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Relapse Prevention Education

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woman staring at prescription pills on tableThe term relapse refers to a return of previous symptoms related to psychological or physical illness. Because addiction is a chronic disease, relapse is not only possible, but often probable during recovery.

The rates of relapse in those who have completed substance abuse treatment are around 40-60%—not too dissimilar from the 30-50% relapse rate of those with type 1 diabetes or the 50-70% relapse rate of people with hypertension.1 Some studies report even higher rates: a study published in the journal Substance Abuse Treatment, Prevention, and Policy states, “12-month relapse rates following alcohol or tobacco cessation attempts generally range from 80-95%, and evidence suggests comparable relapse trajectories across various classes of substance use.”2

Outdated models of addiction have described relapse as a failure or weakness on the part of the person in recovery; some obsolete theories argued that a relapse indicates that treatment was not successful.3 However, overcoming addiction is not a matter of willpower or inner strength, and it does not mean that treatment failed.1

Now most researchers believe relapse is a part of the chronic and progressive disease known as addiction. While addiction might not always be curable, it can be treated. As the National Institute on Drug Abuse (NIDA) explains, “Treatment of chronic diseases involves changing deeply imbedded behaviors.”1 Relapse is a sign that a person should return to treatment to work on addressing these behaviors.

Education and Therapies

person crying and holding hands with therapist in therapy session

Relapse prevention education is an important component of detox, as well as a priority in subsequent rehab programs. Its primary goals are to address the causes of relapse and to provide tools and skills to help prevent relapse from reoccurring.

Components of an effective relapse prevention education program often include:4,5

  • Educational groups. Learning about how relapse happens can help you spot the common reasons and triggers for relapse in your own life once you leave treatment.
  • Self-help groups. 12-step groups (such as Alcoholics Anonymous or Narcotics Anonymous), as well as non–12-step groups (such as SMART Recovery), can provide a home base for people who have either relapsed or fear it will happen again. Many people attend these group meetings during and after treatment as a way to help them stay sober.
  • Coping skills. You learn specific new ways to deal with cravings, manage stress, and avoid relapse triggers during these programs.
  • Social skills. Many people in recovery don’t know how to effectively communicate with others, and they may not always choose the most positive or supportive friendships. Social skills training teaches you how to make better choices and can help you improve your social competence.
  • Lifestyle management. You learn to balance your daily responsibilities in a healthy and less-stressful manner, and you learn how to incorporate more positive activities into your everyday life. Aftercare planning can help you plan out your daily schedules including meetings, therapy, and sober living homes to help you adjust to a sober life outside of rehab.
  • Mindfulness and meditation. Mindfulness means learning to accept the present moment without trying to change it and also learning to let go of the past. Learning to meditate teaches you how to pay close attention to your thoughts and feelings without judgment.

Some of the therapies frequently used for relapse prevention include:5-8

  • Cognitive Behavioral Therapy (CBT). CBT helps you alter any negative thinking patterns and teaches you better coping skills. With the guidance of a qualified therapist, you learn to identify thought patterns that can contribute to relapse, such as all-or-nothing thinking (“Life will never be fun again if I don’t use”) or fear-based thoughts (“I don’t know how to live in the world without using”). You learn to find healthier replacements for these thoughts and redefine your ideas of what fun and relaxation mean in a clean and sober life.
  • Dialectical Behavior Therapy (DBT). Originally developed as a way of treating patients with borderline personality disorder, DBT has shown promise in reducing the length and negative impact of relapse and in encouraging abstinence. In DBT, you learn a variety of techniques that can be applied to relapse prevention, such as how to reduce cravings; alleviate physical discomfort associated with abstinence and withdrawal; avoid triggers; and increase positive, healthy behaviors, such as making new friendships and seeking positive environments.
  • Mindfulness-Based Relapse Prevention (MBRP). Clinical studies have shown this relatively new form of treatment to be effective in reducing relapse. You learn a variety of skills, such as meditation and self-observation, to achieve positive change. These techniques help you become aware of your thoughts, feelings, and sensations, which helps you more successfully face high-risk, triggering situations.
  • Motivational Enhancement Therapy (MET). Although this therapy is most commonly used to help people engage in treatment, it has also shown some promise in preventing relapse, mainly in people with alcohol abuse problems. MET involves addressing your ambivalent feelings about stopping drug and alcohol abuse by focusing on strong personal reasons for change, which helps increase your motivation to stay sober and learn new coping skills.

Using New Skills at Home

Learning new skills in groups, classes, or in therapy is one thing, but implementing them effectively in real-life situations is a necessary part of every recovery journey.

Some of the ways you might use new techniques to help prevent relapse include:9,10

  • Setting a goal to apply what you learned in treatment at least once every day. For example, you might take a time out to stop, breathe, and relax should you feel a craving coming on. Or you might distract yourself with healthier activities, such as going for a walk or calling your sponsor.
  • Managing stress and other psychological concerns. If not properly addressed, stress, anxiety, depression, and negative thinking can contribute to relapse. Keeping your stress levels under control might mean practicing mind-body relaxation techniques, such as deep breathing, meditating, progressive relaxation, or other methods you learned in treatment. Depending on the extent of other issues (such as anxiety and depression), you might also call your sponsor, talk to your therapist, or exercise, which can be a healthy and positive way to manage stress, anxiety, and depression.
  • Using effective communication skills. Communication skills training (CST) is an important part of many treatment programs and is especially useful for people who have experienced chronic relapses. CST teaches assertiveness and how to set appropriate boundaries, including how to say no to others. An example of practicing communication skills in real life might be saying no to a friend who asks you to babysit her children when you don’t have the time or desire to do so. You might demonstrate assertiveness by telling a family member who has a history of belittling you that you don’t like their behavior.
  • Practicing self-care. You may have previously used drugs or alcohol as a way of rewarding yourself. Replacing substance abuse with healthier self-care alternatives can occur on a number of levels. For example, bodily self-care might mean taking time out to get a massage; emotional self-care could mean expressing your feelings in a journal; and spiritual self-care might mean joining a new church or spiritual group or connecting to nature in a way that is meaningful to you.

Common Relapse Triggers

Certain relapse triggers are unavoidable, yet many triggers can be successfully faced and worked through so that relapse does not occur.

Common relapse triggers include:3,11,12

depressed man sitting on side walk

  • Unaddressed trauma. Many people develop addictions as they struggle to cope with unprocessed traumatic experiences from their earlier years, such as abuse, incest, or grief. Some people have PTSD (Post-Traumatic Stress Disorder) in which they experience a number of symptoms—flashbacks of the traumatic event, nightmares, and agitation—that often lead them to abuse substances in an attempt to temporarily numb out the distress these symptoms cause. This condition benefits from proper treatment with medical and psychological interventions. Many people suffering from issues related to previous trauma also benefit from increased support from family and friends. Addressing unresolved issues with talk therapy can be another beneficial way of working through trauma even for people who don’t have PTSD.
  • Mental health issues, such as depression or anxiety. Around one-third of people living with mental illness and half of those with a severe mental illness also have substance abuse issues. So, ignoring a mental health issue might make the problem worse and could contribute to relapse. Entering treatment with a professional counselor or taking medication under a doctor’s supervision can help address any underlying mental health disorders. Support from family and friends is also important; many people also rely on support groups such as Alcoholics Anonymous to decrease feelings of isolation, receive encouragement, and help them stay clean.
  • Fighting with a family member or friend. Interpersonal conflict is a common trigger for relapse. One study found that around half of all relapses were attributable to “interpersonal negative emotional states and interpersonal conflict situations.” A timeout can often help de-escalate a heated situation and allow you both to calm down and refocus. When you do re-engage, remain calm, express your needs, and actively listen to the other person.
  • Feeling overwhelmed by common life challenges. Stresses of a demanding work schedule or difficult relationships can be particularly challenging in the early stages of sobriety. Some of the ways you might handle these challenges could include delegating responsibilities to others in your family instead of trying to handle everything on your own, or prioritizing tasks at work or school and handling the most difficult items first. You might also practice being kinder to yourself, especially if you are in the early stages of sobriety, when frequent thoughts of using and cravings are normal. Try not to criticize yourself; realize that thoughts and cravings do not necessarily mean that you will end up using again—they’re normal.
  • Financial stress. Financial stress is a common relapse trigger for many people. While money issues can be quite complex, some practical tips for managing financial stress could include creating a budget, talking to a financial advisor, and limiting frivolous or unnecessary purchases.
  • Big life stressors. A death in the family, a divorce, a job loss, and moving are all sources of significant stress and, therefore, are potential relapse triggers. Many substance abuse experts advise avoiding making any big changes, such as moving or changing jobs, during the first year of recovery. But some stressors are unavoidable. You might not be able to control external events, but you can control the way you react to them. Practicing self-care and other stress-management techniques is important, as is ensuring that you have proper support from friends, family, a counselor, or a support group during such times.

Moving Forward After a Relapse

Relapse is not a permanent failure. If it happens, view it as a temporary setback on your recovery journey.

If you do relapse, you can take certain steps to make sure that you don’t feel overwhelmed and to help you get back on the right path, such as:

people in embrace in group therapy session

  • Don’t beat yourself up. Remember that it’s a common part of the recovery journey. You can start fresh whenever you choose—it’s not a failure and it doesn’t mean all your recovery gains are lost.
  • Stop using. Avoid taking any more of the substance and get rid of it immediately. While it is obviously more easily said than done, getting back on track early can make a huge difference in the long run.
  • Call your sponsor. They know what you are going through and are willing and prepared to provide you with the support you need in that moment.
  • Go to a meeting. A 12-step or other support group can help you get on the right track, even after a relapse. The support of others who have been in your shoes can help you realize that relapse isn’t an insurmountable obstacle.
  • Meet with an individual therapist. If you already have one, schedule an emergency session. If you don’t, find one and ask if they can squeeze you in as soon as possible.
  • Enroll in an IOP. Sometimes a tune-up at an intensive outpatient program (IOP) can help reinforce your relapse prevention skills and give you the additional support you need to get back on track.
  • Call the Substance Abuse and Mental Health Services Administration (SAMHSA) Helpline. You can get free and confidential information and referrals to treatment at 1-800-662-HELP (4357). Getting into a treatment program as soon as possible can help you stay clean and sober and prevent another relapse.

Sources

  1. National Institute on Drug Abuse. (2014). Drugs, Brains, and Behavior: The Science of Addiction: Treatment and Recovery.
  2. Hendershot, C., Witkiewitz, K., George, W., & Marlatt, G.A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6(17).
  3. Larimer, M., Palmer, R., & Marlatt, G.A. (1999). Relapse Prevention: An Overview of Marlatt’s Cognitive-Behavioral Model. Alcohol Research and Health, 23(2), 151­–160.
  4. Marlatt, G.A. & Witkiewitz, K. (2005). Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press.
  5. Witkiewitz, K., Marlatt, G.A., & Walker, D. (2005). Mindfulness-Based Relapse Prevention for Alcohol and Substance Abuse Disorders. Journal of Cognitive Psychotherapy, 19(3), 211–228.
  6. Melemis, S. (2015). Relapse Prevention and the Five Rules of Recovery. Yale Journal of Biology and Medicine, 88(3), 325–332.
  7. Dimeff, L. A. & Linehan, M. M. (2008). Dialectical Behavior Therapy for Substance Abusers. Addiction Science & Clinical Practice, 4(2), 39–47.
  8. Reijina, C.K. & Riaz, K.M. (2015). Effect of Motivation Enhancement Programme on Relapse Prevention in Patients Admitted with Alcohol Dependence Syndrome. International Journal of Innovative Research and Development, 4(15), 292–298.
  9. Anxiety and Depression Association of America. (2014). Exercise for Stress and Anxiety.
  10. Caravella, K., Tod, L., & Brown, A. (2012). Awareness into Action: How Communication Skills Training Enhances Traditional Substance Abuse Treatment Programs. The Journal of Global Drug Policy and Practice, 6(1), 1–13.
  11. National Institute on Drug Abuse. (2006). NIDA Community Drug Alert Bulletin—Stress & Substance Abuse.
  12. National Alliance on Mental Illness. Dual Diagnosis.

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