emotional
burden and more in control of their own lives when they learn to focus on their own needs
and not solely on the family member who is addicted.
Address Any Coexisting Mental Health Disorder
Three large-scale epidemiological studies and numerous studies of clinical populations in
mental health and addiction treatment systems show high rates of comorbidity in which the
person has both an addiction and a mental health disorder. Treatment for comorbidity may
involve inpatient hospitalization, residential treatment, partial hospitalization, intensive
outpatient or outpatient programs, medication management, and other ancillary services such
as case management, peer counseling, or vocational counseling. Integrated treatment that
addresses both types of disorders is the preferred method of care when possible. Individuals
with more severe types of conditions such as psychotic disorders, bipolar disorders, recurrent
major depression, or borderline personality disorder are best treated in a mental health
program that includes focus on the substance use issues. Addressing both types of disorders
lowers the risk of relapse to either disorder.
Offer Medication-Assisted Treatment for Opioid, Alcohol, or Nicotine Addiction
Many effective medications exist for these addictions when combined with psycho-social
therapies and/or mutual-support programs. Those with an addiction who have had multiple relapses should be evaluated and encouraged to consider medications to aid their recovery
from addiction. These medications may reduce the desire or craving for alcohol, opioids, or
nicotine, and hence are an excellent tool for RP.
Facilitate the Transition Between Levels of Care
Often, individuals who are addicted do not follow through with treatment following medical
detoxification or completion of a hospital-based or residential rehabilitation program.
Motivational interviewing, motivational incentives, and many other counseling interventions
have been shown to increase the follow-up rates among clients discharged from higher levels
of care. Access and adherence to ongoing continuing care is associated with improved
outcomes and lower rates of relapse.
Focus on Lifestyle Issues
Many individuals in recovery from addiction need help with practical matters such as
budgeting and managing money; planning and structuring the use of leisure time; getting
sufficient exercise, rest, and sleep; and getting help for significant dental, medical, financial,
social, or occupational problems. Learning to use problem-solving skills helps the individual
deal with problems in any of these areas. In more recent years, mindfulness skills have been
used as a part of RP.
Prepare to Manage Setbacks
Because many individuals with an addiction relapse, they need to be prepared to take action
quickly, preferably when a lapse occurs and before it gets out of hand. Marlatt recommends
the following to stop a lapse or relapse: stop, look, and listen; keep calm; review the
commitment to recovery; review the situation leading to the lapse; make an immediate plan for recovery; and ask for help. Recovery experts recommend that all individuals in recovery have an emergency plan to use that involves reaching out to others for help and support. They also need to know when to use professional help based on the type and severity of the relapse. For example, one person may need medical help in a hospital if physical addiction occurs, whereas another may be able to stop a lapse after a day or two of bingeing and will not need a high level of professional care.
Individuals with an addiction who engage in long-term recovery and learn RP strategies put
themselves in a position to reduce their risk of relapse or take action quickly should one occur. As in other chronic medical and mental health conditions, relapse in addiction is common. Learning and using RP coping strategies can enhance recovery and lower the risk of relapse.
Contributors: Dennis C. Daley & Billie Jo Smith
Edited by: Amy Wenzel
Book Title: The SAGE Encyclopedia of Abnormal and Clinical Psychology
Chapter Title: "Relapse Prevention"
Pub. Date: 2017
Access Date: April 13, 2017
Publishing Company: SAGE Publications, Inc.
City: Thousand Oaks,
Print ISBN: 9781483365831
Online ISBN: 9781483365817
DOI: http://dx.doi.org/10.4135/9781483365817.n1133
Print pages: 2831-2834
©2017 SAGE Publications, Inc.. All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of
the online version will vary from the pagination of the print book.