Comments: Excellent peer-reviewed paper highlighting addiction recovery and relapse prevention.
Published online 2015 Sep 3.
There are four main ideas in relapse prevention. First, relapse is a gradual process with distinct stages. The goal of treatment is to help individuals recognize the early stages, in which the chances of success are greatest. Second, recovery is a process of personal growth with developmental milestones. Each stage of recovery has its own risks of relapse. Third, the main tools of relapse prevention are cognitive therapy and mind-body relaxation, which are used to develop healthy coping skills. Fourth, most relapses can be explained in terms of a few basic rules. Educating clients in these rules can help them focus on what is important: 1) change your life (recovery involves creating a new life where it is easier to not use); 2) be completely honest; 3) ask for help; 4) practice self-care; and 5) don’t bend the rules.
Relapse prevention is why most people seek treatment. By the time most individuals seek help, they have already tried to quit on their own and they are looking for a better solution. This article offers a practical approach to relapse prevention that works well in both individual and group therapy.
There are four main ideas in relapse prevention. First, relapse is a gradual process with distinct stages. The goal of treatment is to help individuals recognize the early stages, in which the chances of success are greatest . Second, recovery is a process of personal growth with developmental milestones. Each stage of recovery has its own risks of relapse . Third, the main tools of relapse prevention are cognitive therapy and mind-body relaxation, which change negative thinking and develop healthy coping skills . Fourth, most relapses can be explained in terms of a few basic rules . Educating clients in these few rules can help them focus on what is important.
I would like to use this opportunity, having been invited to present my perspective on relapse prevention, to provide an overview of the field and document some ideas in addiction medicine that are widely accepted but have not yet worked their way into the literature. I have also included a link to a public service video on relapse prevention that contains many of the ideas in this article and that is freely available to individuals and institutions .
The Stages of Relapse
The key to relapse prevention is to understand that relapse happens gradually . It begins weeks and sometime months before an individual picks up a drink or drug. The goal of treatment is to help individuals recognize the early warning signs of relapse and to develop coping skills to prevent relapse early in the process, when the chances of success are greatest. This has been shown to significantly reduce the risk of relapse . Gorski has broken relapse into 11 phases . This level of detail is helpful to clinicians but can sometimes be overwhelming to clients. I have found it helpful to think in terms of three stages of relapse: emotional, mental, and physical .
During emotional relapse, individuals are not thinking about using. They remember their last relapse and they don’t want to repeat it. But their emotions and behaviors are setting them up for relapse down the road. Because clients are not consciously thinking about using during this stage, denial is a big part of emotional relapse.
These are some of the signs of emotional relapse : 1) bottling up emotions; 2) isolating; 3) not going to meetings; 4) going to meetings but not sharing; 5) focusing on others (focusing on other people’s problems or focusing on how other people affect them); and 6) poor eating and sleeping habits. The common denominator of emotional relapse is poor self-care, in which self-care is broadly defined to include emotional, psychological, and physical care.
One of the main goals of therapy at this stage is to help clients understand what self-care means and why it is important . The need for self-care varies from person to person. A simple reminder of poor self-care is the acronym HALT: hungry, angry, lonely, and tired. For some individuals, self-care is as basic as physical self-care, such as sleep, hygiene, and a healthy diet. For most individuals, self-care is about emotional self-care. Clients need to make time for themselves, to be kind to themselves, and to give themselves permission to have fun. These topics usually have to be revisited many times during therapy: “Are you starting to feel exhausted again? Do you feel that you’re being good yourself? How are you having fun? Are you putting time aside for yourself or are you getting caught up in life?”
Another goal of therapy at this stage is to help clients identify their denial. I find it helpful to encourage clients to compare their current behavior to behavior during past relapses and see if their self-care is worsening or improving.
The transition between emotional and mental relapse is not arbitrary, but the natural consequence of prolonged, poor self-care. When individuals exhibit poor self-care and live in emotional relapse long enough, eventually they start to feel uncomfortable in their own skin. They begin to feel restless, irritable, and discontent. As their tension builds, they start to think about using just to escape.
In mental relapse, there is a war going on inside people’s minds. Part of them wants to use, but part of them doesn’t. As individuals go deeper into mental relapse, their cognitive resistance to relapse diminishes and their need for escape increases.
These are some of the signs of mental relapse : 1) craving for drugs or alcohol; 2) thinking about people, places, and things associated with past use; 3) minimizing consequences of past use or glamorizing past use; 4) bargaining; 5) lying; 6) thinking of schemes to better control using; 7) looking for relapse opportunities; and 8) planning a relapse.
Helping clients avoid high-risk situations is an important goal of therapy. Clinical experience has shown that individuals have a hard time identifying their high-risk situations and believing that they are high-risk. Sometimes they think that avoiding high-risk situations is a sign of weakness.
In bargaining, individuals start to think of scenarios in which it would be acceptable to use. A common example is when people give themselves permission to use on holidays or on a trip. It is a common experience that airports and all-inclusive resorts are high-risk environments in early recovery. Another form of bargaining is when people start to think that they can relapse periodically, perhaps in a controlled way, for example, once or twice a year. Bargaining also can take the form of switching one addictive substance for another.
Occasional, brief thoughts of using are normal in early recovery and are different from mental relapse. When people enter a substance abuse program, I often hear them say, “I want to never have to think about using again.” It can be frightening when they discover that they still have occasional cravings. They feel they are doing something wrong and that they have let themselves and their families down. They are sometimes reluctant to even mention thoughts of using because they are so embarrassed by them.
Clinical experience has shown that occasional thoughts of using need to be normalized in therapy. They do not mean the individual will relapse or that they are doing a poor job of recovery. Once a person has experienced addiction, it is impossible to erase the memory. But with good coping skills, a person can learn to let go of thoughts of using quickly.
Clinicians can distinguish mental relapse from occasional thoughts of using by monitoring a client’s behavior longitudinally. Warning signs are when thoughts of using change in character and become more insistent or increase in frequency.
Finally, physical relapse is when an individual starts using again. Some researchers divide physical relapse into a “lapse” (the initial drink or drug use) and a “relapse” (a return to uncontrolled using) . Clinical experience has shown that when clients focus too strongly on how much they used during a lapse, they do not fully appreciate the consequences of one drink. Once an individual has had one drink or one drug use, it may quickly lead to a relapse of uncontrolled using. But more importantly, it usually will lead to a mental relapse of obsessive or uncontrolled thinking about using, which eventually can lead to physical relapse.
Most physical relapses are relapses of opportunity. They occur when the person has a window in which they feel they will not get caught. Part of relapse prevention involves rehearsing these situations and developing healthy exit strategies.
When people don’t understand relapse prevention, they think it involves saying no just before they are about to use. But that is the final and most difficult stage to stop, which is why people relapse. If an individual remains in mental relapse long enough without the necessary coping skills, clinical experience has shown they are more likely to turn to drugs or alcohol just to escape their turmoil.
Cognitive Therapy and Relapse Prevention
Cognitive therapy is one of the main tools for changing people’s negative thinking and developing healthy coping skills [9,10]. The effectiveness of cognitive therapy in relapse prevention has been confirmed in numerous studies .
This is a short list of the types of negative thinking that are obstacles to recovery and are topics for cognitive therapy : 1) My problem is because of other people; 2) I don’t think I can handle life without using; 3) Maybe I can just use occasionally; 4) Life won’t be fun — I won’t be fun — without using; 5) I’m worried I will turn into someone I don’t like; 6) I can’t make all the necessary changes; I can’t change my friends; 7) I don’t want to abandon my family; 8) Recovery is too much work; 9) My cravings will be overwhelming; I won’t be able to resist them; 10) If I stop, I’ll only start up again; I have never finished anything; 11) No one has to know if I relapse; and 12) I’m worried I have been so damaged by my addiction that I won’t be able to recover.
The negative thinking that underlies addictive thinking is usually all-or-nothing thinking, disqualifying the positives, catastrophizing, and negatively self-labeling . These thoughts can lead to anxiety, resentments, stress, and depression, all of which can lead to relapse. Cognitive therapy and mind-body relaxation help break old habits and retrain neural circuits to create new, healthier ways of thinking [12,13].
Fear is a common negative thinking pattern in addiction . These are some of the categories of fearful thinking: 1) fear of not measuring up; 2) fear of being judged; 3) fear of feeling like a fraud and being discovered; 4) fear of not knowing how to live in the world without drugs or alcohol; 5) fear of success; and 6) fear of relapse.
A basic fear of recovery is that the individual is not capable of recovery. The belief is that recovery requires some special strength or willpower that the individual does not possess. Past relapses are taken as proof that the individual does not have what it takes to recover . Cognitive therapy helps clients see that recovery is based on coping skills and not willpower.
One of the important tasks of therapy is to help individuals redefine fun. Clinical experience has shown that when clients are under stress, they tend to glamorize their past use and think about it longingly. They start to think that recovery is hard work and addiction was fun. They begin to disqualify the positives they have gained through recovery. The cognitive challenge is to acknowledge that recovery is sometimes hard work but addiction is even harder. If addiction were so easy, people wouldn’t want to quit and wouldn’t have to quit.
When individuals continue to refer to their using days as “fun,” they continue to downplay the negative consequences of addiction. Expectancy theory has shown that when people expect to have fun, they usually do, and when they expect that something will not be fun, it usually isn’t . In the early stages of substance abuse, using is mostly a positive experience for those who are emotionally and genetically predisposed. Later, when using turns into a negative experience, they often continue to expect it to be positive. It is common to hear addicts talk about chasing the early highs they had. On the other hand, individuals expect that not using drugs or alcohol will lead to the emotional pain or boredom that they tried to escape. Therefore, on the one hand, individuals expect that using will continue to be fun, and, on the other hand, they expect that not using will be uncomfortable. Cognitive therapy can help address both these misconceptions.
Learning from Setbacks
How individuals deal with setbacks plays a major role in recovery. A setback can be any behavior that moves an individual closer to physical relapse. Some examples of setbacks are not setting healthy boundaries, not asking for help, not avoiding high-risk situations, and not practicing self-care. A setback does not have to end in relapse to be worthy of discussion in therapy.
Recovering individuals tend to see setbacks as failures because they are unusually hard on themselves . Setbacks can set up a vicious cycle, in which individuals see setbacks as confirming their negative view of themselves. They feel that they cannot live life on life’s terms. This can lead to more using and a greater sense of failure. Eventually, they stop focusing on the progress they have made and begin to see the road ahead as overwhelming .
Setbacks are a normal part of progress. They are not failures. They are caused by insufficient coping skills and/or inadequate planning, which are issues that can be fixed . Clients are encouraged to challenge their thinking by looking at past successes and acknowledging the strengths they bring to recovery . This stops clients from making global statements, such as, “This proves I’m a failure.” When individuals take an all-or-nothing, dichotomous view of recovery, they are more likely to feel overwhelmed and abandon long-term goals in favor of short-term relief. This reaction is termed the Abstinence Violation Effect .
Becoming Comfortable with Being Uncomfortable
More broadly speaking, I believe that recovering individuals need to learn to feel comfortable with being uncomfortable. They often assume that non-addicts don’t have the same problems or experience the same negative emotions. Therefore, they feel it is defensible or necessary to escape their negative feelings. The cognitive challenge is to indicate that negative feelings are not signs of failure, but a normal part of life and opportunities for growth. Helping clients feel comfortable with being uncomfortable can reduce their need to escape into addiction.
The Stages of Recovery
Recovery is a process of personal growth in which each stage has its own risks of relapse and its own developmental tasks to reach the next stage . The stages of recovery are not the same length for each person, but they are a useful way of looking at recovery and teaching recovery to clients. Broadly speaking, there are three stages of recovery. In the original developmental model, the stages were called “transition, early recovery, and ongoing recovery” . More descriptive names might be “abstinence, repair, and growth.”
It is commonly held that the abstinence stage starts immediately after a person stops using and usually lasts for 1 to 2 years . The main focus of this stage is dealing with cravings and not using. These are some of the tasks of the abstinence stage :
Accept that you have an addiction
Practice honesty in life
Develop coping skills for dealing with cravings
Become active in self-help groups
Practice self-care and saying no
Understand the stages of relapse
Get rid of friends who are using
Understand the dangers of cross addiction
Deal with post-acute withdrawal
Develop healthy alternatives to using
See yourself as a non-user
There are many risks to recovery at this stage, including physical cravings, poor self-care, wanting to use just one more time, and struggling with whether one has an addiction. Clients are often eager to make big external changes in early recovery, such as changing jobs or ending a relationship. It is generally felt that big changes should be avoided in the first year until individuals have enough perspective to see their role, if any, in these issues and to not focus entirely on others.
The tasks of this stage can be summarized as improved physical and emotional self-care. Clinical experience has shown that recovering individuals are often in a rush to skip past these tasks and get on with what they think are the real issues of recovery. Clients need to be reminded that lack of self-care is what got them here and that continued lack of self-care will lead back to relapse.
Dealing with post-acute withdrawal is one of the tasks of the abstinence stage . Post-acute withdrawal begins shortly after the acute phase of withdrawal and is a common cause of relapse . Unlike acute withdrawal, which has mostly physical symptoms, post-acute withdrawal syndrome (PAWS) has mostly psychological and emotional symptoms. Its symptoms also tend to be similar for most addictions, unlike acute withdrawal, which tends to have specific symptoms for each addiction .
These are some of the symptoms of post-acute withdrawal [1,18,19]: 1) mood swings; 2) anxiety; 3) irritability; 4) variable energy; 5) low enthusiasm; 6) variable concentration; and 7) disturbed sleep. Many of the symptoms of post-acute withdrawal overlap with depression, but post-acute withdrawal symptoms are expected to gradually improve over time .
Probably the most important thing to understand about post-acute withdrawal is its prolonged duration, which can last up to 2 years [1,20]. The danger is that the symptoms tend to come and go. It is not unusual to have no symptoms for 1 to 2 weeks, only to get hit again . This is when people are at risk of relapse, when they are unprepared for the protracted nature of post-acute withdrawal. Clinical experience has shown that when clients struggle with post-acute withdrawal, they tend to catastrophize their chances of recovery. They think that they are not making progress. The cognitive challenge is to encourage clients to measure their progress month-to-month rather than day-to-day or week-to-week.
In the second stage of recovery, the main task is to repair the damage caused by addiction . Clinical experience has shown that this stage usually lasts 2 to 3 years.
In the abstinence stage of recovery, clients usually feel increasingly better. They are finally taking control of their lives. But in the repair stage of recovery, it is not unusual for individuals to feel worse temporarily. They must confront the damage caused by addiction to their relationships, employment, finances, and self-esteem. They must also overcome the guilt and negative self-labeling that evolved during addiction. Clients sometimes think that they have been so damaged by their addiction that they cannot experience joy, feel confident, or have healthy relationships .
Use cognitive therapy to overcome negative self-labeling and catastrophizing
Understand that individuals are not their addiction
Repair relationships and make amends when possible
Start to feel comfortable with being uncomfortable
Improve self-care and make it an integral part of recovery
Develop a balanced and healthy lifestyle
Continue to engage in self-help groups
Develop more healthy alternatives to using
Clinical experience has shown that common causes of relapse in this stage are poor self-care and not going to self-help groups.
The growth stage is about developing skills that individuals may have never learned and that predisposed them to addiction [1,2]. The repair stage of recovery was about catching up, and the growth stage is about moving forward. Clinical experience has shown that this stage usually starts 3 to 5 years after individuals have stopped using drugs or alcohol and is a lifetime path.
This is also the time to deal with any family of origin issues or any past trauma that may have occurred. These are issues that clients are sometimes eager to get to. But they can be stressful issues, and, if tackled too soon, clients may not have the necessary coping skills to handle them, which may lead to relapse.
Identify and repair negative thinking and self-destructive patterns
Understand how negative familial patterns have been passed down, which will help individuals let go of resentments and move forward
Challenge fears with cognitive therapy and mind-body relaxation
Set healthy boundaries
Begin to give back and help others
Reevaluate one’s lifestyle periodically and make sure the individual is on track
The tasks of this stage are similar to the tasks that non-addicts face in everyday life. When non-addicts do not develop healthy life skills, the consequence is that they may be unhappy in life. When recovering individuals do not develop healthy life skills, the consequence is that they also may be unhappy in life, but that can lead to relapse.
Causes of Relapse in Late Stage Recovery
In late stage recovery, individuals are subject to special risks of relapse that are not often seen in the early stages. Clinical experience has shown that the following are some of the causes of relapse in the growth stage of recovery.
1) Clients often want to put their addiction behind them and forget that they ever had an addiction. They feel they have lost part of their life to addiction and don’t want to spend the rest of their life focused on recovery. They start to go to fewer meetings.
2) As life improves, individuals begin to focus less on self-care. They take on more responsibilities and try to make up for lost time. In a sense, they are trying to get back to their old life without the using. They stop doing the healthy things that contributed to their recovery.
3) Clients feel they are not learning anything new at self-help meetings and begin to go less frequently. Clients need to understand that one of the benefits of going to meetings is to be reminded of what the “voice of addiction” sounds like, because it is easy to forget.
4) People feel that they should be beyond the basics. They think it is almost embarrassing to talk about the basics of recovery. They are embarrassed to mention that they still have occasional cravings or that they are no longer sure if they had an addiction.
5) People think that they have a better understanding of drugs and alcohol and, therefore, think they should be able to control a relapse or avoid the negative consequences.
The Five Rules of Recovery
This section is based on my experience of working with patients for more than 30 years in treatment programs and in private practice. Experience has shown that most relapses can be explained in terms of a few basic rules . Teaching clients these simple rules helps them understand that recovery is not complicated or beyond their control. It is based on a few simple rules that are easy to remember: 1) change your life; 2) be completely honest; 3) ask for help; 4) practice self-care; and 5) don’t bend the rules.
Rule 1: Change Your Life
The most important rule of recovery is that a person does not achieve recovery by just not using. Recovery involves creating a new life in which it is easier to not use. When individuals do not change their lives, then all the factors that contributed to their addiction will eventually catch up with them.
But clients and families often begin recovery by hoping that they don’t have to change. They often enter treatment saying, “We want our old life back — without the using.” I try to help clients understand that wishing for their old life back is like wishing for relapse. Rather than seeing the need for change as a negative, they are encouraged to see recovery as an opportunity for change. If they make the necessary changes, they can go forward and be happier than they were before. This is the “silver lining” of having an addiction. It forces people to reevaluate their lives and make changes that non-addicts don’t have to make.
Recovering individuals are often overwhelmed by the idea of change. As part of their all-or-nothing thinking, they assume that change means they must change everything in their lives. It helps them to know that there is usually only a small percent of their lives that needs to be changed. It can also be assuring to know that most people have the same problems and need to make similar changes.
Examples of Change
What do most people need to change? There are three categories:
Change negative thinking patterns discussed above
Avoid people, places, and things associated with using
Incorporate the five rules of recovery
Clients need to develop a healthy fear of the people, places, and things that were part of using. But this requires significant mental retraining because those people, places, and things were previously associated with positive emotions. Also, clients tend to think that developing a healthy fear of these things is showing weakness or accepting defeat.
Rule 2: Be Completely Honest
Addiction requires lying. Addicts must lie about getting their drug, hiding the drug, denying the consequences, and planning their next relapse. Eventually, addicted individuals end up lying to themselves. Clinical experience shows that when clients feel they cannot be completely honest, it is a sign of emotional relapse. It is often said that recovering individuals are as sick as their secrets. One of the challenges of therapy is to help clients practice telling the truth and practice admitting when they have misspoken and quickly correcting it.
How honest should a person be without jeopardizing his or her work or relationships? Clients are encouraged to understand the concept of a recovery circle. This is a group of people that includes family, doctors, counselors, self-help groups, and sponsors. Individuals are encouraged to be completely honest within their recovery circle. As clients feel more comfortable, they may choose to expand the size of their circle.
Probably the most common misinterpretation of complete honesty is when individuals feel they must be honest about what is wrong with other people. Honesty, of course, is self-honesty. I like to tell patients that a simple test of complete honesty is that they should feel “uncomfortably honest” when sharing within their recovery circle. This is especially important in self-help groups in which, after a while, individuals sometimes start to go through the motions of participating.
Rule 3: Ask for Help
Most people start recovery by trying to do it on their own. They want to prove that they have control over their addiction and they are not as unhealthy as people think. Joining a self-help group has been shown to significantly increase the chances of long-term recovery. The combination of a substance abuse program and self-help group is the most effective [22,23].
There are many self-help groups to choose from. Twelve-step groups include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Marijuana Anonymous (MA), Cocaine Anonymous (CA), Gamblers Anonymous (GA), and Adult Children of Alcoholics (ACA). Every country, every town, and almost every cruise ship has a 12-step meeting. There are other self-help groups, including Women for Sobriety, Secular Organizations for Sobriety, Smart Recovery, and Caduceus groups for health professionals. It has been shown that the way to get the most out of 12-step groups is to attend meetings regularly, have a sponsor, read 12-step materials, and have a goal of abstinence [24,25].
These are some of the generally recognized benefits of active participation in self-help groups: 1) individuals feel that they are not alone; 2) they learn what the voice of addiction sounds like by hearing it in others; 3) they learn how other people have done recovery and what coping skills have been successful; and 4) they have a safe place to go where they will not be judged.
There is one benefit of self-help groups that deserves special attention. Guilt and shame are common emotions in addiction . They can be obstacles to recovery, because individuals may feel that they have been damaged by their addiction and they don’t deserve recovery or happiness. Clinical experience has shown that self-help groups help individuals overcome their guilt and shame of addiction by seeing that they are not alone. They feel that recovery is within their reach.
These are some of the reasons clients give for not joining self-help groups: 1) If I join a group, I would be admitting that I am an addict or alcoholic; 2) I want to do it on my own; 3) I don’t like groups; 4) I’m not a joiner; 5) I don’t like speaking in front of other people; 6) I don’t want to switch from one addiction to becoming addicted to AA; 7) I’m afraid I’ll be recognized; and 8) I don’t like the religious aspects. The negative thinking in all these objections is material for cognitive therapy.
Rule 4: Practice Self-Care
To understand the importance of self-care, it helps to understand why most people use drugs and alcohol. Most people use to escape, relax, or reward themselves . These are the primary benefits of using. It helps to acknowledge these benefits in therapy so that individuals can understand the importance of self-care and be motivated to find healthy alternatives.
Despite its importance, self-care is one of the most overlooked aspects of recovery. Without it, individuals can go to self-help meetings, have a sponsor, do step work, and still relapse. Self-care is difficult because recovering individuals tend to be hard on themselves . This can present overtly, as individuals who don’t feel they deserve to be good to themselves or who tend to put themselves last, or it can show up covertly as individuals who say they can be good to themselves but who are actually ruthlessly critical of themselves. Self-care is especially difficult for adult children of addicts .
A missing piece of the puzzle for many clients is understanding the difference between selfishness and self-care. Selfishness is taking more than a person needs. Self-care is taking as much as one needs. Clinical experience has shown that addicted individuals typically take less than they need, and, as a result, they become exhausted or resentful and turn to their addiction to relax or escape. Part of challenging addictive thinking is to encourage clients to see that they cannot be good to others if they are first not good to themselves.
Individuals use drugs and alcohol to escape negative emotions; however, they also use as a reward and/or to enhance positive emotions . Poor self-care also plays a role in these situations. In these situations, poor self-care often precedes drug or alcohol use. For example, individuals work hard to achieve a goal, and when it is achieved, they want to celebrate. But as part of their all-or-nothing thinking, while they were working, they felt they didn’t deserve a reward until the job was done. Since they did not allow themselves small rewards during the work, the only reward that will suffice at the end is a big reward, which in the past has meant using.
Self-Care: Mind-Body Relaxation
Numerous studies have shown that mind-body relaxation reduces the use of drugs and alcohol and is effective in long-term relapse prevention [28,29]. Relapse-prevention therapy and mind-body relaxation are commonly combined into mindfulness-based relapse prevention .
Mind-body relaxation plays a number of roles in recovery . First, stress and tension are common triggers of relapse. Second, mind-body relaxation helps individuals let go of negative thinking such as dwelling on the past or worrying about the future, which are triggers for relapse. Third, mind-body relaxation is a way of being kind to oneself. The practice of self-care during mind-body relaxation translates into self-care in the rest of life. Part of creating a new life in recovery is finding time to relax.
Rule 5: Don’t Bend the Rules
The purpose of this rule is to remind individuals not to resist or sabotage change by insisting that they do recovery their way. A simple test of whether a person is bending the rules is if they look for loopholes in recovery. A warning sign is when clients ask for professional help and consistently ignore the advice.
Broadly speaking, once clients have been in recovery for a while, they can be divided into two categories: non-users and denied users. Non-users say that using was fun but acknowledge that it has not been fun lately. They want to start the next chapter of their life.
Denied users will not or cannot fully acknowledge the extent of their addiction. They cannot imagine life without using. Denied users invariably make a secret deal with themselves that at some point they will try using again. Important milestones such as recovery anniversaries are often seen as reasons to use. Alternatively, once a milestone is reached, individuals feel they have recovered enough that they can determine when and how to use safely. It is remarkable how many people have relapsed this way 5, 10, or 15 years after recovery.
Clients are encouraged to identify whether they are non-users or denied users. A denied user is in chronic mental relapse and at high-risk for future relapse. Clinical experience has shown that everyone in early recovery is a denied user. The goal is to help individuals move from denied users to non-users.
Summary and Conclusions
Individuals do not achieve recovery by just not using. Recovery involves creating a new life in which it is easier to not use. If individuals do not change their lives, then all the factors that contributed to their addiction will still be there. But most individuals begin recovery by hoping to get back their old life without the using. Relapse is a gradual process that begins weeks and sometimes months before an individual picks up a drink or drug. There are three stages to relapse: emotional, mental, and physical. The common denominator of emotional relapse is poor self-care. If individuals do not practice sufficient self-care, eventually they will start to feel uncomfortable in their own skin and look for ways to escape, relax, or reward themselves. The goal of treatment is to help individuals recognize the early warning signs of relapse and develop coping skills to prevent relapse early, when the chances of success are greatest. Most relapses can be explained in terms of a few basic rules. Understanding these rules can help clients focus on what is important: 1) change your life; 2) be completely honest; 3) ask for help; 4) practice self-care; and 5) don’t bend the rules.
|HALT||hungry, angry, lonely, and tired|
|ACA||Adult Children of Alcoholics|
|PAWS||post-acute withdrawal syndrome|
- Gorski T, Miller M. Staying Sober: A Guide for Relapse Prevention. Independence, MO: Independence Press; 1986.
- Brown S. Treating the Alcoholic: A Developmental Model of Recovery. New York: Wiley; 1985.
- Marlatt GA, George WH. Relapse prevention: introduction and overview of the model. Br J Addict. 1984;79(3):261–273. [PubMed]
- Melemis SM. I Want to Change My Life: How to Overcome Anxiety, Depression and Addiction. Toronto: Modern Therapies; 2010.
- Melemis SM. A Relapse Prevention Video: Early warning signs and important coping skills. AddictionsandRecovery.org [Internet] 2015. Available from: http://www.addictionsandrecovery.org/relapse-prevention.htm .
- Gorski TT, Miller M. Counseling for Relapse Prevention. Independence, MO: Herald House/Independence Press; 1982.
- Bennett GA, Withers J, Thomas PW, Higgins DS, Bailey J, Parry L. et al. A randomised trial of early warning signs relapse prevention training in the treatment of alcohol dependence. Addict Behav. 2005;30(6):1111–1124. [PubMed]
- Larimer ME, Palmer RS, Marlatt GA. Relapse prevention: an overview of Marlatt’s cognitive-behavioral model. Alcohol Res Health. 1999;23(2):151–160. [PubMed]
- Beck AT, Wright FD, Newman CF, Liese BS. Cognitive Therapy of Substance Abuse. New York: Guilford Press; 1993.
- Hendershot CS, Witkiewitz K, George WH, Marlatt GA. Relapse prevention for addictive behaviors. Subst Abuse Treat Prev Policy. 2011;6:17. [PMC free article] [PubMed]
- Connors GJ, Longabaugh R, Miller WR. Looking forward and back to relapse: implications for research and practice. Addiction. 1996;91 Suppl:S191–S196. [PubMed]
- Frewen PA, Dozois DJ, Lanius RA. Neuroimaging studies of psychological interventions for mood and anxiety disorders: empirical and methodological review. Clin Psychol Rev. 2008;28(2):228–246. [PubMed]
- Holzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T. et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. 2011;191(1):36–43. [PMC free article] [PubMed]
- Alcoholics Anonymous World Services. Alcoholics Anonymous Big Book. 4th ed. New York: Alcoholics Anonymous World Services; 2001.
- Hasking P, Lyvers M, Carlopio C. The relationship between coping strategies, alcohol expectancies, drinking motives and drinking behaviour. Addict Behav. 2011;36(5):479–487. [PubMed]
- Tate P. Alcohol: How to Give It Up and Be Glad You Did, A Sensible Approach. 1st ed. Altamonte Springs, FL: Rational Self-Help Press; 1993.
- Miller WR, Harris RJ. A simple scale of Gorski’s warning signs for relapse. J Stud Alcohol. 2000;61(5):759–765. [PubMed]
- Le Bon O, Murphy JR, Staner L, Hoffmann G, Kormoss N, Kentos M. et al. Double-blind, placebo-controlled study of the efficacy of trazodone in alcohol post-withdrawal syndrome: polysomnographic and clinical evaluations. J Clin Psychopharmacol. 2003;23(4):377–383. [PubMed]
- Ashton H. In: Comprehensive handbook of drug and alcohol addiction. Miller NS, editor. New York: Dekker; 1991. Protracted Withdrawal Syndromes for Benzodiazepines.
- Begleiter H. Brain dysfunction and alcoholism: problems and prospects. Alcohol Clin Exp Res. 1981;5(2):264–266. [PubMed]
- Corley MD, Schneider JP. Disclosing Secrets: When, to Whom, & How Much to Reveal. Carefree, AZ: Gentle Path Press; 2002.
- Kelly JF, Stout R, Zywiak W, Schneider R. A 3-year study of addiction mutual-help group participation following intensive outpatient treatment. Alcohol Clin Exp Res. 2006;30(8):1381–1392. [PubMed]
- Pagano ME, White WL, Kelly JF, Stout RL, Tonigan JS. The 10-year course of Alcoholics Anonymous participation and long-term outcomes: a follow-up study of outpatient subjects in Project MATCH. Subst Abus. 2013;34(1):51–59. [PMC free article] [PubMed]
- Johnson JE, Finney JW, Moos RH. End-of-treatment outcomes in cognitive-behavioral treatment and 12-step substance use treatment programs: do they differ and do they predict 1-year outcomes? J Subst Abuse Treat. 2006;31(1):41–50. [PubMed]
- Zemore SE, Subbaraman M, Tonigan JS. Involvement in 12-step activities and treatment outcomes. Subst Abus. 2013;34(1):60–69. [PMC free article] [PubMed]
- Bradshaw J. Healing the Shame That Binds You. Deerfield Beach, FL: Health Communications; 1988.
- Woititz JG. The Complete ACOA Sourcebook: Adult Children of Alcoholics at Home, at Work, and in Love. Deerfield Beach, FL: Health Communications; 2002.
- Shafil M, Lavely R, Jaffe R. Meditation and the prevention of alcohol abuse. Am J Psychiatry. 1975;132(9):942–945. [PubMed]
- Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH. et al. Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry. 2014;71(5):547–556. [PMC free article] [PubMed]
- Witkiewitz K, Lustyk MK, Bowen S. Retraining the addicted brain: a review of hypothesized neurobiological mechanisms of mindfulness-based relapse prevention. Psychol Addict Behav. 2013;27(2):351–365. [PMC free article] [PubMed]