Much more occurs prior to a full-blown relapse than one might think. When individuals are in addiction recovery or remain abstinent for a period of time, they just don’t slip on a banana peel and end up in a bar or on a drug dealer’s doorstep. Many behavioral lapses occur prior to a relapse that result in resuming substance use.
When prepared with behaviors in mind, relapse prevention programs are often beneficial to the overall discharge plan. Unfortunately, many of the relapse prevention programs designed for substance use disorder clients focus on avoidance and external factors. Listing people, places, and things is very helpful, and it also encourages the use of one’s willpower while avoiding the underlying reasons why substances were used in the first place. A person who is self-medicating a childhood trauma or who has an issue with older men with brown hair, for example, probably isn’t going to benefit from a relapse prevention plan focused on external cues alone. Suggesting it would be better not to go to a baseball game where alcohol is readily available may not be enough. A relapse prevention program that suggests not doing certain things or avoiding certain places alone does not address the underlying triggers nor does it address the character defects or the shortcomings that led to substance use.
What are the Benefits of Relapse Prevention Programs?
Relapse prevention programs employ evidence-based techniques to reduce or prevent a return to active substance use. Evidence-based treatment research has identified strong precursors to why addicts relapse as well as areas of focus to help prevent or minimize the chances of relapse.
Involves recalling or having triggers of negative experiences that cause damaging feelings or emotions.
This is self-awareness and involves understanding the reasons behind doing certain things. Going to the gym to get healthy is great. However, going to the gym when married to meet women and be noticed to achieve external validation is not. Knowing the difference is self-efficacy.
There are effective and ineffective ways of coping with unhealthy behaviors and substances. Executing effective coping strategies and asking for help is important. The most effective coping strategy is one that seeks guidance from others. For most substance users, a lack of willpower and self-imposed solutions cause many of their problems.
In sum, we have to change the way we think or perceive things. This includes four areas of focus. The first is changing bad behaviors such as selfishness. The second is addressing misplaced emotions such as resentments; taking ownership of this area has helped many substance users. A third is acquiring healthy social skills and relationships. And finally, there is the need to address our overall mental health. This does not necessarily mean addressing a mental disorder. In the final analysis, the question to ask is: “Is there another way to look at things?”
The American Society of Addiction Medicine (ASAM) defines six dimension assessments. Of these six, two focus on relapse potential. The first, dimension 3, indirectly focuses on relapse prevention by addressing the client’s emotional, behavioral, and cognitive complications and conditions. This dimension addresses many factors that lead to the use of substances and maladaptive coping skills. In doing so, the treatment plan can be designed to take into account many of the behaviors and problems associated with substance use. This can have a significant impact on the four precursors to relapse and help to reduce relapse potential.
The other dimension, the 5th dimension of ASAM criteria, directly addresses relapse, continued use, and the potential of continued problems. This dimension addresses many aspects of relapse, including external and internal cues. As stated above, focusing on external factors is helpful and should be part of the plan. We also believe the more the focus is on the internal cues such as behaviors, ego, selfishness, resentments, trauma, transferences, and dishonesty, the more likely external factors are diminished. In other words, focusing on the internal will most likely reduce or eliminate the need to consider external forces such as bad places, people, and things of temptation. Becoming more self-aware about how to handle unexpected situations when they arise may result in less likelihood of a relapse.
Addiction treatment programs should implement relapse prevention techniques and teach substance use disorder clients effective strategies to address both internal and external triggers in order to avoid relapse. This can prepare clients for the opportunity to achieve long-term addiction recovery. Whether directly or indirectly, relapse prevention strategies should be part of the overall recovery plan and implemented into each phase of the recovery process:
Drug and Alcohol Assessment > Intervention > Drug & Alcohol Detox > Residential Addiction Treatment > Outpatient Substance Abuse Treatment > Substance Abuse Counseling > Aftercare
Many are under the impression that a relapse is the result of an alcohol use disorder client or a substance use disorder client experiencing negative feelings or situations. Although relapses can occur when bad things happen, in our experience they are more frequent when things are going well. The reason for this often comes from the alcohol or substance users not understanding what they are truly up against. This could be why relapse prevention and long-term sobriety are often achieved when the client addresses the internal problems as well as the external triggers that led to the substance use. Many substance users strive to address the symptoms or the losses, but they forget about the behaviors that contributed to substance use and led to the losses. They often believe that by gaining things back and avoiding bars and known drug areas, they will be ok. Although helpful, we have observed that these two strategies in and of themselves often fail. Below are examples of the symptoms of the problem and what happens when the focus is solely on them or they are addressed incorrectly:
- Financial: Many substance users run into financial difficulties. Drug and alcohol use can cause most or all of one’s resources to pay for substances, legal fees, medical bills, and so forth. So, a substance user gets sober and puts all his or her energy into a job, paying bills, and saving some money. Then what? Far too often, we see “Then what?” turns into “What happened? I was doing so well.” This is because when substance users gain their stuff back, they fail to address the behavior that led to the substances and subsequently to the financial problems. If they focus instead on the internal reasons, they may be able to handle the situation much better and ensure success.
- Physical: Alcohol and drug use can cause physical problems. There is a reason you have to prove a minimum of 6 months of sobriety before you’re eligible to be considered for a liver transplant. Far too often, we see substance users build relapse prevention and treatment plans around external cues alone. As soon as they get their physical ailments under control, they are back to using drugs and alcohol. Why is this? Because drugs and alcohol are not the only problems. The person’s behavior and perception are equally problematic. As long as we focus on addressing the symptoms alone, the more likely we are to revert to substance use when we feel better.
- Emotional: So now you have the kids, the spouse, and the job back, and you’re feeling happy and no longer depressed. You paid your bills, there are no more creditors, you’re back at the gym, and people like having you around again. But you have not addressed any of the reasons that caused you to lose all those things in the first place. You think you lost it all because you drank too much or were using drugs. You have no clue that you lost those things because of the behavior that caused you to drink too much or use drugs. If left unaddressed, you will most likely lose it all again.
- Mental: If your recovery is about your ego and learning how to fix, manage, or control things better, then using substances again is not a relapse, it’s called resuming. Relapses occur after a period of sobriety, not abstinence; there is a difference. Far too often, substance use disorder clients blame their downfall on other people, places, or things, and they make their recovery about trying to better manage people, places, and things. A substance use disorder is a problem of selfishness, ego, resentment, and perception. If fifty people are telling you the wall is white, but you insist it is blue, then you may be the one with the problem. Unfortunately, drug tests do not check for this.
It is not a question of if someone will have thoughts or temptations to use drugs and alcohol after recovery; rather, it is a question of when. Individuals who have worked on coping and relapse prevention skills throughout their recovery often have better outcomes than those who do not.
Common Behavioral Relapse Triggers in Alcohol and Drug Addiction
Recovering addicts, alcoholics, and their families want to know why the loved one might relapse, and it is understandable why many fear this possibility. While everyone’s situation is different, there are often common denominators to a relapse, regardless of what the final trigger might be.
These commonalities represent a series of behavioral lapses that occur prior to the actual relapse. Some of them are insidious while others are blatantly obvious. If and when a family notices some of the old behaviors coming back, that is the best time to address the concerns. Although they may be met with denial or a “what are you talking about?” response, it is still important to say something. The substance user is often the last person to recognize the lapses that led to the relapse. This is why staying involved in recovery and being part of a fellowship for accountability is so important. Here are some of the behavior lapses that occur prior to relapses that involve substances. They are often referred to as pre-lapse behaviors:
For some suffering from addiction, it is common for dishonesty to replace truth even when the truth would offer a better outcome. Real addiction recovery is centered around behavioral change, and honesty starts with being honest with oneself. Once dishonesty begins, this warning sign indicates the person in recovery is headed in the wrong direction. For many working a recovery program, they experience an uncomfortable feeling when they do something dishonest. They then quickly address the misstep and recognize the behavior. For those headed down the wrong road, dishonesty can return and become their normal behavior again. This can lead to justifying the missteps and blaming others.
Resentments, Blaming Others & Justifications:
A significant focus of recovery efforts should be to address the substance user’s behaviors and motives. Substance users often lead with their ego and selfish motives. They do things with planned expectations. When things do not go their way, they become resentful, blame others for any wrongs and mistreatments, and thus justify why they should be able to retaliate. Substance users in recovery who address their ego and selfish motives can avoid these resentments. When people engage in unselfish acts, they avoid expectations that lead to resentments. Relinquishing control or clinging to the belief they have control over people, places, and things is another trait many substance users have in common. Being a professional victim with the blame thrower on full blast does not help in terms of avoiding relapse.
Becoming a Victim Again:
When substance users start to engage in the destructive behaviors that previously led to substances, they often put themselves in a position to be hurt. They act out in a negative way, and when someone retaliates, they are beside themselves. “How dare they do that to me?” they ask, taking no ownership for the initial act or behavior. People headed down the wrong path, away from recovery, can easily believe they are victims yet again of society’s plot to hurt them. When people in recovery revert to dishonesty, become resentful and blame others, they view themselves as victims. What often happens next is they justify themselves as poor victims who were wronged again, taking no ownership for their role, and then drinking or using drugs to punish others. As they start reusing substances, some have an attitude: “I’ll show you how much you hurt me.” In the end, they wind up hurting themselves the most, and they can also hurt their families. This is why it is so important that the family of a substance user be engaged in their own recovery program and even more so when the substance user is not engaged in his or hers.
No longer engaged in recovery efforts:
When a substance user feels, thinks, or states “I’ve got this,” it signals that the recovery is lost. As with any fatal illness or medical problem, when we stop taking our medication or following professional suggestions, we become susceptible to a relapse of the disorder or condition. Although many view the God concept and higher power philosophy of Alcoholics Anonymous as a turn off, there is some validity in it. We’re not suggesting a necessity to believe in God… or else. The larger message is that people in recovery can greatly benefit from surrendering to something beyond their self-will and isolated thoughts. A substance use disorder is far bigger than a physical dependence on alcohol or drugs. It is largely a thinking problem involving distorted perception where the substance user claims to be the smartest person in the room. Many substance users believe that if not for them, the world wouldn’t turn, and the sun wouldn’t rise. When ego drives the bus and selfishness prevails, relapses often occur. Finding fault in a sponsor, self-help groups, or the treatment team may be a way of justifying bad behaviors that led to substances in the first place. It is important to remember that things aren’t always what they seem. There is always much more to feelings than what we perceive them to be on the surface. Self-awareness and mindfulness can be extremely helpful in addressing thoughts and feelings.
Engaging in high-risk behaviors and engaging with old acquaintances:
Calling your former using friends while saying you were only doing so to check in on them is a huge red flag. The saying, “your disease is doing pushups waiting to pounce on you at any time” has some validity. Resuming old behaviors leads to relapse. When substance users start justifying reuniting with old acquaintances or significant others with whom they previously engaged in risky behaviors, it almost never ends well. A favorite saying often heard around Alcoholics and Narcotics Anonymous meetings is, “If you hang around the barbershop long enough, you’re eventually going to get a haircut.” The point is, substance users in a strong recovery program aren’t engaging in risky behaviors any longer. When we are able to process a relapse with someone, it doesn’t take very long to identify where it started. At some point, self-will made a comeback along with many or all of the other negative thoughts and behaviors, at which point the substances were used. Nobody just slips and falls into a bar or drug dealer’s house; much happens before that occurs. It often starts with an “I’ve got this” comment.
Triggers and thoughts of using drugs and alcohol are unavoidable. Over time and with ongoing recovery efforts, these thoughts and triggers become fewer and far between and far less intense. When they start becoming more intense and more frequent, however, that is the time for substance users to take notice and evaluate their recovery efforts. Substance use disorders are daunting, and substance users would benefit from respecting and believing they are up against a force far greater than their willpower can handle on its own. Substance users utilize many resources such as people, places, and things to stay active in their addiction. They most likely would benefit from using that same strategy in their recovery. Unfortunately, this does not always happen and substance use disorders appear to be the only fatal illness where patients and their families try to treat themselves and fight to stay sick.
Effective Relapse Prevention Intervention Strategies
Intervention instruments such as cognitive behavioral therapy, acquired coping skills, and modifying or changing bad behavior have a huge impact on long-term recovery. Many clinicians believe it is impossible to address and prepare a substance user for any and all challenges. With that in mind, it is helpful for many substance users to acquire additional skills or tools that can prevent them from relapsing. Just as the addiction becomes a habit and causes a substance user to be on autopilot, so too can recovery and changes in routines become an acquired habit.
Over the years, many substance users have disclosed to us that the enticement to that lifestyle was as addictive and as hard to shed as the substances themselves. With that in mind, two strategies are considered to be global relapse prevention strategies. Keep in mind, these in and of themselves are not end-all, be-all solutions. They are suggested to supplement all the internal and external relapse prevention strategies available. We still believe the stronger the recovery program and the more attention paid to relapse prevention strategies, the greater the likelihood of being able to face any and all challenges. The 2 strategies are:
This strategy includes caring about yourself, your health, and your overall well-being. Lifestyle can include diet, exercise, and spirituality. Although we have yet to see someone remain sober on a gym membership and a healthy diet alone, it does have a profound impact on well-being. Of these, the one that has a proven impact on one’s recovery is spirituality. This is not to be confused with religion. Spirituality is, in its simplest form, letting go of the belief that each of us is the end-all, be-all. It is understanding that more is out there that is greater and bigger than any one of us. It is about good-in and good-out, unselfishness, regard for others, and being a kinder person with an open heart and mind. Sometimes, as the saying goes, you have to stop and smell the roses. It is more helpful to be grateful for what you do have than it is to be ungrateful for what you don’t.
Another benefit of a changed lifestyle beyond what is directly perceived is that it creates a barometer of accountability. Once substance users have engaged in healthy changes, stopping or telling themselves they no longer need or want to engage in these healthy changes can be a great predictor of relapse down the road. Anything substance users can do that will help them see a warning sign before a full-on relapse can greatly decrease the chances of a relapse.
Viktor Frankl, a well-known psychiatrist, is the founder of logotherapy or therapy through meaning. Logotherapy focuses on finding one’s purpose in life and sums up mindfulness best in this famous quote:
“Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” (Victor Frankl)
Mindfulness and acceptance-based treatment approaches are built on behavioral therapy. They are therapeutic intervention methods that include: being mindful, acceptance, finding one’s purpose, being present, being non-judgmental, counselor/client relationship, values, spirituality, meditation, and emotional expression. When mindfulness is combined with relapse prevention strategies (also known as MBRP or Mindfulness-Based Prevention Strategies), the goal is to reduce reactivity and instincts previously used to respond to situations. This helps clients separate or acknowledge that what is actually happening is different from how they perceive it. By being present in the moment and being aware of current surroundings, it is possible to reduce compulsive behaviors and reactions that may have previously brought trouble to substance users.
MBRP is helpful because it brings awareness to behaviors and instincts that caused drug use in the past. Think of it as the drifter alert in a vehicle. When the car starts to drift into another lane, the vehicle’s steering wheel vibrates or an alarm sounds. If substance users can incorporate mindfulness-based relapse prevention strategies into their overall plan, they can increase their self-awareness. The next time they have a bad thought and they recognize it, they may call their sponsor instead of their drug dealer. This can become an instinctive reaction where the goal is to get the substance user off of autopilot and using drugs and alcohol and instead to autopilot toward self-awareness while utilizing relapse prevention skills.
Understanding the relapse triggers your loved one may face in their recovery journey can help you better support them. However, it’s important for the family not to neglect their own recovery. Learn more about how Family First Intervention can help your family.