Relapse Prevention for Sustained Recovery from Alcoholism and Drug Addiction

A basic premise in the treatment of chemical dependency, alcoholism and drug addiction, is that an addict in recovery cannot learn to consume alcohol or drugs in a controlled way.  There is ample scientific evidence and anecdotal testimony to this effect.  Ongoing recovery work over an extended period of time is necessary for long-term sobriety.  When it comes to relapse prevention, patients should avail themselves of all possible tools.  Psychologist, psychotherapists, and counselors with addiction training can provide evidence based relapse-prevention-education to facilitate long term recovery.  Based on years of research and scientific discovery, it is evident that this is an important aspect to maintain sobriety.

Research results also show that self-help groups during treatment and as a long-term support system are vital for a person’s recovery.  Furthermore,  it is beneficial when the family system can receive counseling by a psychologist, psychotherapist, or counselor, since the disease of alcoholism and drug addiction affects each person in the family.  Self-help groups are available for the families of addicts as well, such as Al-Anon, or Alateen.

Experienced psychologists, psychotherapists and counselors with addiction training draw from several schools of thought during drug and alcohol treatment:

1. Relapse Prevention (RP),

2. Center for Applied Science (CENAPS) Model of Relapse Treatment,

3. Classical Conditioning Theory of Cravings and Relapse Prevention, and 4. Self Help Groups.

4. Relapse Prevention (RP) by Marlatt and Gordon:

Since relapse is a process there are observable events that precede the relapse and continue into the relapse episode.  Marlatt and Gordon in 1985 developed a relapse prevention (RP) model that is based on social learning theory and cognitive-behavioral psychotherapy.  The basic assumption is that people are able to acquire new skills and behaviors when they change the way they think about situations.  Addiction according to the RP model is not seen as a physiological disease, but as a learned habit consisting of maladaptive thoughts and behaviors that can be altered.  “The goals of RP are to anticipate and prevent a relapse and to assist recovery from a slip before it becomes a relapse.   Recovery occurs gradually as the person increases his or her sense of self-efficacy and self-esteem from prolonged abstinence (Gordon, 2003, p. 8).  Lapses and relapses are not treated as personal failures, but as temporary setbacks.  From such a setback, an individual can learn and thus the lapse or relapse can serve as a prolapse.  “Prolapses are defined as mistakes that clients learn from that improve their eventual chances of success (Marlatt, Parks & Witkiewitz, 2002, p.9).

According to this model, individuals are not held responsible for negative habits acquired in the past, but it does put responsibility on the patient to change his or her addictive behaviors to functional behavioral coping skills and to use cognitive restructuring which will replace negative thoughts with positive functional thoughts.  Generally, a patient will pass through 3 stages which are:

    1. Commitment and motivation to prepare for the change
    2. Active implementation of the change
    3. Maintenance of the change (Gordon, 2003)

RP focuses on events of factors that can bring about a relapse episode.  Here factors and situations are classified that can precipitate or add to the relapse episodes.  According to this model there are two categories of such factors:  immediate determinants and covert antecedents.

Immediate determinants or relapse include:

  • Intrapersonal high-risk situations: Negative emotional states, such as anger, anxiety, depression, frustration, and boredom as a result of a person’s perception of a situation.  An example for this might be feelings of anger because of being passed up on a promotion, or feeling depressed due to being alone on one’s birthday.   These negative emotional states are associated with the highest rate of relapse.
  • Interpersonal high-risk situations: Negative emotions due to conflict with another person or group can precipitate a relapse.  Research showed that intrapersonal negative emotional states and interpersonal conflict formed the basis for more than 50% of all relapse episodes studied.
  • Social pressure: Direct verbal or nonverbal pressure to consume, or indirect pressure such as being around individuals who consume accounted for more than 20% of relapse episodes.
  • Positive emotional states: Celebrations, seeing alcohol related ads on TV, or passing one’s favorite bar, or a test of one’s willpower by trying to use one’s substance of choice in a controlled way are also associated with high risk situations that can trigger relapse (Larimer et al., 1999).

According to RP, another dimension to the danger of a lapse or relapse is added depending on how an individual has learned to cope with high risk situations, what expectations he or she has about the effects of using again, and how a lapse is perceived.  If a person has behavioral and cognitive coping skills, he is more likely to get out of a high-risk situation and not lapse/relapse.  Additionally, the expectation of the effect of drugs is important:  If a person sees the alcohol/drug as an aid in coping with a high-risk situation without considering long-term negative consequences a lapse might occur.  Lastly, a lapse does not have to progress into a full-blown relapse.  Marlatt and Gordon in their research found that the abstinence violation effect is a relevant issue.   The abstinence violation effect is how a person thinks about his relapse.  If a person interprets a lapse as a failure and has guilt about a lapse it is very likely that the relapse progression will be set in motion.  Additionally, some individuals attribute their lapse to internal factors such as lacking willpower and might come to believe they will never be able to stay sober.  However, when someone experiences a lapse and comes to understand it as an inability to cope with a high-risk situation, they can learn from their mistake and avoid such situations in the future (Larimer et al., 1999).

Covert antecedents of relapse include:

  • Life-style factors: Here the degree of balance between what persons “should” do and what persons “want” to do is relevant.  When the balance tips toward too many responsibilities and not enough activities people enjoy, negative emotional states can be caused which are conducive to relapse, and using drugs or alcohol might be seen as the only way to obtain pleasure.  Life-style imbalance was seen as the factor that most strongly related to a relapse risk.
  • Cognitive factors: Rationalization, denial, and a desire for immediate gratification.  This faulty thinking can increase the risk of relapse, because it can increase exposure to high risk situations and decrease motivation to resist substance use.  An example for such thinking is when someone thinks that he or she can drop by their favorite bar to say hi to a friend and not sit down for a drink.
  • Apparently irrelevant decisions (AID): Seemingly inconsequential decisions set a person up for a lapse/relapse.  Here decisions are made that on the surface do not seem to add to a relapse risk.   Denial keeps the person at risk from accurately assessing the risk and rationalization provides a reason for making the decision.    A good example cited for an AID is about a recovering alcoholic who buys a bottle of wine in anticipation of guests.  Once guests come and a lapse occurs the presence of alcohol is blamed without greater thought of personal responsibility.  Another example could be to have a bottle of wine on hand for cooking thereby creating a temptation at a later point.
  • Urges and cravings: The RP model proposes that urges and cravings are due to psychological or environmental stimuli.  According to Marlatt and Gordon urge is defined as a relatively sudden impulse to consume the substance of choice, and craving is the subjective desire to have the effects or consequences of using (Larimer et al., 1999).

This RP model proposes to use cognitive and behavioral approaches that target each step of the relapse process.  Psychologists, psychotherapists, and counselors encourage specific intervention strategies that address the immediate determinants of relapse and global self-management strategies to address the covert antecedents of relapse.  These strategies fall into the categories of skills training, cognitive restructuring, and lifestyle balancing.  In short, specific intervention strategies include identifying and coping with high-risk situations.  During counseling, the patient learns to identify the warning signs of entering or being in a high-risk situation.  The patient’s ability and motivation to cope in such a situation is assessed and enhanced.  Additionally, self-efficacy-enhancement procedures help a patient improve his sense of mastery and of being able to cope with difficult situations without relapsing.  The patient will benefit from a client-psychotherapist relationship that is collaborative rather than “top down.”  Patients are made aware that RP is an acquisition of skills and not a test of willpower.  During counseling, patients are encouraged to set small, manageable tasks to increase a sense of self-efficacy. Lastly, psychologists, psychotherapists and counselors can highlight general accomplishments to increase a patient’s sense of mastery, in general, to achieve a carry-over effect into drug and alcohol related efficacy (Larimer et al., 1999).

During counseling, a drinkers’ subjective expectation of the effect of alcohol also must be addressed.  Often positive expectations of the outcome of drinking are based on myths or placebo effects.  Counselors and psychotherapists can assist patients in bringing objectivity into the experience and to juxtapose short and long-term consequences (Larimer et al., 1999).

Lapse management is also incorporated in this RP model.  The idea is to halt the progression into a relapse and to help clients cognitively restructure the event to see that they have not suffered a failure of willpower or morality, but failed to adequately address a high-risk situation.  Psychologists, psychotherapists, and counselors might want to facilitate a lapse-management-plan, which could include a limit of how much of the substance can be ingested, reasons why it is important to put a halt to consumption, to leave the high-risk situation, and to contact the counselor or a supportive person as soon as possible (Larimer et al., 1999).

Psychologists, psychotherapists, and counselors also bring focus to global lifestyle self-control strategies, which include helping patients balance their lifestyles so that a balance is achieved between stress and enjoyment of life.  During counseling patients can be encouraged to tap into enjoyable activities they pursued before they became substance dependent.  Furthermore, specific cognitive-behavioral skills such as relaxation training, stress-management, and time management can improve a client’s life-style balance.  Counseling also fosters positive addictions, such as meditation or exercise, and can have long-term positive effects on mood, health, and coping ability (Larimer et al., 1999).

Psychologists, psychotherapists, and counselors also instruct patients to practice stimulus control techniques to decrease urges and cravings by removing all items relating to their use from their living environment.  This would include alcohol, shot glasses, or any other drug or drug related paraphernalia.  Things associated with using, such as music or furniture can be changed to reduce cues to using.  Lastly, during counseling, psychologists, psychotherapists, and counselors for the benefit of their patients impart avoidance strategies to decline events and places that were associated with use (Larimer et al., 1999).

Patients are taught to anticipate and accept cravings and urges as normal and not to interpret this as a desire to drink, but to see it as a conditioned response to cues in the environment.  It is important that patients learn that they can ride this feeling out, as it will come, swell, and go like a wave in the ocean (Larimer et al., 1999).

Lastly, counseling will show patients how they will benefit from having a relapse road map.  Here patients can apply cognitive-behavioral analysis to a situation and see available choices to cope with or avoid these situations and their consequences.  This approach also assists in identifying AIDs, so that people can make choices and decisions from which they benefit (Larimer et al., 1999).

An evaluation of this RP model found the relapse process and the effectiveness of treatment strategies were supported.  This RP model has been applied to various addictive behaviors successfully, but that it was most effective with alcoholism.  There is a suggestion that in the future modifications be made to this RP model reflecting changes about the assessment of high-risk situations and the conceptualization of covert and immediate antecedent of relapse.  Significant research indicates the effectiveness of RP for alcoholism and to a lesser degree nicotine or cocaine addiction.  It was also noted that people’s self-efficacy might not necessarily rise if they handle a high-risk situation well.  Lastly, research findings show that RP in conjunction with medication assisted treatment (pharmacotherapy) appears to have an enhanced effect on abstention rates (Gordon, 2003).

An extensive review of relapse prevention therapy (RPT) and detailed information on how to work with clients can be found in the Clinical Guidelines for Implementing Relapse Prevention Therapy by Marlatt, Parks, and Witkiewitz.  These downloadable guidelines also contain information on various assessment tools and other valuable resources (Marlatt et al., 2002).

Center for Applied Science (CENAPS) Model of Relapse Treatment:

Terence Gorski developed this approach.  He classifies addiction as a disease that affects bio-psycho-social functioning and asserts that treatment must include ways to address the biological damage caused by addiction, specifically brain dysfunction, and means to enhance psychological well-being and social relationships.  Relapse is framed as the “relapse syndrome,” which indicates that there are a number of symptoms and warning signs preceding a relapse, most notably the presence of unmanaged post acute withdrawal (PAW) symptoms.  Gorski adheres to the 12-Step philosophy, and the therapeutic underpinning is cognitive-behavioral with a focus on lifestyle changes to foster long-term recovery.

Gorski identifies 3 types of chemically dependent people:

    1. recovery prone
    2. transitionally relapse prone
    3. chronically relapse prone

a) Unmotivated to change

b) Motivated to change

His model of relapse prevention is designed especially for the motivated relapse-prone individuals (Gordon, 2003).

CNAPS teaches psychologists, psychotherapists, and counselors to focuses on brain dysfunction as a major physical consequence of addiction as it interferes with one’s ability to think clearly, manage emotions, and regulate behavior.  This brain dysfunction manifests in what Gorski and Miller (1985) call post acute withdrawal (PAW) symptoms…symptoms that occur after a person has gone through acute withdrawal, or detoxification.   Most commonly PAW symptoms are expected to diminish over time. However, there are some who will experience ongoing stable PAW symptoms, and some who will experience more PAW symptoms over time.  It is this last category of people in recovery that have the highest relapse rates. During times of stress, often triggered by change in a person’s life, PAW symptoms can be prompted which can create even more stress.  “This personal distress, caused by the compromised ability to handle thoughts, emotions and behaviors, is the precipitating cause of a relapse (Ibid., p.10).  During counseling, patients in recovery are made aware of PAW symptoms.

Symptoms of PAW are the following:

  • Inability to think clearly:  Inability to concentrate for more than a few minutes, impairment of abstract reasoning, rigid and repetitive thinking/going around and round.
  • Memory problems:  Short and long term memory is affected
  • Emotional overreactions or numbness
  • Sleep disturbances:  Short-term, or life-long
  • Physical coordination problems:  Dizziness, balance problems, hand-eye coordination problems, and slow reflexes.
  • Stress sensitivity:  Difficulty managing stress and inability to assess stress realistically (Ibid.)

Gordon and Miller (1985) describe CENAPS as a developmental model of recovery (DMR).  There are 6 developmental periods that clients pass through in which certain recovery tasks completed:

  • Pretreatment: recognizing addiction. Learning by the consequences that you cannot safely use addictive chemicals.
  • Stabilization: Withdrawal and crisis management. Regaining control of thought processes, emotional processes, memory, judgment, and behavior
  • Early recovery: Acceptance of the disease and learning to function without drugs and alcohol
  • Middle recovery: Developing a normal, balanced lifestyle.  Resisting substitute addictions.
  • Late recovery: Personality change. Development of healthy self-esteem, spiritual growth, healthy intimacy, and meaningful living
  • Maintenance: Growth and development

Staying sober and living productively

As a person progresses through the recovery stages the CENAPS model proposes to use a number of skills to alleviate stress and manage PAW symptoms should they occur.

“Because stress triggers and intensifies the symptoms of post acute withdrawal, PAW can be controlled by learning to manage stress.  You can learn to identify sources of stress and develop skills in decision making and problem solving to help reduce stress.  Proper diet, exercise, regular habits, and positive attitudes all play important parts in controlling PAW.  Relaxation can be used as a tool to retrain the brain to function properly and to reduce stress (Ibid., p. 70).”  During counseling, a psychologist, psychotherapist, or counselor can assist patients to identify and manage their stress.

Classical Conditioning Theory of Cravings and Relapse Prevention:

According to Gordon (2003) classical conditioning theories put an emphasis on the importance of internal and external cues on cravings.

Cravings are strong desires or compulsions to engage in a behavior, such as drug or alcohol use, to experience positive effects or to avoid negatives ones.   Two types of cravings are common among individuals with a chemical addiction:  cravings to alleviate unpleasant emotional states or symptoms of acute withdrawal, and cravings to increase he short-term positive effects of drug use.  (p.10)

Tiffany (1999) emphasized that the first researcher to discover the underlying principle of classical conditioning was Ivan Pavlov and illustrated how this principle could be applied to drug and alcohol cravings:  Someone drinks alcohol (unconditioned stimulus) and experiences positive feelings (unconditioned response).  This person likes to consume the alcoholic beverage while sitting in an easy chair.  Over time, the easy chair becomes associated with the alcohol and becomes a conditioned stimulus.   As a result of this, the sight or thought of sitting in the easy chair can bring out alcohol cravings in the individual.

Alcohol:  unconditioned stimulus à positive feelings

Easy Chair:  conditioned stimulus à craving

Based on this theory many possibilities of classical conditioning can occur during a person’s time of using.  Thus, there will be many conditioned stimuli that will bring out cravings in people in recovery that could bring about a relapse.  Conditioned stimuli are very unique to the individual and the degrees of cravings vary from person to person.  Some more typical conditioned stimuli for addictive behaviors are the presence of the person’s substance of choice, and places were drugs and alcohol are sold.  Additionally,

classical conditioning theories postulate that responses to conditioned stimuli last a very long time.  For example, after years of sobriety, a craving can occur if a person returns to a place where he bought his substance of choice (Gordon, 2003).

Tiffany (1999) described the application of the classical conditioning concept to withdrawal effects.  “Perhaps the most influential model of conditioned craving was developed by Wikler (1948), who hypothesized that stimuli paired repeatedly with AOD withdrawal could become conditioned stimuli that elicited [sic] conditioned withdrawal effects, which, in turn, would generate craving” (p. 216).

In the language of classical conditioning the drop in blood alcohol levels constitutes the unconditioned stimulus that leads to withdrawal symptoms, the unconditioned response.  When the unconditioned stimulus (low BAC) is paired with a certain situation, i.e. counseling, the person in recovery during counseling can experience conditioned withdrawal reactions and cravings that could possible lead to relapse (Ibid., 1999).

Relapse prevention strategies with classical conditioning theories focus on dealing with strong, seemingly irrational, cravings.  There are a number of approaches, such as MT to reduce cravings, or breaking the “pleasure memory.”  One particular method is cue-exposure treatment.  During this treatment, a patient is continuously exposed to their cues of conditioned stimuli in a setting that is safe.  Then the patient can practice coping skills to reduce cravings.  Behaviorist psychologists, psychotherapists and counselors believe that repeated exposure to a drug or alcohol cue in the absence of the usual response (consumption of alcohol or drugs) leads to a reduction in cravings over time.  This reduction in craving however is unique to the stimulus and this positive effect will not carry over to other craving inducing stimuli.  It must be noted that the extinction effect of cues from the clinical setting do not always transfer to a client’s natural environment.  There even are patient reports that cues to which they had become neutral triggered strong cravings once they had returned to their usual setting.  Lastly, even a once extinct cue will be reactivated when a person pairs the cue with a former response (Gordon, 2003).

The Role of Self-Help Groups:

Traditional approaches for the treatment of chemical dependency, in the United States, mostly follow the “Minnesota Model,” which includes a 28-day inpatient/residential rehabilitation program based on the 12-step Alcoholics Anonymous (AA) principles.  The underlying idea is for the psychologist, psychotherapist, or counselor to treat the patient holistically, the mind, body, and spirit.  Typically, at the end of treatment people in recovery are referred to AA for continuing care (McKay & Hiller-Sturmhoefel, 2011).  Gordon and Miller (1986) asserted, “Alcoholics Anonymous is the single most effective treatment for alcoholism.  … AA needs to be a vital part of any recovering alcoholic’s sobriety plan (p.52).   Most certainly, a 12-step self-help group can be chosen according to the substance to which a client is addicted, such as Narcotics Anonymous (NA), Cocaine Anonymous (CA) etc., as the basic steps and principles remain the same regardless of the substance, or behavior over which someone has lost control.  It must be kept in mind though that not everyone embraces the AA concept.  Many patients do not like to share their thoughts and feelings in a group setting and some are not spiritual.  For the less spiritual clients, there are viable alternatives such as SMART Recovery, of Save Our Selves (SOS).  These self-help groups have a more secular focus (supra).  However, these groups are not as prolific as the AA based self-help groups which may make it difficult to find such a self-help group within a reasonable commuting distance.  Technological innovation is evident, as there is the option to attend virtual meetings online. Those who do embrace the AA concept, will be able to benefit from the social support other members offer, and from the structure of the 12 steps as a spiritual and behavioral guide.  People interested in attending a 12-step program can try a variety of meetings to find groups with whom they feel they share a commonality (sex, age, socio-economic status, etc.) (McKay & Hiller-Sturmhoefel, 2011).  Based on the structure of 12 step groups, it is very difficult to assess the drop-out rates.  From a patient follow-up perspective, such statistics are also difficult to obtain, due to tracking issues and possible deception at the time of a follow-up interview.  McKay and Hiller-Sturmhoefel reported on studies that tracked group counseling with 12 step attendance that saw a drop-out rate of 50% before patients reached the 3-month mark.  Despite the difficulties in obtaining statistics on AA attendance and drop-out rates, anyone who has ever attended AA meetings will have discovered many individuals with long-term sobriety and a record of regular attendance.  There is also ongoing anecdotal evidence that not attending meetings is often associated with the relapse process, and many recovering alcoholics report that they attend AA meetings to remember that their disease of addiction is a chronic disease that must continually be kept in check.

RP, CENAPS, classical conditioning models, and information about self -help groups constitute effective tools for relapse prevention.  Each model has significant validity and people in recovery can benefit from learning skills and gaining insights based on all models.  There is enough commonality so that these tools can be seen as complimentary rather than contradictory.  An experienced psychologist, psychotherapist or counselor will use an integrated approach during counseling, so that patients in recovery will acquire skills and gain insights that they can quickly access to avert a lapse, or a relapse.  This knowledge will also assist them in adopting a life-style that is balanced and enjoyable thereby setting the stage for long-term sobriety.

List of References:

Counselor’s manual for relapse prevention with chemically dependent criminal offenders Technical Assistance Publication (TAP) Series 19 / Chapter 3-Relapse (n.d.). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 03, 2011, from http://www.kap.samhsa.gov/products/manuals/taps/19b.htm

Extended abstinence is predictive of sustained recovery.  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching8.html

Gordon, S.  (2003). Relapse & recovery:  Behavioral strategies for change.  Retrieved Jul 02, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf

Gorkski & Miller (1986).  Staying sober:  A guide for relapse prevention.  Independence, MO:  Herald House/Independence Press

Larimer, M., Palmer, R. & Marlatt, G. (1999).  Relapse prevention:  An overview of Marlatt’s cognitive-behavioral model.  Retrieved Jul 01, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

Marlatt, A, Parks, G. & Witkiewitz (2002).  Clinical guidelines for implementing relapse prevention therapy.  Behavioral Health Recovery Management. Retrieved Jul 07, from http://www.bhrm.org/guidelines/RPT%20guideline.pdf

McKay & Hiller-Sturmhoefel (2011).  Treating alcoholism as a chronic disease:  Approaches to long-term continuing care. .  National Institute on Alcohol Abuse and Alcoholism (NIAAA), 33(4). Retrieved Jul 25, 2011, from http://pubs.niaaa.nih.gov/publications/arh334/356-370.pdf

McLellan, T. (2003).  Forward:  Relapse – Removing the taboos on the topic and promoting honest efforts to address it.  Retrieved Jul 01, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf

National Survey of Substance Abuse Treatment Services:  The N-SSATS Report (2010, October 14).  Clinical or therapeutic approaches used by substance abuse treatment facilities. U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 02, 2011, from http://www.oas.samhsa.gov/2k10/238/238ClinicalAp2k10Web.pdf

Relapse rates for drug addiction are similar to those of other well-characterized chronic illnesses (n.d.).  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching8.html

(2005). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved Jul 02, 2011, from http://www.kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf

Tiffany, S. (1999).  Cognitive concepts of craving.  National Institute on Alcohol Abuse and Alcoholism (NIAAA),23(3). Retrieved Jul 10, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-3/215-224.pdf

Walitzer, K. & Dearing, R. (2006).  Gender difference in alcohol and substance use relapse.  Clinical Psychology Review, 26,  128-148.  Retrieved Jul 06, 2011, from http://www.genderbias.net/docs/resources/guideline/Gender%20differences.pdf