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Relapse Prevention Planning
Building a solid relapse prevention plan is one of the cornerstones of long-term sobriety from drugs or alcohol. There are four main ideas in relapse prevention. First, relapse is a gradual process with distinct stages. 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, and building sober social support. Fourth, most relapses can be explained in terms of a few basic rules. These rules include:
The Stages of Relapse
While it may seem like a relapse came out of nowhere, a relapse is a gradual process called B.U.D., Build Up to Drink, or Build Up to Drugs. The physical relapse follows distinct phases. Learning to identify these stages early on and take corrective action is critical to avoid a relapse on drugs or alcohol.
The pain is so great from a rock bottom moment that we are willing to do anything to scratch, claw, and climb our way out of this painful rock bottom. And we do. However, as the pain decreases, so does our motivation to stick with our sobriety routine that has worked thus far. One of the first stages of relapse is that we begin to relapse on our recovery routine. We may skip going to a treatment appointment. We may decide that we no longer need to go to our 12-step meeting or forget to start our morning with prayer. Regardless, learning to identify and correct these relapses of recovery routine is important to stop the progression towards a physical relapse. This is one of the reasons that it is important to have a formal daily recovery routine and routinely follow your schedule for success in recovery.
During an emotional relapse, individuals are not thinking about using. They remember their last relapse, and they do not 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:
- bottling up emotions;
- not going to meetings;
- going to meetings but not sharing;
- focusing on others (focusing on other people's problems or focusing on how other people affect them); and
- poor eating and sleeping habits.
The common denominator of emotional relapse is poor self-care, in which self-care is broadly defined as emotional, psychological, and physical care.
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, be kind to themselves, and permit themselves to have fun.
The transition between emotional and mental relapse is not arbitrary but the natural consequence of prolonged, poor self-care. They begin to feel restless, irritable, and discontent. As their tension builds, they start to think about using it to escape.
In mental relapse, there is a war going on inside people's minds. Part of them wants to use it, 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:
- craving for drugs or alcohol;
- thinking about people, places, and things associated with past use;
- minimizing consequences of past use or glamorizing past use;
- thinking of schemes to better control using;
- looking for relapse opportunities; and
- planning a relapse.
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 never to 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 using it. 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 to escape their turmoil.
Cognitive-Behavioral Therapy (C.B.T.) and Relapse Prevention
Cognitive-behavioral therapy is one of the main tools for changing people's negative thinking and developing healthy coping skills. The effectiveness of cognitive therapy in relapse prevention has been confirmed in numerous studies. C.B.T. focuses on identifying and correct thinking errors that contribute to negative emotions and dysfunctional behaviors.
This is a shortlist of the types of negative thinking that can contribute to negative emotions and lead to a relapse.
- I will do it just once;
- No one will ever know;
- It will be different this time;
- I can't deal with things without drinking or using;
- My problem is because of other people;
- I don't think I can handle life without using;
- Life won't be fun — I won't be fun — without using;
- I'm worried I will turn into someone I don't like;
- I can't make all the necessary changes; I can't change my friends;
- I don't want to abandon my family;
- Recovery is too much work;
- My cravings will be overwhelming; I won't be able to resist them;
- If I stop, I'll only start up again; I have never finished anything;
- No one has to know if I relapse; and
- I'm worried my addiction has so damaged me 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.
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 tough 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 their progress 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 can be fixed. Clients are encouraged to challenge their thinking by looking at past successes and acknowledging the strengths they bring to recovery.
Examining a setback with a sponsor or counselor can strengthen your recovery and prevent similar ones in the future. Working with them to piece together the chain of events can help you identify early warning signs and create a corrective action plan next time you are faced with a similar challenge. Over time, your relapse prevention plan gets stronger and stronger, and you can achieve long-term sobriety.