• Dr. Dennis C. Daley

Relapse Prevention

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.

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. Physical: Strong cravings, pain, and other medical symptoms increase the desire to use substances and influence relapse for some addicted individuals.

  6. 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.

  7. 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.

  8. 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.

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