Relapse Prevention – The Question of When

By Terence T. Gorski at www.thesoberworld.com

Young man with ripped jeans and hat on backwards talking to a therapist

Relapse Prevention is important in addiction recovery. People who learn relapse prevention skills have a lower risk of relapse, and a better quality of life during periods of recovery. If they do relapse, many are able to stop quickly before serious consequences develop.

Relapse Prevention was originally developed in the 1970’s to help chronically relapse-prone people achieve long-term recovery. Relapse prevention was based upon research that identified a predictable sequence of early warning signs and high-risk situations that led from stable recovery back into addictive use.

The high-risk situations, usually the last step of the relapse process, did three things- it isolated people from recovery support; it increased social pressure to use; and activated a strong craving or urge to use. The early warning signs that drove relapse-prone people into high-risk situations were automatic and unconscious. In other words, they were habits done without thinking.

Initially, relapse prevention was focused on two things: identifying and managing the primary high-risk situations that caused craving and addictive use. This helped some people, but in others, their behavior was already out of control before they got into the high-risk situation. As a result, they were unable to use the high-risk situation management strategies they were taught.

The focus then shifted to identifying the specific behaviors that increased stress and problems, and allowed recovering people to slip into the high-risk situations that they believed would relieve their stress and solve their problems.

Initial research showed that thirty-seven warning signs preceded high-risk situations and could be used to predict relapse in many people. Using this list of warning signs, many relapse prone people were able to identify the specific pattern of problems that led them from a stable recovery back into addictive use.

This led to focusing not just on the high-risk situations, but also on the progressive problems in thinking, feeling and acting, that allowed people to fall back into those high-risk situations. These immediate problems fit into five general categories:

  1. Severe denial of addiction
  2. Cognitive impairments caused by the protracted or post acute withdrawal syndrome (PAW)
  3. Extremely stressful life problems in early recovery
  4. Inadequate family and social support for continuing in recovery
  5. Lack of problem solving, coping, and stress management skills 

Under the high stress caused by these problems, many relapse-prone people develop difficulty in thinking clearly, managing their feelings and emotions, and controlling urges to act out in self-defeating and addictive ways. These self-destructive urges cause them to stop important recovery activities; distance themselves from sober and responsible people; and move back into an addiction-centered lifestyle.

As the neuropsychological studies of addiction progressed, it was discovered that these symptoms were part of a long-term withdrawal syndrome caused by the affects of chronic addictive use upon brain chemistry. The brain, it seems, does not suddenly spring back to normal. A period of abstinence, recovery education, low stress, proper nutrition, exercise and amino acid supplementation helped these symptoms to clear up more quickly.

Relapse Prevention was first conceptualized as a specialty form of treatment for these relapse-prone people. Relapse Prevention was initially provided by a specialty relapse prevention program designed to meet the special needs of people who had completed primary addiction treatment and then returned to addictive use.

The assumption was, that people who relapsed after completing one or more primary addiction treatment programs, were either unmotivated, or had special problems that caused them to relapse.

The primary addiction treatment process involves: stabilization, motivation, education, recovery skills training, continuing care, and active involvement in a community-based recovery program. The primary recovery skills that were taught in treatment involved teaching people to recognize and manage addictive thoughts, feelings, urges, actions, and relationships. An important focus was on teaching clients to build sober and responsible relationships by getting involved with other sober and responsible people. People accomplished these goals by regularly attending recovery support groups and continuing care as an outpatient.

The assumption was, that primary recovery was successful with most people who were willing to actively participate, and resulted in them recognizing and accepting their addiction, developing and participating in a standard recovery program, and building sober and responsible relationships and lifestyles.

One thing became obvious very quickly – many chronic relapsers never started this recovery process. These relapse prone people had strong denial and were defensive and resistant to treatment. Special treatment methods that involved Denial Management Counseling and Motivational Counseling were developed to help these people recognize and accept their need for addiction treatment and to develop the motivation needed to start and maintain an effective recovery program.

Another thing became obvious – about one out of every three people entering primary recovery for the first time, making a commitment to their recovery, ended up going back into addictive use. These people who had never attempted recovery and relapsed, showed the same early relapse warning signs and high-risk situations that were experienced by relapse-prone people who had completed primary treatment.

This led to the awareness that many people in primary recovery for the first time could benefit from relapse prevention. Relapse prevention, however, was generally placed as the last thing to be addressed in primary treatment. Some programs even scheduled relapse prevention to be completed in outpatient treatment. The problem was that many people would leave treatment and return to addictive use before they learned to use the relapse prevention techniques.

Integration With Primary Recovery

As a result of these experiences, relapse prevention methods have been integrated into the primary addiction recovery process. In this approach, critical factors that increase the risk of relapse are focused upon as people go through the primary treatment process.

Primary Addiction Treatment involves techniques for teaching addicted people how to:

  • Break the self-reinforcing addiction cycle; stabilize physically, psychologically, and socially;
  • Complete a comprehensive assessment of their presenting problems, a life and addiction history, a treatment history;
  • Educate people about the progressive addiction process;
  • Show them the evidence from their own assessment that presents overwhelming and undeniable evidence that they are addicted and could benefit from recovery;
  • Developing an individualized treatment plan involving teaching people how to manage addictive thoughts, feelings, urges, actions, and relationships; and
  • Involving significant others in the process of building sober and responsible relationships.

Relapse prevention showed us three primary things that needed to be integrated into this process:

1. Stress Management: Since high stress caused cognitive impairments to get worse, it was critical to teach recovering people relapse prevention skills.

2.  Early Relapse Warning Signs: The early relapse warning signs are subtle. Many of these warning signs are felt internally and can only be reported and observed. The warning signs are activated by an environmental cue or trigger, and in the presence of high stress they are acted out automatically and unconsciously. Once activated, the warning signs increase stress, impair judgment, and create a spiral of life problems that may appear to have nothing to do with the addiction. The warning signs cause such severe pain and problems that people need relief. They remember how good they used to feel in old addiction-related situations and mistakenly believe they can still feel better in these situations.

3.  High-Risk Situations: High-risk situations put recovering people around the old people, places, and things related to addiction. When recovering people put themselves into high-risk situations, three things happen very quickly:  they lose the support and feedback from people in their recovery program;  they feel strong social pressure to start addictive use; they are exposed to environmental cues or trigger events that activate craving; and they are in a situation that makes addictive social use acceptable and easy to get involved in.

Starting Recovery With Relapse Prevention

The workbook, Starting Recovery With Relapse Prevention was designed to present an effective way of integrating primary recovery and relapse prevention methods with the specialty methods of teaching people how to recognize and manage early relapse warning signs, the triggers that activate these warning signs, and the high risk situations that remove support for recovery and encourage a return to addictive use, and activate the craving to use. Using this integrated method of relapse prevention, people are taught to recognize when the primary recovery methods themselves activate a high stress state that causes a return of denial and addictive thinking, and causes the patient to begin acting out automatically and unconsciously.

Here is the general sequence of combined primary and relapse prevention exercises that have been proven to be most effective:

Exercise #1: The Morning Plan and Evening Review: Self-monitoring increases self-awareness. Higher levels of self-awareness allow people to recognize when they are getting into trouble with their recovery. To encourage continuous and growing awareness, people are taught to develop a morning plan that includes both recovery activities and their normal life activities, how to anticipate any high risk situations they may encounter during the day, and to review their progress and problems every evening.

Exercise #2: Understanding & Recognizing Addiction: Before a person can relapse, they must know that they are addicticed. The second exercise quides people through a brief but complete list of the common symptoms of addiction and how those symptoms have affected their lives.

Exercise #3: Making the Recovery Decision: In order to make a commitment to a process of recovery and relapse prevention, people need to make a decision to stop their addictive use and to start a recovery process. This exercise takes them through the process of making that decision.

Exercise #4: Making A Commitment to Abstinence: Recovery involves making a formal commitment to stop the addictive cycle, stabilize, and start an addiction recovery program. It also involves having people recognize the logical consequences they will experience if they stop the recovery process.

Exercise #5: Managing Stress: People are taught to manage stress by learning self-monitoring using a Stress Thermometer and then using relaxed breathing and other simple relaxation methods. The stress thermometer divides stress into three levels of severity:

  • Level 1: Mild Stress: the stress is a nuisance, but, with extra effort, one can manage the stress without any interference with the normal acts of life.
  • Level 2: Moderate Stress: the stress is a nuisance, and at times even with extra effort, the stress interferes with the normal acts of life.
  • Level 3: Severe Stress: The stress is a serious problem that frequently or continuously interferes with normal acts of life.

Exercise #6: Managing Denial: Denial management is an important part of relapse prevention. How can someone return to addictive use if they believe that they don’t have it. Unlike other illnesses, addiction requires an accurate self-awareness of the probem for recovery to start. The exercise on denial introduces the idea that denying pain and problems is a normal and natural part of the human condition. Denial, however, can be a serious probem when it is so rigid and engrained in the person that seeing the truth even when it is undeniable to others, becomes impossible.

People are taught to monitor their thoughts and feelings, recognize the people, places, and things that drive them into denial, and learn to detach and stop using denial through specialized cognitive therapy methods.

Exercise #7: Managing Craving: Craving, the irrational feeling or need for the addictive release, is a serious problem for many recovering people. To manage craving, it is helpful for people to identify and manage their triggers which creates the initial urge or craving to use addictively, and the craving cycle, which becomes a self-reinforcing cycle of addiction-seeking behavior. Breaking the addiction cycle is best done if the patient has developed a plan that involves other people during periods of stable recovery.

Exercise #8: Managing High Risk Situations: Craving activitates automatic and habitual drug seeking behavior. The drug seeking behavior takes people into high risk situations that remove support for recovery, provides pressure for addictive use, and activates a powerful internal feeling of craving, or need for the addictive release.

Exercise # 9: Managing Thoughts: Addictive thoughts can lead to relapse. Sober and responsble thoughts strengthen recovery. This exercise presents a model for identfying and challenging addictive thoughts and developing and reinforcing sober and responsible ways of thinking.

Exercise #10: Managing Feelings: Emotional overreaction and emotional numbness are both serious problems that can lead to relapse. This exercise explains the difference between thoughts and feelings, suggests a simple yet comprehensive feelings checklist to help people recognize and manage their feelings, and gives general guidelines for effective emotional management.

Exercise #11: Managing Behavior: Stopping addictive and other self-defeating habitual behaviors is critical to successful long-term recovery and relapse prevention. This exercise describes the common addictive and self-defeating behaviors that can lead to relapse and suggests several simple systems for stopping the old behavior, starting new and more effective behaviors, and reinforcing those behaviors in recovery.

Exercise #12: Evaluating Your Progress (Self-Monitoring): In any change process, self-monitoring of progress and problems is important to long-term success. This exercise provides a checklist of the critical recovery skills needed to build a stable recovery program and relapse prevention plan in the first several months of recovery. Using this checklist on a regular basis helps recovering people stay connected with the basic recovery skills and consciously evaluates if they are regularly and effectively using these skills. This gives them a critical checklist that can keep them coming back to the basics in order to promote recovery while preventing relapse.

Terence T. Gorski has spent many years developing resources, publications and relapse prevention models and mechanisms to change behavior patterns of those who suffer from mental illness and substance abuse disorders. He has helped people abstain from drugs and alcohol, and assists with their mental health conditions.

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