Article Title

 

Relapse Prevention

 

Author

 

Dr. Vickie Gregory

 

Article Type

 

Articles

 

Article

 

"To cease smoking is the easiest thing I ever did. I ought to know because I've done it a thousand times."1 Anyone who has ever tried to quit smoking (drinking, using drugs, over-eating, etc.) understands Mark Twain's humorous comment. It is difficult to change behavior, particularly addictive behaviors. Once changed, it can be even more difficult to maintain the change, especially abstinence from substances. Realizing this difficulty, psychologists began to focus on long-term effects of intervention, i.e. the maintenance of treatment gains. The working assumption was that the maintenance of behavior change was associated with different factors than the cessation of the behavior. During the 1980's Marlatt & Gordon's2 seminal work in this area resulted in the development of a new treatment approach. They designed a self-control program aimed specifically at teaching individuals with addictive behavior problems how to anticipate and cope with relapse crises. Their Relapse Prevention model is a maintenance plan which begins after an initial cessation of treatment. This model applies to individuals who have made the commitment to abstinence, following voluntary cessation of the use of the addictive substance. Since its development in the early 1980's, the Relapse Prevention model has been expanded and applied in the treatment of mental disorders (e.g. depression and anxiety) as well as addictive behaviors. The specific examples given below will be discussed in terms of addictive behaviors (cigarettes, alcohol, drugs) although many will apply to other addictions and to treatment of mental disorders. What follows is a starting point for developing your own road map to maintaining behavioral changes, based on the Relapse Prevention model. It is not meant to replace aftercare and traditional treatment methods of psychotherapy. It focuses on enhancing self-management skills. What I like about this approach is the focus on analyzing and solving the problems associated with your own individual situation. (Sounds somewhat like practicing law?) A major component of relapse prevention is the identification of high-risk situations, i.e. those triggers for the addictive behavior. Negative emotional states are such an important facet of high-risk situations that they deserve to be discussed separately. They are only briefly mentioned in this article. The next step is to develop coping strategies when encountering a high-risk situation. Successful coping will enhance self-efficacy,3 thereby reducing the risk of relapse. Finally, the Abstinence Violation Effect4 is addressed in the event of an actual relapse. 1.Identification of high risk situations Analysis of past relapses and self-monitoring of current temptations increase awareness of situations in which relapse is most likely to occur. Keeping a journal might prove useful in the analysis. Some common high-risk factors identified by research and clinical experience include: Presence of other drinkers/smokers (easy access, support) Alcohol consumption Following a meal Avoidance of food Social pressure Deadlines/trials 2.Negative emotional states One of the highest risks for relapse is a negative emotional state. Think about past experiences and develop a list of your own negative emotional states related to the behaviors you want to change. Common emotions triggering relapse episodes include: Frustration Anger Restlessness Boredom Impatience Anxiety & Depression While mood fluctuations are normal, symptoms of anxiety and depression become clinical concerns when the symptoms are severe/chronic and result in impairment in ability to function at work or socially. This degree of anxiety or depression may require professional intervention and treatment with medication. Many people use alcohol and drugs in an attempt to self-medicate, i.e. treat a psychological disorder. Anxiety disorders, affective disorders (depression, bipolar disorder), and Attention Deficit Hyperactivity Disorder are common underlying diagnoses in individuals who abuse substances. Treatment of these disorders with therapy and medication will aid in recovery and decrease the risk of relapse via self-medication. 3. Coping skills training The most powerful determinant of the outcome of a relapse crisis is the coping response. Use of coping responses leads to increases in self-efficacy and reduces the risk of relapse. Below is a list of coping skills. Stress management/Relaxation Training - Take advantage of community resources, e.g. stress management seminars List alternative/incompatible behaviors - Draft a contract promising not to continue the behavior further (Make it legal - don't forget the consideration) Take a brisk walk after dinner Exercise, exercise, exercise - A moving target's hard to hit List rationalizations - Make a list of the rationalizations that reinforce the behavior.. Once recognized, rationalizations lose their influence on the behavior. For example, some common rationalizations include: I'll only have one. No one will know. (The substance) really wasn't so bad. I could get through this mess if I could only use. I'm beginning to gain weight and I could lose it if I started again. A (substance) would help me to relax and calm down. Note the number of rationalizations related to negative affective states. Improve decision making skills - List reasons for behavioral change Recall rationalizations Detail short-term pay-offs versus long-term consequences Educate yourself Use your legal training in decision making/analysis to advance your personal goals Seek outside assistance - Attend a support group Attend Alcoholics Anonymous (or the equivalent) Participate in group or individual therapy Call Lawyer's Helping Lawyers 4.Beware the Abstinence Violation Effect The Abstinence Violation Effect is the feeling that once you have used, you have blown it. You feel guilty, like failure, ashamed. . . Self-efficacy decreases and you continue to use. Steps to cope with these feelings include: Recognize and label the Abstinence Violation Effect Remind yourself that to err is human Don't panic Analyze the lapse, the high-risk situation How could you have coped? Talk to someone who is sympathetic and helpful Go immediately back to your cessation program Don't get caught up in I blew it; I can't stop 5.Have some fun So basic, yet so frequently forgotten Get a hobby Catch up with friends Enjoy your pet (or adopt one) Contact Rich Uday, he's always up for a game of golf Relapse prevention is a psycho-educational treatment combining behavioral skills training with cognitive interventions. The Relapse Prevention model assumes that addictive behaviors are over-learned, maladaptive habits developed by performance before or during stressful, unpleasant occasions. Further addictive behaviors are strongly influenced by the individual's expectations associated with the use of the substance. Importantly, this model does not adopt the traditional treatment method equating use of any substance as a treatment failure, inducing guilt. Rather, the relapse prevention model views a lapse (substance use) as a learning experience rather than a failure. The model assumes that abstaining individuals experience a sense of perceived control and enhanced self-efficacy. Thus, the strategy develops a game plan for use when high-risk situations are encountered. New coping skills are developed. Self-efficacy increases. The probability of a relapse decreases, and after all, that is what we are after. Footnotes 1. Mark Twain 2. Marlatt. G. A., & Gordon, J. R. (Eds.) (1985) Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press. 3. Bandura, A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 1977, 84, 191-215. 4. Marlatt & Gordon, supra, note 2.