Introduction
In the struggle to be free from addiction, for most individuals, repeated attempts are required to stop the addictive behavior. Multiple attempts to change and multiple treatment events are the norm rather than the exception in recovery from addiction. There seems to be a predictable cycle in the path to recovery. Once addicted individuals become convinced that they need to change problematic addictive behaviors (illegal or nonprescription drug use, excessive alcohol consumption, tobacco use, or gambling), they will attempt either to quit completely or to significantly modify these behaviors (e.g., cutting down or using methadone or buprenorphine instead of heroin). The majority of these individuals who make an attempt to change, however, are unsuccessful. In any cohort of individuals who enter treatment and make a bona fide attempt to change, the majority, between 60% and 80%, return to the problematic behavior after some period of success. This event, although defined in various ways, has been labeled a “relapse.”
Understanding the Concept of Relapse and Its Role in Recovery
The definition of what constitutes a relapse varies depending on the definition of success and failure in changing an addictive behavior. The most stringent definitions define success as complete abstinence from the behavior and identify relapse as any engagement in the addictive behavior (any consumption of alcohol, use of cocaine, and so on). Other clinicians and researchers make a distinction between a slip or lapse and a full-blown relapse. Slips and lapses have been defined variably as a single use, a single period of use, minimal amounts of use, or use without any consequences. Relapse is then a more significant engagement in the behavior than a single event or a brief period of use. Lapses could indicate that there are some vestiges of the behavior present that may create problems for sustained abstinence or lead to a relapse. Making a distinction between a lapse and a relapse can be clinically useful because the very strict definition of complete abstinence or failure can have unintended consequences, as described later. It is important first to note some common misconceptions about the phenomenon of relapse. Relapse is often viewed as a unique problem of substance abusers by practitioners and the public. However, relapse and lapsing back to unhealthy behaviors occur in all types of health behavioral change and is not limited to addictions. Many health behaviors, such as dietary change, diabetes management, regular physical activity, and medication adherence have a similar course, with large numbers of individuals lapsing and relapsing. , Relapse is not merely a function of physiological addiction, it is a function of the process of behavioral change when individuals attempt to change difficult-to-modify patterns of behavior. ,
Another misconception is that relapse is often viewed as failure, since the desired behavioral change is not sustained. However, although it does not represent complete success, relapse is an integral part of learning during the recovery process. Individuals do not become addicted or recover from an addiction with a single learning event. Within the stages of change model, relapse represents an event that not only involves a return to a problematic behavior but also signifies a return to an earlier stage of change for that behavior. After relapsing, individuals can return to any of the pre-Action or even to Action stages; Precontemplation (not considering change in the near term), Contemplation (considering and decision making), Preparation (building commitment and planning), or Action (initial change lasting for 3–6 months). Individuals returning to the Precontemplation stage after relapse likely believe they cannot change or they are no longer interested in changing the addictive behavior. Relapsers who reconsider the pros and the cons of the addiction, try to resolve the associated ambivalence and make a new decision to quit have returned to the Contemplation stage. Those who determine what went wrong during the last quit attempt and are poised to make another attempt return to the Preparation stage. Relapsers who quickly make another attempt move back into the Action stage of change. The return to earlier stages of change after relapsing from the Action or Maintenance stage is called “recycling” back through the stages and often leads to another attempt that is successful. The cyclical movement through the stages of change represents the learning process of successive approximations whereby an individual learns gradually through trial and error how to avoid the problems from past attempts and make a successful change in behavior.
Relapse, considered from this perspective, is not so much a failure as an opportunity to learn what went wrong and what was missing in the unsuccessful process of change. Most individuals who enter stable recovery do so only after multiple attempts to change. This pattern is true of individuals who have changed the addictive behavior without the aid of formal treatment as well as those who have been successful after a particular course of treatment. In any case, understanding relapse and recycling is critical to understanding successful recovery. Helping individuals avoid relapse and/or to learn how to profit from the experience and become more successful is the goal of relapse prevention and of successful recycling. This chapter examines relapse prevention models, highlights critical components of relapse prevention, identifies key clinical strategies that can be used in the service of preventing relapse, and discusses how to promote successful recycling for those who were unable to change their behavior at any one point in time.
Relapse Prevention
As the field of addiction moved from a moral explanation of addiction to a focus on habit and disease, the challenge of maintaining change and avoiding relapse became a focus of research and theory. Interest and research activity expanded to understand what precipitates relapse and the possible interventions that would reduce the relapse rate and increase the potential for recovery from a slip or a relapse. There were several dominant theories that were developed during the 20th century, not all of which were compatible with one another.
Models for Relapse Prevention
The two partially compatible models for understanding relapse came from different explanatory frameworks. The Medical Model countered the prevailing perspective at the beginning of the 20th century that alcoholism and other addictions were moral problems that could be overcome with willpower and by observing moral standards. The view of addiction as a disease was intended to change the conversation about addiction, remove some of the stigma, and make it a medical condition that was treatable. This model was not only adopted by medical professionals but also by the influential founders of Alcoholics Anonymous and the Twelve-Step model for recovery. At the same time in the academic community, the social and behavioral learning perspectives described addictions as overlearned behaviors that were supported by contextual forces. More recently, addiction has also been described as a reward deficit disorder in which an individual progresses from impulsivity to compulsivity and from positive reinforcement to negative reinforcement in the development of their addiction. This model focuses more on how substances affect brain functioning, emotion regulation, and stress management, creating behaviors that are difficult to stop and maintain cessation. Of interest, all models arrived at some similar relapse-prevention strategies.
Medical and Mutual Help Model
In the Medical Model, addiction is viewed in terms of the changes that are made in the neurochemistry of the addicted individual, which causes physiological dependence. The perspective is that the addiction acts as a disease and changes biological processes which, in turn, pose significant barriers for change for the addicted individual. The physiological changes that result from prolonged substance abuse manifest themselves in craving, which continually pushes the addicted individual to return to the addictive behavior. For the addicted individual, their normal biological state is inherently resistant to behavior change. Medical Model–oriented interventions to prevent relapse include periods of hospitalization that focus on breaking the physiological and psychological connections to addiction as well as using medications that decrease cravings.
In the Medical/Mutual Help or Twelve-Step Model, addiction is also described as an illness or disease that addicted individuals are powerless to control. One analogy for the disease is an allergy such that the individual cannot have contact with the substance without a loss of control. This perspective supports the view of relapse as any contact with addictive substance or behavior. The addicted individual is seen as someone who has a defect such that willpower cannot be the solution for recovery. Preventing relapse must include an admission of powerlessness and a reliance on a higher power, whether that is seen as a spiritual power or the power of the mutual help network that is created by associating with Alcoholics Anonymous and working the 12 steps of recovery. The program includes a number of strategies (e.g., approach recovery, one day at a time, you are always an alcoholic and must always be vigilant, meeting attendance) and support systems (e.g., sponsors, fellowship of Alcoholics Anonymous) for the prevention of relapse.
Reward Deficit Model
Addiction, particularly a severe alcohol use disorder, has been conceptualized as a reward deficit disorder. It is a chronically relapsing disorder that, like in the medical model, is defined by a loss of control in limiting one’s intake. It is also characterized by a compulsion to use the substance driven also by the negative affectivity in the form of dysphoria, anxiety, or irritability occurring as a result of withdrawal from the substance. When an individual initiates substance use, impulsivity, a predisposition to quick unplanned actions without considering negative consequences, is the dominant precipitant to substance use. Later in the addiction cycle, once negative affectivity and withdrawal has begun, substance use becomes compulsive, meaning one continues to use the substance in the face of negative consequences. When substance use is more of an impulsive behavior, it is positively reinforced by the pleasurable effects of the drug. Use becomes compulsive as the motivational force changes to negative reinforcement and use becomes necessary to relieve a negative affective state. This model asserts that it is the reward deficit caused by neurobiological changes in the brain that is the chief vulnerability for relapse. Interventions based on this model often include use of a pharmacological agent to assist in breaking the addiction cycle and in supporting behavioral strategies that will enable abstinence and avoidance of relapse.
Cognitive-Behavioral Models
In 1980, G. Alan Marlatt and Judith Gordon developed the Relapse Prevention Model, an extensive, empirically focused conceptual model that we use as the basis of our discussion of relapse in this chapter. Their cognitive-behavioral model of the relapse process is based on social cognitive and learning models of behavior and posits that addiction stems from maladaptive habit patterns. Relapse is conceptualized as resulting from a series of predictable cognitive and behavioral events that lead to a return to substance use. This relapse prevention model hypothesizes that common cognitive, behavioral, and affective mechanisms underlie the process of relapse for a variety of problem behaviors. This view of recovery is based on learning theory and differs from the disease model in many ways, although it does share some theoretical precipitants of relapse.
The model assumes that a complex array of determinants is involved in the development of an addiction and the ability to successfully change addictive behaviors. Some influential factors include genetics, environmental/situational factors, family history of addiction, peer influence, early use of substances, and expectancies of the effects of the substance. During periods of abstinence, individuals must engage in cognitive and behavioral coping activities that lead to successful behavior change. Along the way, they are likely to face situations that put them at risk for relapse. High risk situations that become triggers for relapse are at the center of the cognitive-behavioral model of relapse.
The most recent refinement to this model emphasizes that relapse processes are interactive, dynamic, and nonlinear. They also define two sets of processes that contribute to relapse. More stable (called tonic) processes encompass risks for relapse that include background factors like genetics, social support, and dependence; cognitive processes include global self-efficacy, outcome expectancies, craving and motivation; as well as physical withdrawal. More immediate processes (called phasic) processes include the individual’s affective states and coping behaviors (including cognitive/behavioral strategies and self-regulation). The more stable tonic processes determine one’s vulnerability for relapse, but the more immediate phasic responses determine how and when that happens.
Research has elucidated several experiences that lead to relapse, which have been incorporated into the cognitive-behavioral relapse model. Cummings et al. found that the most frequently reported precipitants of relapse included negative emotional state (35% of relapses), social pressure (20%), interpersonal conflict (16%), and urges and temptations (9%). Factor analysis of the Reason for Drinking Questionnaire revealed three major factors that differentiated the types of relapses people experienced: (1) negative emotions, (2) social pressure and positive emotions with others, and (3) temptation and craving.
According to the cognitive-behavioral relapse model, individuals who use effective coping responses and have high self-efficacy are less likely to relapse. Moreover, successful use of this coping behavior increases self-efficacy, which should reduce the probability of subsequent relapse in similar high-risk situations. If an individual fails to use effective coping behaviors, the lure of the substances will increase while self-efficacy to abstain decreases, thereby escalating the likelihood that the individual will use the substance in that particular situation. Guilt and low self-esteem can occur if the substance is used during this period of abstinence. These feelings can propel an individual from the initial use of alcohol, often termed a “lapse,” into a full-blown relapse.
Marlatt and Gordon describe the onset of guilt and lowered self-efficacy as a possible effect of a lapse from an initial goal of abstinence. They label this reaction the Abstinence Violation Effect. This reaction is related to the individual’s causal attribution for the slip. For example, when drinkers attribute the lapse to their own personal failure, they tend to experience guilt and negative emotions that can lead to increased drinking in an attempt to avoid or escape those feelings. When people attribute the lapse to stable, global factors that are beyond their control, they are more likely to avoid a full-blown relapse. A subsequent relapse is more likely for persons who attribute the lapse to a personal inability to cope with high-risk situations. It is the individuals who are able to learn from the mistake and avoid future relapses that are better able to develop effective coping skills to deal with triggers. Of interest, research has found that contrary to the proposed inevitable loss of control that occurs after a lapse, some people are able to slip or engage in a first use and then regain control. If an individual is able to reinstate abstinence after a slip, they have achieved a prolapse or positive lapse experience.
Review of Relapse Prevention and Substance Abuse Studies
Since the advent of a focus on relapse and maintenance and, in particular, the response to the detailed, conceptual perspective of the Relapse Prevention Model, interventions designed to prevent relapse have been developed as clinical applications of Marlatt and Gordon’s model. The conceptual foundations of this model and a review of its applications have been updated by Marlatt and Donovan and Hendershot and colleagues. These interventions are designed to enhance the maintenance stage tasks of sustaining and integrating change into the person’s lifestyle and emphasize self-management and coping skills in order to withstand the challenges presented by relapse precipitants. The goals of relapse prevention are twofold: to prevent an initial lapse and to provide lapse management to prevent a complete relapse if a lapse does occur. Most controlled studies that administered relapse prevention treatment measured outcome success based on the goal of abstinence, although treatment goals based on harm reduction and decreasing substance use have also been attempted.
The effectiveness of relapse prevention as an intervention has been reviewed for different substances and compared to a number of alternative interventions. Relapse prevention programs have been designed specifically for smoking, alcohol, marijuana, cocaine, and other drug use. Although early reviews concluded that there was little evidence for differential effectiveness of relapse prevention across classes of substance abuse, later reviews found some support for the greater effectiveness of relapse prevention when applied to alcohol or polydrug use disorders in combination with medication treatment.
In terms of comparative efficacy, relapse prevention has been found to be superior to no-treatment control groups, and equally as effective as other treatments, such as supportive therapy, social support groups, and interpersonal psychotherapy. Another review found that relapse prevention has a greater impact on improving psychosocial functioning than on reducing substance use. In addition, relapse prevention was more effective when combined with the use of prescribed medication. Although results were based on a small number of studies and should be interpreted with caution, Irvin et al. concluded that individual, group, and marital modalities were equally effective in preventing relapse in cohorts of substance abusers. What follows is a brief review of the literature on the efficacy and use of relapse- prevention strategies with different types of addictive behaviors. A detailed presentation of the standard elements is included in the section entitled “Strategies for Relapse Prevention.”
Effectiveness Studies Across Addictive Behaviors
More research has been conducted on the effectiveness of relapse prevention for alcoholism and nicotine addiction than for any other addictive behaviors. The second edition of Relapse Prevention by Marlatt and Donovan provides a detailed chapter on relapse prevention for each of the addictive behaviors. For most drugs of abuse, relapse prevention constructs and strategies have been applied in clinical settings. However, there is limited literature on specific relapse prevention treatments separate from more generic cognitive-behavioral approaches, and the research consists mainly of trials focusing on the Abstinence Violation Effect or other dimensions of the model. It is disappointing that more studies of the entire model and specifically its efficacy in preventing relapse across multiple behaviors have not been conducted. However, because cognitive-behavioral therapy approaches have incorporated many aspects of the relapse-prevention strategies, and evaluations of these approaches in addictions have been favorable in terms of effectiveness and efficacy in trials, there is empirical support for many of the constructs and the strategies that are described later in this chapter.
Relapse prevention has been found to be most effective in treating alcohol and polysubstance use compared with other substances alone (cocaine, marijuana, cigarettes, and so on) or abusive behaviors. Reviews of alcohol and drug treatment studies generally report a broad, multidimensional range of outcomes that include reductions in use, increased time before relapse, and improvement in functioning.
In addition to the more commonly used cognitive-behavioral interventions, new theoretical approaches to relapse prevention are gaining popularity and being researched, including Mindfulness-Based Relapse Prevention (MBRP), which is discussed in more detail later in the chapter. A study that compared the effectiveness of MBRP, a standard cognitive-behavioral relapse-prevention protocol, and treatment as usual (TAU) among substance users who completed initial substance use treatment found that there were no group differences at 3 months after treatment, yet at the 6-month follow-up, both MBRP and relapse prevention fared better than TAU in reducing the risk of relapse to heavy drinking and/or drug use. Of interest, relapse prevention performed better than MBRP in time to first drug use, while participants who received MBRP had significantly fewer days of drug use and a lower probability of engaging in heavy drinking at the 12-month follow-up. This study is one of the first comparing these relapse prevention approaches and strongly supports the notion that continued intervention after initial treatment, particularly over extended periods, promotes relapse prevention among alcohol and drug users.
A recent comprehensive review of smoking cessation relapse prevention interventions found that self-help materials can promote relapse prevention among previously unaided quitters and that pharmacotherapies (i.e., varenicline, nicotine replacement therapy [NRT], and bupropion) can be effective in preventing relapse after initial treatment or a period of abstinence. However, comprehensive reviews for smoking cessation conducted by the Cochrane Collaborative in 2009 and Agboola and colleagues found insufficient evidence to support the use of behavioral approaches to prevent smoking relapse in individuals who already successfully quit—these interventions were aimed at teaching patients skills to identify and cope with triggering situations via face-to-face, telephone, or worksheet formats. However, the methodological soundness of these studies overall was low. Nevertheless, many relapse prevention strategies have been included in standard tobacco dependence treatment (knowing personal and environmental cues for smoking, delaying and urge management, relaxation, rewards, and so on) and are incorporated into self-help and Internet-assisted programs. Thus relapse prevention has become a core component of intervention for smoking cessation, rather than a separate and independent intervention specifically designed to prevent relapse.
Critical Mechanisms for Relapse Prevention
An increasing number of studies indicate that the prevention of relapse or promotion of successful maintenance of change involves several key overarching constructs: motivation, coping, and self-efficacy. These three elements are critical to the long-term success of recovery and are important components to address in any program attempting to prolong abstinence and prevent relapse.
Motivation
Motivation plays an important role in relapse prevention. There is ample evidence that motivation for change as well as treatment outcome expectancy and client goals of abstinence are related to successful treatment outcomes. Motivation at the beginning of treatment and the attitudes and intentions that individuals bring into treatment are related to early cessation of drinking and drug use as well as to long-term success. Individuals who enter treatment after making a decision to change and taking steps toward change have a better prognosis compared with those who enter treatment and have not yet made a decision or taken steps. Overall, motivation is one of the most consistent predictors of long-term outcomes. In addition, studies have found that increase in motivation during pharmacobehavioral treatment predicted drinking outcomes posttreatment, and relapse prevention is less effective for individuals who have low initial readiness.
How motivation and expectancies affect successful change and prevent relapse are not completely understood. Motivation is clearly multidimensional and involves different mechanisms of change. Motivation has been conceptualized as having multiple components: problem recognition and endorsement of taking steps toward changing. Problem recognition is necessary but not sufficient for change in substance use behavior; it is only when problem recognition is followed with commitment and endorsement of taking steps that there is a documented long-term change in substance use behavior. Relapse prevention is less effective for individuals who have low initial readiness ; enhancing problem recognition should precede relapse prevention efforts
If motivation is viewed as a series of tasks outlined by the stages of change, there are multiple elements that are necessary for the success of recovery and the prevention of relapse. For example, to avoid relapse, addicted individuals need to have some continuing, compelling reasons to abstain, a firm decision based on realistic expectations, commitment to follow through despite difficulties, an effective set of strategies and plans on how to manage triggers, and the ability to problem solve effectively when the plan is not working. These tasks outlined in the five stages of change have to be accomplished adequately to be able to sustain change and overcome the difficult challenges presented to anyone stopping or modifying an addictive behavior. As individuals begin to have some success at changing the addictive behavior, their motivation to make an attempt to change has to shift to motivation to sustain the change over time in the face of the multiple personal and environmental barriers that could undermine the decision, the commitment, the determination, and the plan. Triggers have to be met successfully and the centrifugal forces that bring one back to the addictive behavior, be they physiological, behavioral, or social/environmental, must be countered.
One way to understand the function of relapse in recovery is to see it as a sign that the motivational tasks involved in the stages have not been adequately addressed or successfully mastered. So relapse serves to indicate that the process of change has not been done well enough to support success. Recycling through the stages then serves to help the addicted individual adequately accomplish these tasks to a degree that enables change to be maintained and relapse to be avoided. Much of the work of relapse prevention has focused on the cues and triggers that precipitate relapse. Although those precipitants are important, they do not explain relapse. Looking more broadly at the entire process of change and successful completion of multiple tasks of the stages can help clinicians explore a range of challenges and topics that span the entire motivational process instead of focusing only on the moment of the slip, lapse, or relapse.
Coping
Strong support also has been found for the relationship between coping and relapse prevention. Individuals who fail to use any coping response in a crisis have been found to be more likely to relapse. There are two main theoretical aspects of coping responses: (1) the focus of coping and (2) the methods of coping. In both of these areas, there is an important distinction between active coping and avoidant coping. In terms of focus, active coping strategies are those which are oriented toward the problem, whereas avoidant coping strategies rely on avoidance of the problem. Active strategies are most appropriate when an individual has some control over the situation, whereas avoidant coping may be more useful when dealing with situations or events in which there is little or no control. Methods of coping involve strategies and coping activities that involve both cognitive and behavioral strategies.
An individual’s inability to utilize an effective coping behavior when he or she is experiencing a high-risk situation results in decreased self-efficacy and increased use of a substance as a coping mechanism. However, differential effects have not been found for cognitive coping skills versus behavioral coping skills. Rather, actively engaging either type of coping skill seems to facilitate positive outcomes. In summary, it appears that in preventing relapse there is an important role for the addicted individual’s response to any threats to abstinence or recovery. However, it is not only the actual effectiveness of the response that helps to prevent relapse but also the sense of confidence that the individuals have in their ability to perform the behaviors critical to recovery and needed to sustain change.
Self-Efficacy
Confidence in one’s ability to perform behaviors seems to be a critical mechanism in intentional behavior change. Bandura defined self-efficacy as the degree to which an individual feels confident and capable of performing a certain behavior in specific situations. The self-evaluation of one’s confidence to remain abstinent has been associated with lower rates of relapse for both men and women, in inpatient and outpatient settings, and for both short-term and long-term follow-up.
Deficits in abstinence self-efficacy have been found to be a significant predictor of relapse in a number of studies. Ecological momentary assessment, or repeated sampling of research participants’ experiences, has made possible the investigation of the dynamic nature of self-efficacy and other relapse predictors; a recent study of 305 recently abstinent smokers demonstrated that daily reports of lower abstinence self-efficacy and positive smoking outcome expectancies predicted the occurrence of a first lapse and that downward shifts in abstinence self-efficacy predicted onset of relapse. Moreover, the longer an individual stays abstinent, the stronger their self-efficacy and sense of personal control becomes. Higher levels of self-efficacy have been found to be predictive of improved alcohol treatment and tobacco use outcomes in a variety of contexts
In a study that investigated abstinence self-efficacy of inpatient alcoholics in predicting their ability to remain abstinent after treatment, the level of abstinence self-efficacy measured at discharge from the residential center was the strongest predictor of abstinence at 1-year follow-up. A meta-analysis of self-efficacy and smoking cessation revealed that self-efficacy measured postquit has a stronger relation to future smoking behavior than when self-efficacy is measured prior to a quit attempt. Additional support has been found for the predictive power of abstinence self-efficacy using the Alcohol Confidence Questionnaire. Higher levels of confidence to resist the urge to drink in high-risk situations were associated with greater likelihood to maintain abstinence 6 months after treatment. In addition, lower levels of confidence in situations related to urges and testing control were found to predict relapse to heavy drinking during a 12-week treatment period. Greenfield and colleagues found that individuals who relapsed to alcohol the year after hospitalization had lower overall confidence scores than individuals who did not relapse. This later relapse onset for the group with higher self-efficacy indicates a relation between efficacy to abstain and duration of abstinent behavior following treatment.
A large clinical treatment trial for matching participants to optimal alcohol treatments based on a number of client characteristics, Project MATCH, considered abstinence self-efficacy to be an important variable for determining appropriate treatment. Levels of abstinence self-efficacy were measured at the start of the study (baseline) and at the end of treatment (posttreatment). For the outpatient arm of the study, baseline abstinence self-efficacy was predictive of drinking outcomes during treatment, throughout the 1-year follow-up, and at a 3-year follow-up. However, for aftercare clients, baseline self-assessment of abstinence self-efficacy did not predict posttreatment drinking, suggesting that efficacy was a more powerful predictor for those individuals who were just beginning therapy compared with those who were continuing treatment and may have already experienced changes to their levels of abstinence self-efficacy or who evaluated their self-efficacy in a residential setting.
Strategies for Relapse Prevention
The challenge of preventing relapse is one of trying to find strategies that can support and increase motivation, can teach or implement appropriate coping activities when internal or external cues trigger a desire or temptation to drink or use drugs, and can encourage and strengthen the self-efficacy of the addicted individual. Proper motivation, coping and efficacy would then support recovery and prevent relapse. Most programs and models of treatment and mutual help provide activities and support that target these variables. Alcoholics Anonymous, for example, encourages continued self-reevaluation (e.g., moral inventories, reading supportive literature), active coping both in avoiding high-risk situations and turning to meetings and a sponsor to support sobriety, and supports efficacy with a focus on one day at a time and messages of empowerment based on support from a higher power. However, the most extensive discussion of relapse prevention strategies comes from the social learning and relapse prevention models.
Relapse prevention is best used with clients who have finished an initial detoxification round of treatment and/or may be coming to the end of initial phases of treatment, since these are the clients who have been able to achieve some measure of abstinence or change. In addition, rates of relapse are highest in the initial phases of the action stage and once initial treatment has been completed. Relapse prevention would also be appropriate for individuals who have experienced a slip after a period of sustained abstinence and as a follow-up treatment for individuals in the maintenance stage of change.
Relapse prevention treatment strategies have been divided into five specific categories of activities: (1) assessment, (2) increasing insight/awareness, (3) skills trainings, (4) cognitive strategies, and (5) lifestyle interventions. Each of these activities will be described in detail below. The activities are interconnected and there is a logical flow beginning with the initial strategy of behavioral assessment, which often starts with self-monitoring by the client. The goal of this behavioral assessment is to get a clear and complete picture of the circumstances surrounding potential substance use and the client’s reactions to each of those situations or cues. If the client is still actively using substances, it is critical to obtain accurate information about the amount, the environment surrounding the use, and the events that preceded and followed the use. The next step is to identify high-risk situations, coping skills, and the effectiveness of both cognitive and behavioral coping strategies being used to address the cues.
Once key skill deficits are identified, coping skills training can be conducted using either group or individual sessions. An advantage of the group format is that peers are natural partners for role plays and can provide examples of coping or scenarios for group brainstorming. Including significant others in sessions can also potentially assist in cue reduction and coping training and have a comprehensive impact on a client’s recovery. Finally, the focus turns to the lifestyle of the individual to see how overall patterns of life activities can help or hinder continued recovery and the maintenance of change. We review each of these components in greater detail and then discuss two newer strategies that have been added to the relapse prevention tool box: mindfulness strategies and medications.
Assessment
Behavioral assessments can be conducted using direct observation by a therapist (when cues are available or presented), role play, interviews with family members or peers, self-report questionnaires (Alcohol or Drug Abstinence Self-Efficacy; Alcohol Confidence Questionnaire, Situational Confidence Questionnaire), and self-monitoring. In fact, self-monitoring serves not only as a means of gathering information but also as an intervention. In a recent review, prompting self-monitoring and secondarily seeking commitment were found to be associated with better drinking outcomes in the use of brief interventions for excessive alcohol consumption. Although clients may initially be resistant to self-monitoring as a homework assignment, frequently after completing it, they report that it is a positive experience. In addition to the insight gained though the self-assessment, monitoring often acts as a catalyst for behavioral change and leads to a reduction of the monitored behavior. In addition, self-monitoring can be an effective tool to combat denial, challenge cognitive distortions, and identify substance-related automatic processes and negative thoughts that promote an automatic sequence of behaviors that lead to using.
If the individual is still engaging in the addictive behavior, then using self-monitoring to assess the factors surrounding use is important. If the client has been able to achieve abstinence, a self-assessment of cravings is appropriate to identify their personal high-risk situations. A frequently used type of self-assessment is assigning a drinking diary or craving diary to identify habit patterns; potential triggers; high-risk situations; consequences of use to themselves as well as others; and the physical, emotional, and financial costs of using. It is important for the individual to understand the social, situational, emotional, cognitive, and physiological precipitants of relapse that make up a high-risk situation. Technologies like telephone-based Interactive Voice Responding (IVR) and ecological momentary assessment (periodic daily assessment prompts) can be used for repeated self-monitoring. More recently, this method of self-monitoring is being used in clinical settings to provide clients and clinicians with real-time information.
High-risk situations are any situation that threatens an individual’s abstinence self-efficacy and poses a strong potential for relapse back to the addictive behavior. High-risk situations include both intrapersonal determinants as well as interpersonal determinants. The intrapersonal determinants include both positive and negative emotional states as potential risk factors. Negative emotional states such as anger, depression, anxiety, boredom, and frustration can be triggering, particularly if substances were used as a way of dealing with the emotional states. Clients may need additional treatment such as anger management or therapy for depression in addition to drug counseling to give them the coping skills to deal with such negative emotions. Positive emotional states such as feeling good, confident, or celebrating can bolster overconfidence in being able to handle “just one” use of the substance. Interpersonal determinants include conflicts with friends, spouses, family members, and coworkers. Another interpersonal determinant is social pressure that can either be overt encouragement to use or covert pressure to conform in a situation where everyone else may be smoking, drinking, or drugging.
Once the self-assessment has been completed, this information can be used to create a decisional balance sheet that helps to concretely lay out the pros and cons of using in particular situations. Such a worksheet can clarify the specific reasons for maintaining abstinence and increase motivation, particularly for individuals who are not fully committed to treatment or recovery. Assessments not only identify high-risk situations but also examine the commitment, self-efficacy, and coping skills that the individual may use to address challenging situations.
Insight and Awareness
Increasing insight and awareness assists clients in understanding the processes that trigger a relapse, including social pressure, physiological mechanisms, and emotion management. Understanding these mechanisms is an important part of preparing for high-risk situations and unexpected triggers and urges. This can be made more concrete by creating an ongoing road map to relapse by which clients identify upcoming high-risk situations, as well as potential unexpected risks and emergency situations. They can also identify early warning signs that predict a high-risk situation. The road map can also identify ways they can refrain from using with an effective coping strategy for a particular situation. The next challenge is to make sure that clients have access to the types of skills and self-management strategies that would be needed to effectively address their risk situations that could provoke a return to the substance use or addictive behavior.
Behavioral Coping Skills
The behavioral skills training component involves training in a number of skills and strategies in different life domains to assist clients in resisting relapse. Skills training is designed to develop specific skills needed to cope with situations and to increase the client’s sense of self-efficacy to sustain recovery and overcome risks for relapse. For example, relaxation training can be particularly helpful with clients who used substances to alleviate anxiety or to cope with stressful situations. Progressive relaxation training or mindfulness meditation can assist in decreasing anxiety in a high-risk situation sufficiently so that an alternative coping strategy can then be employed. Assertiveness training, including practicing refusal skills, can assist clients with poor social skills in navigating interpersonal pressures to use and is associated with improved drinking outcomes, assisted by improved self-efficacy. Encouraging the use of social support has also led to continued abstinence, and perceived general social support is also associated with abstinence self-efficacy. Practicing ways to refuse substances, deal with criticism, and appropriately express feelings of frustration, anger, or anxiety can assist clients in building their repertoire of coping skills.
Cue exposure is another cognitive behavioral technique that is used to build up client’s abstinence self-efficacy through gradually exposing them to substance-related cues. It is a counterconditioning procedure in which clients are progressively desensitized to the stimuli associated with the addictive behavior in controlled conditions. Clients practice using coping skills as they are gradually exposed to different high-risk situations. To avoid iatrogenic effects from putting clients in potentially very unsettling conditions, exposure should always end with adequate processing of the experience and debriefing, such as a relaxation exercise or meditation. Clients who were encouraged to practice cue exposure with careful guidance from their therapist achieved significant improvement in drinking outcomes over time.
There are numerous skills that can be developed and there are manuals for various types of addictive behaviors that contain modules for specific skills training in effective communication, anger management, coping with negative emotions, depression, assertiveness, handling rejection, meditation, and managing family members who use substances. These modules can be used depending on the types of situations that are identified by the addicted individual so that the relapse prevention strategies can be personalized to the types of situations and cues that are most salient for that individual.
Cognitive Strategies
In addition to behavioral skills, there are also a number of cognitive strategies that can be taught and used to combat relapse. Often, relapse is precipitated not just by the external cues but by the interpretations and self-statements from within the individual when confronted with a high-risk situation. Cognitive strategies are designed to challenge and change ways that individuals process information and problematic self-statements that undermine coping and efficacy. These cognitive strategies include cognitive restructuring, relapse rehearsal, labeling and detachment, and coping imagery. Cognitive restructuring is the process of correcting addiction-related cognitive distortions and frequent patterns of thinking such as seemingly irrelevant decisions and the abstinence violation effect. Seemingly irrelevant decisions are decisions that are not inherently related to the actual substance use but can put the client in a high-risk situation. An example would be a client getting his car fixed at a mechanic one block from his favorite bar (alcohol-associated cues). Doing so could prompt him to go in to see if any friends (interpersonal pressure) were around as a way to alleviate the boredom (negative emotion) of waiting for his car to be fixed. The goal of cognitive interventions is to help individuals examine and prevent such seemingly irrelevant decisions that put individuals in harm’s way and can lead to relapse.
As was noted previously, the abstinence violation effect is a potential reaction to initial use or reengagement in the addictive behavior. If after a lapse, clients feel they have failed and experience a significant decrease in abstinence self-efficacy, they are more likely to go back to using as much as they used rather than attempt to regain abstinence. It is important to put a lapse into proper perspective so that clients can return to the recovery process rather than returning to their prior habits. Recovery from a slip seems to require an interpretation and attribution of the lapse as caused by external or environmental factors, a continuing commitment to the change goal, a confidence in the ability to recover from a lapse, and a reactivation of active coping to avoid or manage the triggering situations or cues.
Relapse rehearsal and relapse fantasies are a means of associating the coping skills learned in treatment with a crisis situation. By imagining a high-risk situation and imagining oneself using an effective coping skill to avoid substance use, the client is able to prepare for a variety of high-risk situations and evaluate the expected effectiveness of different coping strategies. Coping imagery is another cognitive technique that can assist with combating high-risk situations. Making use of guided fantasy, the therapist and client can use personally relevant imagery that can bolster the client’s self-efficacy to avoid relapse.
Labeling and detachment are coping strategies aimed at helping clients experience urges and cravings without succumbing to them. This strategy reframes cravings as temporary sensations of desire as opposed to unending compulsions that dictate a client’s behavior. Helping clients view cravings as coming from environmental cues, and not coming from within themselves, can assist in decreasing the subjective strength of the cravings.
Cognitive coping strategies can be considered useful in two different contexts, both as urge-specific coping strategies and general lifestyle change strategies . The former can best be used when cravings come on strong with little notice. If the client can practice these specific skills when exposed to threatening cues with their therapist, they will be more prepared to handle real-world high-risk situations outside of treatment. Lifestyle cognitive skills can be used at any time and are thought to prevent relapse independent of specific triggers. Numerous cognitive strategies have been found to be effectively used in either category, and include (1) identifying positive consequences of staying sober and negative consequences of returning to drinking, (2) using mastery/strength messages, (3) challenging thoughts, (4) thinking through a behavior chain from past consequences, (5) encouraging oneself to wait it out, (6) reminding oneself they are a sober person, and (7) leaving the situation.
Seeking support for abstinence and recovery from a slip involves both cognitive and behavioral strategies. Individuals that have social networks filled with drinking or drug use that they cannot leave are more prone to relapse and need to recognize the need to change the composition of the network and build another one that is supportive of recovery. Mutual help groups like Alcoholics Anonymous and Smart Recovery provide opportunities to listen and understand the perspectives and experiences of others and offer both cognitive and behavioral coping activities for the addicted individual.
Lifestyle Interventions
The final stage of the process of change is to integrate the new behavior into the lifestyle of the individual. Replacing dependence with abstinence or excess with moderation generally involves a change not only in one behavior but in the addicted individual’s overall way of life. Lifestyle interventions for relapse prevention include lifestyle balance, substitute indulgences, positive addictions, and stimulus control techniques. Lifestyle balance is a global strategy used to ameliorate stressful situations, promote appropriate coping, improve problem solving, and increase pleasurable activities such as hobbies or spending time with friends and family that were replaced by substance use. It is also important for clients to understand that their desires not to be depressed or to be social, which can lead to high-risk situations, are reasonable desires. However, they need to find alternative ways of fulfilling these needs without using substances or turning to other problematic, addictive behaviors. In treatments that have encouraged clients to integrate new activities into their daily schedules, individuals with substance use disorders have reported experiencing decreased negative emotional states such as depression and anxiety. Mutual help groups and activities can play an important role in offering a venue and a series of activities that can support the lifestyle changes.
Substitute indulgences are activities that are immediately gratifying and can serve as a substitute for the addictive behavior when a client experiences an urge or craving. One example is to take a hot shower or bubble bath instead of going to a bar to relax after a difficult day at work. It is important, however, that the pleasurable activities are not harmful in the long term. Positive addictions have a similar function in that they replace the activity of substance use, but have more long-term rewards and value, rather than immediate gratification. Examples of positive addiction include taking up a sport, regular exercise, or a new hobby. In general, increased engagement in substance-free behaviors is associated with decreases in substance use in the general population. In addition, individuals who identify future goals that are meaningful to them are less likely to have alcohol-related problems and heavy drinking episodes. It is important that positive and enjoyable activities be practical and something that the client is able to perform and sustain on their own.
Stimulus control techniques attempt to address the physical cues for relapse. A frequent example is the strong association of drinking and smoking, either of which could serve as a cue for the other. While experiencing some cues is inevitable, it is an important step for a client to eliminate the cues under their control by changing their routine as much as possible. An example for a client who is quitting smoking would be to throw out all cigarettes, ashtrays, and lighters, rearrange the furniture so that a favorite smoking area is not present, and change the morning routine so that it does not revolve around the first cigarette of the day.
New Approaches for Relapse Prevention
Recently, another set of strategies has been added to relapse prevention treatment called Mindfulness-Based Relapse Prevention (or MBRP). The basic structure and goals of relapse prevention remain the same but there is an emphasis on the use of mindfulness techniques throughout the intervention process. Mindfulness meditation is a metacognitive skill learned through the practice of meditation that allows the individual to achieve perspective, patience, and inner peacefulness that can reduce relapse cues and create lifestyle changes to promote recovery.
Mindfulness is a state of detached awareness of emotions, cognitions, and physical sensations. It is a state of attentional focus that can be used to change client’s attitudes toward their thoughts, feelings, and sensations. MBRP uses development of the mindfulness state to disrupt maladaptive cognitions by heightening awareness of cravings without identifying with, judging, or reacting to them. The mindfulness state interrupts the chain of cognitions and emotions that follow an urge or craving, thus decreasing the likelihood of an action based on them. A theorized mechanism on how MBRP works is that meditation improves higher-order executive control and loosens the strength of the learned reactions to the experienced cravings. As the number of automated reactions decrease, eventually the number of self-reported cravings also decreases. Mindfulness appears to work differently than thought suppression, which prior studies have found to be an ineffective coping technique. Researchers believe its long-term effects can be explained by an individual’s improved ability to recognize and tolerate discomfort associated with craving or negative affect.
Although much of the current research on relapse prevention strategies has assessed these approaches in the context of in-person therapy, there has been an effort to make these approaches available to the general public through technology. With the accessibility of the Internet and smart phones, researchers have begun to capitalize on these venues for treating addictions and preventing relapse. Given the novelty of these approaches, there are relatively few (and inconsistent) findings for relapse prevention. A review of text messaging–based interventions for smoking cessation and relapse prevention stated that all studies included demonstrated reduced smoking and prevention of relapse. Furthermore, participants responded well to the application and its flexibility. One recent study investigated a mobile application that was used as a supplement to aftercare from residential treatment for alcohol abuse. This app included a component in which participants identified high-risk locations (i.e., bars they used to frequent), and the app would deliver just-in-time support to help participants cope with the high-risk situation. This app also included a panic button that participants could activate when they felt they might relapse. This feature provided automated support messages, computer generated alerts to key support people, and tools for addressing cravings. Participants who used the app and attended treatment had fewer risky (binge) drinking days at 4 and 12 months and were more likely to be abstinent at 8 and 12 months compared to a control group that received treatment as usual. Alternatively, another study using a computer-delivered relapse prevention treatment for smoking showed no benefit compared with the assessment-only group. Therefore it is clear that further research on these approaches is warranted, but initial findings suggest that the flexibility and accessibility of technology-based approaches are appealing to consumers and may add benefit to in-person treatment.
Medications for Relapse Prevention
Medications have also been found to be a useful adjunct to promote change and prevent relapse in treatments for nicotine, alcohol, and opiate addiction. Since the 1990s, both naltrexone and acamprosate (Campral), have been added to disulfiram (Antabuse) as approved medications in the United States to be prescribed for alcoholism treatment. More recently on the market is an extended-release alternative form of naltrexone, under the trade name Vivitrol, requiring once monthly injections. Use of disulfiram causes a flushing or sick reaction when alcohol is ingested, which results in extremely low compliance, and as a result has not been found to be superior to placebo. Comprehensive reviews of acamprosate and naltrexone, conducted by the Cochrane Collaborative, revealed that both are effective in improving outcomes. Acamprosate significantly reduced drinking risk, while also increasing days abstinent. Alternatively, naltrexone was associated with 83% reduction in risk of heavy drink and a 4% decrease in drinking days. Secondary outcomes for naltrexone were also significant, including reduction in the amount of alcohol consumed and fewer heavy drinking days. Therefore acamprosate may be more effective in promoting complete abstinence, while naltrexone may be more effective when the treatment goal is reduced drinking.
Methadone, buprenorphine, levo-alpha-acetylmethadol, and naltrexone have been used to treat heroin addiction. Opiate maintenance using methadone, buprenorphine, or levo-alpha-acetylmethadol assist in decreasing the extremely high rates of relapse in treatment of opiate addiction, although the medications themselves can be addictive at high doses, have negative side effects, and naltrexone specifically can have low compliance. More recently, an injectable form of long-acting naltrexone has been approved to treat heroin dependence. A comprehensive review showed promising results—the long-acting naltrexone was well tolerated by participants, had improved compliance, and was more effective for relapse prevention than the daily, oral tablets.
Medications for nicotine cessation include a variety of nicotine replacement products (i.e., NRT), varenicline tartrate (Chantix), and the antidepressant bupropion (Zyban). In a comprehensive review, the Cochrane Collaborative found that use of NRT, bupropion, or varenicline nearly doubles the likelihood of quitting compared with placebo. They also found that varenicline outperformed single forms of NRT but not combination NRT (e.g., patch plus gum). In addition, the effectiveness of medications are substantially increased when added to behavioral interventions.
Although there have been studies of medications to treat cocaine addiction, they have not resulted in improved treatment outcomes with any consistency and there is currently no FDA-approved medication for treating cocaine addiction. It is generally recommended that medications be administered in addition to a psychosocial intervention such as relapse prevention for opiate and nicotine treatment, although investigations of combined therapy and medication have showed mixed results compared with either alone for treating alcoholism.
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