Relapse usually does not occur suddenly, nor does it start with the first use of an addictive substance or behavior. Many times, relapse-prone individuals experience progressive warning signs that eventually make substance use seem like a good idea.
People don’t consciously plan their return to addictive substance use. From the client’s point of view, it just seems to happen without warning. But there are always indicators that trouble is brewing. Once patients learn to identify relapse-warning signs, they can begin to manage them. This concept is the core of Relapse Prevention Therapy (RPT).
Cunning, Baffling, Powerful
Early students of addiction—the members of Alcoholics Anonymous—noticed a paradox: people with substance use disorders often act in ways inconsistent with their conscious intentions. The Big Book contains a vignette about Jim, a salesman, who stopped at a restaurant for lunch. Although he wasn’t thinking about alcohol or relapse:
Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn’t hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the milk on a full stomach.
Decades later, some vulnerabilities and mechanisms for relapse have been identified. Environmental factors include high-risk situations where cues to use substances are present. These cues are generally described as “people, places and things” that have been associated with prior drug use. In Jim’s case, for example, relapse occurred in a restaurant that he had visited many times prior. The restaurant was likely full of drug-using cues that shaped his cognitions and behavior.
Relapse Prevention Therapy
The Gorski-CENAPS model, one form of RPT, has been evolving since the early 1970s (Gorski TT, J Chem Depend Treat 1989;2(2):153–169; Gorski TT, J Psychoactive Drugs 1990;22(2):125– 33; Gorski TT, The CENAPS Model of Relapse Prevention Therapy.
In: Approaches to Drug Abuse Counseling. Bethesda, MD: National Institute on Drug Abuse, 2000, p. 23–38). As currently delivered, there are nine principles and associated counseling procedures.
Principle 1 involves self-regulating thinking, feeling, memory, judgment and behavior. The primary procedure entails breaking the addiction cycle, often through formal substance abuse treatment, and stabilizing physically, psychologically and socially. The key metric for success at this stage is the client’s ability to perform basic activities of living.
Principle 2 involves integration, or developing a conscious understanding and acceptance of the situations and events that led to prior relapses. The primary procedure is self-assessment through the use of a personal life history and addiction history and listing the problems that caused the person to enter treatment. The goal is to discover what the client wanted substances to do for them (positive expectancies) and what happened once they started acting out their addiction again.
Principle 3 involves understanding the general factors that cause relapse. The primary procedure is relapse education.
Principle 4 involves self-knowledge. The primary procedure is warning sign identification and management. Clients develop a long list of early warning signs and high-risk situations that may lead them back to substance use. Warning signs represent irrational thoughts, unmanageable feelings (negative affect, stress) and self-defeating behaviors that can prompt clients to seek out high-risk situations (e.g., old drug-using peers). High-risk situations, in turn, undermine recovery supports, expose clients to cues and reinforce cognitive distortions.
Principle 5 involves coping skills. The primary procedure is recovery planning to increase clients’ self-efficacy. Techniques include mental rehearsal, role-playing and therapeutic assignments. Therapeutic work occurs in three domains. The first is situational-behavioral, where clients are taught to avoid situations that trigger warning signs and to modify their behavioral responses should such situations arise. The second is cognitive-affective, where clients are taught to challenge irrational thoughts and deal with unmanageable feelings triggered by warning signs. The last domain deals with core issues where clients are taught to identify how their cognitions and emotions can generate warning signs in the first place.
Principle 6 involves change. The primary procedure is recovery planning whereby clients develop a schedule of recovery activities and appropriate self-care.
Principle 7 involves awareness. The primary procedure is inventory training consisting of a Morning Planning Inventory and Evening Review. The former entails getting up, reading something that focuses the mind on sober and responsible living, and planning out the day. The goal is to anticipate stressful problems, warning signs and unavoidable high-risk situations. During the Evening Review, the client examines their day and reflects on how they dealt with various challenges. If there are residual issues, the client then decides
whether to tap into their support network before going to bed.
Principle 8 involves significant others. The primary procedure is incorporating family into the relapse prevention plan. Evidence suggests that family involvement represents a protective factor that improves drug use outcomes.
Principle 9 involves maintenance. The primary procedure is ongoing professional monitoring, which is sometimes described as Recovery Management Check-ups. Field studies have demonstrated that such protocols yield better results compared to non-intervention. At minimum, I recommend monthly visits for 3 months, quarterly visits for the next 2 years and then annual visits for at least the next 5 years. A detailed clinical manual describing the conduct of care is available (http://bit.ly/18NlGRi).
RPT generally occurs in a group context. A typical RPT session is structured in the following way:
1) Introduction and pretest (15 minutes);
2) Educational presentation (30 minutes);
3) Interactive exercise conducted in pairs or small groups
4) Large group processing (15 minutes); and
5) Posttest and wrap-up (15 minutes).
The format can be condensed and modified when dealing with individual clients during shorter appointments.
References available upon Requests
Terence T. Gorski is the Founder and President, The CENAPS Corporation. Terence T. Gorski is an internationally recognized expert on substance abuse, mental health, violence, & crime. He is best known for his contributions to relapse prevention, managing chemically
dependent offenders and developing community-based teams for managing the problems of alcohol, drugs, violence, and crime. He is a prolific author and has published numerous books and articles.
Gorski’s Relapse Prevention Certification Workshop is being held in Ft. Lauderdale, Florida, November 10-14, 2014. Gorski-CENAPS’s Advanced Relapse Prevention training has been “a turning point” in both the professional and personal lives of many former participants. Upon completion of this training, participants will be able to develop comprehensive Relapse Prevention Plans for identifying and managing both high risk situations in early recovery and the core personality and lifestyle problems that lead to relapse in latter recovery, after initial stabilization. For information and Registration: Contact – The CENAPS Corporation or Tresa Watson at 1-352-596-8000 or email@example.com.