Chapter 9-Relapse Prevention

Addiction is a chronic relapsing disorder, thereby making the prevention of relapse one of the critical elements of effective treatment for alcohol and other drug (AOD) abuse. Studies have shown that 54 percent of all alcohol and other drug abuse patients can be expected to relapse, and that 61 percent of that number will have multiple periods of relapse. It is not unusual for addicts to relapse within one month following treatment, nor is it unusual for addicts to relapse 12 months after treatment; 47 percent will relapse within the first year after treatment (Simpson, Joe & Lehman 1986). Although relapse is a symptom of addiction, it is preventable. A key factor in preventing relapse is improved social adjustment (Joe et al. 1985a). The poor social adjustment by criminal offenders makes them especially prone to relapse and to associated criminal behavior.

Relapse prevention methodologies are critical to the success of substance abuse treatment. This chapter will examine the process of relapse, along with information about recognizing its "warning signs," or triggers, and the elements of relapse prevention treatment methodologies.

Understanding Relapse

Relapse does not occur within a vacuum. There are many contributing factors, as well as identifiable evidence and warning signs which indicate that a patient may be in danger of returning to substance abuse. Relapse can be understood as not only the actual return to the pattern of substance abuse, but also as the process during which indicators appear prior to the patient's resumption of substance use (Daley, 1987).

Relapse, however, is not an automatic sentence to a lifetime of substance abuse for an individual. Studies of lifelong patterns of recovery and relapse indicate that approximately one-third of patients achieve permanent abstinence through their first serious attempt at recovery. Another third have brief relapse episodes which eventually result in long-term abstinence. An additional one-third have chronic relapses which result in eventual recovery from chemical addiction (Gorski, Kelley & Havens, 1993).

Because relapse is a common occurrence during the process of substance abuse recovery, it is imperative that it be examined carefully. Treating the disease of AOD abuse is not possible without a thorough understanding of the role that relapse prevention plays.

Whether or not treatment and criminal justice personnel provide initial treatment services, these personnel have a significant opportunity and responsibility to intervene with recovering persons when they recognize signs of relapse. Some of the skills required include assessment, education, confrontation of denial, brokering of community resources, and building support systems.

In order for relapse prevention to be successful, effective systems coordination is necessary. This involves coordination and communication between various agencies and systems. Community treatment programs must work cooperatively to ensure that relapse prevention programming is an integral part of treatment for all patients. State and community decision makers need to recognize that relapse prevention is a critical component of the treatment process, and consider and coordinate policy and funding decisions with this in mind. When it is treated as such, with comprehensive efforts on the parts of all involved agencies and systems, treatment dollars are spent most effectively.

Several situations may lead to relapse, such as social and peer pressure or anxiety and depression. Studies have indicated that the highest proportion of high-risk situations for alcoholics involve interpersonal negative emotional states, while the highest proportion of high-risk situations reported by heroin addicts involves social pressure. (Marlatt & Gordon, 1985).

Contributing Factors

An understanding of some of the personal factors which may contribute to substance abuse relapse is useful in any discussion of relapse prevention. These may include (Peters, 1993):

• inadequate skills to deal with social pressure to use substances;
• frequent exposure to "high-risk situations" that have led to drug or alcohol use in the past;
• physical or psychological reminders of past drug or alcohol use (e.g., drug paraphernalia, drug-using friends, money);
• inadequate skills to deal with interpersonal conflict or negative emotions;
• desires to test personal control over drug or alcohol use; and
• recurrent thoughts or physical desires to use drugs or alcohol.

Drug and alcohol addiction is a chronic and relapsing condition. Recovery requires changes in attitudes, behaviors, and values. Because of these issues, recovery is not a static condition; it is an ongoing process. Relapse occurs when attitudes and behaviors revert to ones similar to those exhibited when the person was actively using drugs or alcohol. Although relapse can occur at any time, it is more likely earlier in the recovery process. At this stage, habits and attitudes needed for continued sobriety, skills required to replace substance use, and identity with positive peers are not firmly entrenched (Nowinski, 1990).

Categories of Patients

According to Gorski & Miller (1986), chemically addicted individuals can be categorized according to their recovery and relapse history. Patients are: prone to recovery; briefly prone to relapse; or chronically prone to relapse. Individuals who are relapse-prone can be further divided into three subgroups:

• Transition patients. Transition patients do not accept or recognize that they are suffering from chemical addiction, even though their substance abuse may have created obvious adverse consequences. This usually results from the patient's inability to accurately perceive reality, due to chemical interference.
• Unstabilized relapse-prone patients. Unstabilized patients have not been taught skills to identify their addiction. In such cases, treatment fails to provide these patients with the necessary skills to interrupt the process and disease of addiction. As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change.
• Stabilized relapse-prone patients. Stabilized patients recognize and are aware of their chemical addiction, that abstinence is necessary for recovery, and that an ongoing recovery program may be required to maintain sobriety. Despite their efforts, however, these individuals develop dysfunctional symptoms which ultimately lead them back to AOD abuse.

It has been estimated that 40 to 60 percent of persons who are recovering from chemical dependence relapse at least once following their first serious attempt at treatment. Studies have shown that offenders who are actively using drugs are involved in approximately three to five times the number of crime days as non-drug users; thus, relapse tends to accelerate the level of subsequent criminal activity (Bell, 1990; Peters, 1993).

It is often thought that most relapse-prone persons are not motivated to recover. This is particularly common for those working with individuals in the criminal justice system, where relapse to drug use coincides with a return to criminal activity. Clinical experience, however, does not support this perception. In one study of relapse-prone patients at a national relapse prevention center in Maryland, over 80 percent of the patients had a history of cognizance of their addiction, as well as motivation to follow recovery recommendations. In spite of this, the individuals were unable to maintain abstinence on their own (Gorski et al., 1993).

Adolescent Risk

Adolescents are at particularly high risk for relapse because of their developmental stage. Many typical adolescent issues include physical and emotional changes which exacerbate relapse tendencies. Chemical dependency may have delayed normal development, making it difficult for recovering youth to function in age-appropriate ways. This produces discomfort in the all-important social milieu of youth. Some may return to substance use as a way of managing these uncomfortable feelings (Bell, 1990).

Bell (1990) also indicates there are predisposing factors and precipitating events that may result in relapse for adolescents. Predisposing factors place youth (and adults, as well) at increased risk and include elements such as:

• learning disabilities;
• dual or multiple diagnosis;
• high stress personalities;
• inadequate coping skills;
• lack of a support system;
• dysfunctional families; and
• lack of impulse control.

Precipitating factors are upsetting events that interfere with adolescents' abilities to work through recovery. Examples of these include:

• divorce or separation of parents;
• moving away from old friends; changing schools;
• loss or death of family members; and
• breakup of relationship with boyfriend or girlfriend.

Precipitating events for adults might include loss of job, loss of significant others, and similar events. Relapse prevention emphasizes teaching recovering persons to recognize and manage relapse warning signs. Peters (1993) offers some suggestions for relapse prevention among criminal offenders. While these are specific for populations of incarcerated adults, many of the recommendations could be applied to youth in various parts of the juvenile justice system. The program approaches he suggests include:

• Assessment of past relapses. This approach involves development of an individualized description of the sequence of events leading to relapse. This should include structured programs providing education and opportunities for rehearsal of coping skills. Relapse prevention should be provided well before an individual's expected release from a program to allow time for building relapse prevention skills.
• Strategies to aid community re-entry. Persons who have been removed from the community need assistance with the transition and help in establishing contact with needed treatment services. Frequent monitoring for drug use also may be important.
• Court-ordered treatment. Follow-up community treatment may be stipulated by the court as a condition of probation or after-care. Requiring substance abusers to participate in relapse prevention programs can aid in successful recovery. Community supervision can provide needed incentives to sustain the recovery process until internal motivation can be strengthened through peer support, confrontation, and other methods. Court-ordered treatment is effective in preventing relapse for persons who are unlikely to attend treatment on their own.

Principles and Procedures of Relapse Prevention

Gorski et al. (1993) have isolated a number of principles underlying relapse prevention therapy. They include:

• Self-regulation and stabilization. As the patient's capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases, the risk of relapse will decrease. Self-regulation can be achieved through stabilization. Stabilization may include:
  -detoxification from alcohol and other drugs;
  - recuperation from the effects of stress that preceded the chemical use;
  -resolution of immediate interpersonal and situational crises that threaten sobriety; or
  -establishment of a daily structure including proper diet, exercise, stress management, and regular contact with both treatment personnel and self-help groups.

The risk of relapse is highest during this period of stabilization.

• Integration and self-assessment. As understanding and acceptance increases, the risk of relapse will decrease. During this phase, it is important to explore the presenting problems which may have led to relapse in the past, and which might trigger future relapse.
• Understanding and relapse education. An understanding of the general factors which cause relapse will aid patients in relapse prevention. Basic information provided in this phase should include, but not be limited to:
  -medical, clinical, and social models of addictive disease;
  -developmental model of recovery;
  - common "stuck points" in recovery;
  -complicating factors in relapse;
  - identification of warning signs;
  - management strategies for relapse warning signs; and
  -planning for effective recovery.

It should be noted that many relapse-prone patients may have memory problems associated with the chemical abuse, which may impede the learning process and retention of educational information.

• Self-knowledge and identification warning signs. This process teaches patients to identify the sequence of problems that has led from stable recovery to chemical use in the past, and then to synthesize those steps into future circumstances that could cause relapse.
• Coping skills and warning sign management. This process involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur.
• Change and recovery planning. Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they occur in sobriety.
• Awareness and inventory training. Inventory training teaches relapse-prone patients to do daily inventories that monitor compliance with their recovery program and check for the development of relapse warning signs.
• Significant others and involvement of others. Relapse-prone individuals need the help of others during the process of recovery. Treatment should ensure that others (e.g., family members, 12-step sponsors, supportive peers) are involved in the recovery.
• Maintenance and relapse prevention plan updating. Ongoing outpatient treatment is necessary for effective relapse prevention. Even highly effective short-term inpatient or primary outpatient programs will be unable to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy. A relapse prevention plan update session may involve:
  - a review of the original assessment, warning sign list, management strategies, and recovery plan;
  -an update of the assessment by adding as an addendum any documents that are significant to the patient's progress or problems since the previous update;
  -a revision of the relapse warning sign list to incorporate new warning signs that have developed since the previous update;
  -the development of management strategies for the newly identified warning signs; and
  -a revision of the recovery program to add recovery activities, to address the new warning signs, and to eliminate activities that are no longer needed.

Conclusion

Chemical addiction is a disease, and, like many diseases, there is always the possibility of relapse. The process of AOD abuse is complex, and is impacted by social, clinical, and medical factors. The solutions to the problem of chemical addiction are multi-faceted. Treatment strategies benefit from a relapse prevention component in virtually every case. It is a definite means of stretching the effectiveness of State treatment dollars. In order for relapse prevention to work, agencies and systems must cooperate and communicate in their search for the best means of successfully intervening with substance abusing patients.

References

Bell, T. (1990). Preventing adolescent relapse: A guide for parents, teachers and counselors. Independence, MO: Herald House/ Independence Press.

Daley, D. (1987) Relapse prevention with substance abusers: clinical issues and myths. Social Work, 45(2), 38-42.

Gorski, T. T., Kelley, J. M., & Havens, L. (1993). An overview of addiction, relapse, and relapse prevention. In Relapse prevention and the substance-abusing criminal offender (An executive briefing) (Technical Assistance Publication Series 8). Rockville, MD: Center for Substance Abuse Treatment.

Gorski, T.T., & Miller, M. (1986). Staying sober-A guide for relapse prevention. Independence, MO: Independence Press.

Joe, G.W., Chastain, R.L., Marsh, K.L., & Simpson, D.D. (1985a). Opioid recidivism factors: 12-year followup of 1969-1972 admissions to DARP drug abuse treatments. College Station, TX: Texas A&M University, Behavioral Research Program.

Marlatt, G.A., & Gordon, J.R. (1985). Relapse Prevention. New York: Guilford Press.

Nowinski, J. (1990). Substance abuse in adolescents and young adults: A guide to treatment. New York: W.W. Norton & Company.

Peters, R.H. (1993). Relapse prevention approaches in the criminal justice system. In Relapse prevention and the substance-abusing criminal offender (An executive briefing) (Technical Assistance Publication Series 8). Rockville, MD: Center for Substance Abuse Treatment.

Simpson, D.D., Joe, G.W., Lehman, W.E.K., & Sells, S.B. (1986b). Addiction careers: Etiology, treatment, and 12-year followup outcomes. Journal of Drug Issues, 16(1), 107-121.

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