Principle 1: Self-Regulation
The risk of relapse will decrease as a patient's capacity to
self-regulate thinking, feeling, memory, judgment, and behavior
increases.
Relapse Prevention Procedure 1: Stabilization
An initial treatment plan is established that allows relapse-prone
individuals to stabilize physically, psychologically, and socially. The
level of stabilization is measured by the ability to perform the basic
activities of daily living. Because the symptoms of withdrawal are
stress-sensitive, it is important to evaluate the patient's level of
stability under both high and low stress. Many people who appear stable
in a low-stress environment become unstable when placed in a more
stressful environment.
The stabilization process often includes
- Detoxification from alcohol and other drugs
- Solving the immediate crises that threaten sobriety
- Learning skills to identify and manage Post Acute Withdrawal and
Addictive Preoccupation
- Establishing a daily structure that includes proper diet,
exercise, stress management, and regular contact with treatment
personnel and self-help groups.
Because the risk of using alcohol or drugs is highest during the
stabilization period, steps must be taken to prevent use during this
time. The patient needs to be in a drug-free environment. Any irrational
thoughts (thoughts that don't make sense to a healthy person) that are
creating immediate justification for relapse need to be identified and
discussed. The patient should then be helped to remember the
consequences of past chemical use and to develop new coping strategies.
An early relapse intervention plan can be developed by the counselor
and patient to decide what action to take if the patient begins to use
alcohol or drugs. This early intervention plan motivates the patient to
stay sober and provides a safety net should chemical use occur.
Principle 2: Integration
The risk of relapse will decrease as the level of conscious
understanding and acceptance of situations and events that have led to
past relapses increases.
Relapse Prevention Procedure 2: Self-Assessment
Self-assessment first involves a detailed reconstruction of the
presenting problems (problems that caused the patient to seek treatment)
and the alcohol and drug use history. A careful exploration of the
presenting problems identifies critical issues that can trigger relapse.
This allows the counselor to design intervention plans that help to
solve crises that can be used for relapse justification in the early
treatment stages. The next step is a reconstruction of the recovery and
relapse history. This helps identify past causes of relapse.
In reconstructing the recovery/relapse history, it is important to
identify the recovery tasks that were completed or ignored, and to find
the sequence of warning signs that led back to drug or alcohol use. The
assessment is most effective if the counselor reconstructs the relapse
history using exercises (done as homework assignments), such as making a
list of all relapse episodes and identifying the problems that led to
relapse. These assignments should be reviewed in group and individual
sessions.
Principle 3: Understanding
The risk of relapse will decrease as the understanding of the general
factors that cause relapse increases.
Relapse Prevention Procedure 3: Relapse Education
Relapsers need accurate information about what causes relapse and
what can be done to prevent it. This is typically provided in structured
relapse education sessions and reading assignments, which provide
specific information about recovery, relapse, and relapse prevention
planning methods. This information should include, but not be limited to
- A bio/psycho/social model of addictive disease
- A DMR
- Common Astuck points" in recovery
- Complicating factors in relapse
- Warning sign identification
- Relapse warning sign management strategies
- Effective recovery planning.
The recommended format for a relapse education session is as follows:
- Introduction and pretest (15 minutes)
- Educational presentationClecture, film, or videotape (30 minutes)
- Educational exercise conducted in dyads or small groups (15
minutes)
- Large group discussion (15 minutes)
- Post-test session and review of correct answers (15 minutes).
It is important to test patients to determine their retention and
understanding of the material. Many relapsers have severe memory
problems associated with Post Acute Withdrawal that prevent them from
comprehending or remembering educational information.
Principle 4: Self-Knowledge
The risk of relapse will decrease as the patient's ability to
recognize personal relapse warning signs increases.
Relapse Prevention Procedure 4: Warning Sign Identification
Warning sign identification is the process of teaching patients to
identify the sequence of problems that has led from stable recovery to
alcohol and drug use in the past and then recognizing how those steps
could cause relapse in the future. The process of developing a personal
relapse warning sign list is (1) reviewing warning signs, (2) making an
initial warning sign list, (3) analyzing warning signs, and (4) making a
final warning sign list.
The patient develops his or her own individualized warning sign list
by thinking of irrational thoughts, unmanageable feelings, and
self-defeating behaviors. Most final warning sign lists identify two
different types of warning signs: those related to core psychological
issues (problems from childhood) and those related to core addictive
issues (problems from the addiction). Warning signs related to core
psychological issues create pain and dysfunction, but they do not
directly cause a person to relapse into chemical use. When patterns
of addictive thinking that justify relapse are reactivated, a return to
using alcohol and drugs occurs.
Principle 5: Coping Skills
The risk of relapse will decrease as the ability to manage relapse
warning signs increases.
Relapse Prevention Procedure 5: Warning Sign Management
This involves teaching relapse-prone patients how to manage or cope
with their warning signs as they occur. The better they are at coping
with warning signs, the better their ability will be to stay in
recovery.
Warning sign management should focus on three distinct levels. The
first is the situational-behavioral level, where patients are taught to
avoid situations that trigger warning signs. At this level, they are
taught to modify their behavioral responses should these situations
arise. The second level is the cognitiveBaffective (thoughts and
feelings) level, where patients are taught to challenge their irrational
thoughts and deal with their unmanageable feelings that emerge when a
warning sign is activated. The third level is the core issue level,
where patients are taught to identify the core addictive and
psychological issues that initially create the warning signs.
Principle 7: Awareness
The risk of relapse will decrease as the use of daily inventory
techniques designed to identify relapse warning signs increases.
Relapse Prevention Procedure 7: Inventory Training
Inventory training involves teaching relapse-prone patients to
complete daily inventories. These inventories monitor compliance with
the recovery program and check for the emergence of relapse warning
signs. A daily recovery plan sheet is used to plan the day, and an
evening inventory sheet is used to review progress and problems that
occurred during that day.
A typical morning inventory asks the patient to identify three
primary goals for that day, create a to-do list, then schedule time for
completion of each task on the to-do list on a daily calendar. During
the evening review inventory, the patient should review his or her
warning sign list and recovery plan to determine whether he or she
completed the required activities and experienced any relapse warning
signs.
Whenever possible, these inventories should be reviewed by someone
who knows the patient and who can assist him or her in looking for
emerging patterns of problems that could cause relapse.
Principle 8: Significant Others
The risk of relapse will decrease as the responsible involvement of
significant others in recovery and in relapse prevention planning
increases.
Relapse Prevention Procedure 8: Involvement of Others
Relapse-prone individuals cannot recover alone. They need the help of
others. Family members, 12-step program sponsors, counselors, and peers
are just a few of the many recovery resources available. A counselor
should ensure that others are involved in the recovery process whenever
possible. The more psychologically and emotionally healthy the
significant others are, the more likely they are to help the
relapse-prone patient remain abstinent. The more directly the
significant others are involved in the relapse prevention planning
process, the more likely they are to become productively involved in
supporting positive efforts at recovery and intervening on relapse
warning signs or initial chemical use.
Principle 9: Maintenance
The risk of relapse decreases if the relapse prevention plan is
regularlyupdated during the first 3 years of sobriety.
Relapse Prevention Procedure 9: Relapse Prevention Plan Updating
The patient's relapse prevention plan needs to be updated on a
monthly basis for the first 3 months, quarterly for the remainder of the
first year, and twice a year for the next 2 years. Once a person has
maintained 3 years of uninterrupted sobriety, the relapse prevention
plan should be updated on a yearly basis.
Nearly two thirds of all relapses occur during the first 6 months of
recovery. Less than one quarter of the variables that actually cause
relapse can be predicted during the initial treatment phase. As a
result, ongoing outpatient treatment is necessary for effective relapse
prevention. Even the most effective short-term inpatient or primary
outpatient programs will fail to interrupt long-term relapse cycles
without the ongoing reinforcement of some type of outpatient therapy.
A relapse prevention plan update session involves the following:
- A review of the original assessment, warning sign list, management
strategies, and recovery plan.
- An update of the assessment by adding documents that are
significant to 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.
- 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.
Basic Relapse Prevention Techniques
There are a number of techniques that are used when doing relapse
prevention counseling.
Centering
When you begin a group or an individual session or when you want a
patient to calm down and get in touch with thoughts and feelings, you
can use a technique called centering. This is basically a
relaxation technique. Instruct the patient to do the following:
- Put both feet on the floor, sit up straight and close your eyes.
- Breathe in through your nose and out through your mouth.
- Breathe in deeply, hold it for a second, then breathe out.
- Do this again and feel your lungs fill with air, then empty.
- Slow your breathing to a steady rhythm.
- See if any thoughts are entering your mind.
- Ask yourself if you are feeling any body tensions.
- Open your eyes when you are ready.
Speak slowly as you give the instructions. This will help the patient
calm down.
Sentence completion
Sentence completion is a technique used to help patients identify
thoughts that they have that may not be true. These thoughts are called
mistaken beliefs. Many times when a patient is acting in a
self-defeating way, it is a result of mistaken beliefs he or she has
about the world and himself or herself. When a patient is behaving in a
way that hurts himself or herself and others, it is because the patient
believes that this is the only choice he or she has. Sentence completion
is a way to help a patient identify and correct mistaken beliefs. You do
this by doing the following.
- Have the patient form a sentence stem: A sentence stem is the
beginning of a sentence that has meaning for the patient. You can
form these stems based on topics the patient is talking about.
Examples are:
"I know my recovery is in trouble when . . ."
"When I think about drugs, I . . ."
"Right now, I am feeling . . ."
- Have the patient write down the sentence stem.
- Have the patient repeat it out loud and end it differently six to
eight times or until he or she cannot think of new endings.
- Have the other group members write down the endings. If you are in
an individual session, do this yourself.
- Have the group members read the endings back to the patient as
they write them down. Have them use the following form: A(patient's
name), I heard you say (sentence stem)(first ending)." Repeat
the exercise until all the endings have been read.
- Look for a common theme in the endings. You may form a new
sentence stem from the common theme and repeat the exercise, or stop
here if the mistaken belief is identified.
- Have the patient identify the mistaken belief if he or she can and
write it down.
Sentence repetition
Sentence repetition is a way for a patient to become conscious of
mistaken beliefs and the thoughts, feelings, and actions they cause.
Identify the mistaken belief and ask the patient to write it down.
- Ask the patient to repeat it out loud, slowly.
- After each repetition, ask the patient to take a deep breath, let
it out, and report any thoughts, feelings, or urges that surfaced.
- Have the patient write down these thoughts, feelings, and urges.
- Ask the patient if he or she can remember who caused this mistaken
belief or where it came from.
- Ask the patient if the person could have been wrong.
- Ask the patient if there are other ways to believe that could be
true. You may have to ask the group to help.
- Ask the patient to complete the following sentences:
"If I continue to believe this, the best that can happen is . .
."
"The worst that can happen is . . ."
"The most likely to happen is . . ."
"If I change what I believe, the best that can happen is . .
."
"The worst that can happen is . . ."
"The most likely to happen is . . ."
- The probable outcomes can be discussed and a course of action
decided by the group. The most important decision is to identify a
rational thought that the patient can substitute when the mistaken
belief occurs. Example are as follows.
Mistaken belief—I can't tell others what I feel or they will
look down on me.
