Relapse Prevention and Recycling in Addiction

Introduction

In the struggle to be free from addiction, for most individuals, repeated attempts are required to stop the addictive behavior. Multiple attempts to change and multiple treatment events are the norm rather than the exception in recovery from addiction. There seems to be a predictable cycle in the path to recovery. Once addicted individuals become convinced that they need to change problematic addictive behaviors (illegal or nonprescription drug use, excessive alcohol consumption, tobacco use, or gambling), they will attempt either to quit completely or to significantly modify these behaviors (e.g., cutting down or using methadone or buprenorphine instead of heroin). The majority of these individuals who make an attempt to change, however, are unsuccessful. In any cohort of individuals who enter treatment and make a bona fide attempt to change, the majority, between 60% and 80%, return to the problematic behavior after some period of success. This event, although defined in various ways, has been labeled a “relapse.”

Understanding the Concept of Relapse and Its Role in Recovery

The definition of what constitutes a relapse varies depending on the definition of success and failure in changing an addictive behavior. The most stringent definitions define success as complete abstinence from the behavior and identify relapse as any engagement in the addictive behavior (any consumption of alcohol, use of cocaine, and so on). Other clinicians and researchers make a distinction between a slip or lapse and a full-blown relapse. Slips and lapses have been defined variably as a single use, a single period of use, minimal amounts of use, or use without any consequences. Relapse is then a more significant engagement in the behavior than a single event or a brief period of use. Lapses could indicate that there are some vestiges of the behavior present that may create problems for sustained abstinence or lead to a relapse. Making a distinction between a lapse and a relapse can be clinically useful because the very strict definition of complete abstinence or failure can have unintended consequences, as described later. It is important first to note some common misconceptions about the phenomenon of relapse. Relapse is often viewed as a unique problem of substance abusers by practitioners and the public. However, relapse and lapsing back to unhealthy behaviors occur in all types of health behavioral change and is not limited to addictions. Many health behaviors, such as dietary change, diabetes management, regular physical activity, and medication adherence have a similar course, with large numbers of individuals lapsing and relapsing. ^, Relapse is not merely a function of physiological addiction, it is a function of the process of behavioral change when individuals attempt to change difficult-to-modify patterns of behavior. ^,

Another misconception is that relapse is often viewed as failure, since the desired behavioral change is not sustained. However, although it does not represent complete success, relapse is an integral part of learning during the recovery process. Individuals do not become addicted or recover from an addiction with a single learning event. Within the stages of change model, relapse represents an event that not only involves a return to a problematic behavior but also signifies a return to an earlier stage of change for that behavior. After relapsing, individuals can return to any of the pre-Action or even to Action stages; Precontemplation (not considering change in the near term), Contemplation (considering and decision making), Preparation (building commitment and planning), or Action (initial change lasting for 3–6 months). Individuals returning to the Precontemplation stage after relapse likely believe they cannot change or they are no longer interested in changing the addictive behavior. Relapsers who reconsider the pros and the cons of the addiction, try to resolve the associated ambivalence and make a new decision to quit have returned to the Contemplation stage. Those who determine what went wrong during the last quit attempt and are poised to make another attempt return to the Preparation stage. Relapsers who quickly make another attempt move back into the Action stage of change. The return to earlier stages of change after relapsing from the Action or Maintenance stage is called “recycling” back through the stages and often leads to another attempt that is successful. The cyclical movement through the stages of change represents the learning process of successive approximations whereby an individual learns gradually through trial and error how to avoid the problems from past attempts and make a successful change in behavior.

Relapse, considered from this perspective, is not so much a failure as an opportunity to learn what went wrong and what was missing in the unsuccessful process of change. Most individuals who enter stable recovery do so only after multiple attempts to change. This pattern is true of individuals who have changed the addictive behavior without the aid of formal treatment as well as those who have been successful after a particular course of treatment. In any case, understanding relapse and recycling is critical to understanding successful recovery. Helping individuals avoid relapse and/or to learn how to profit from the experience and become more successful is the goal of relapse prevention and of successful recycling. This chapter examines relapse prevention models, highlights critical components of relapse prevention, identifies key clinical strategies that can be used in the service of preventing relapse, and discusses how to promote successful recycling for those who were unable to change their behavior at any one point in time.

Relapse Prevention

As the field of addiction moved from a moral explanation of addiction to a focus on habit and disease, the challenge of maintaining change and avoiding relapse became a focus of research and theory. Interest and research activity expanded to understand what precipitates relapse and the possible interventions that would reduce the relapse rate and increase the potential for recovery from a slip or a relapse. There were several dominant theories that were developed during the 20th century, not all of which were compatible with one another.

Models for Relapse Prevention

The two partially compatible models for understanding relapse came from different explanatory frameworks. The Medical Model countered the prevailing perspective at the beginning of the 20th century that alcoholism and other addictions were moral problems that could be overcome with willpower and by observing moral standards. The view of addiction as a disease was intended to change the conversation about addiction, remove some of the stigma, and make it a medical condition that was treatable. This model was not only adopted by medical professionals but also by the influential founders of Alcoholics Anonymous and the Twelve-Step model for recovery. At the same time in the academic community, the social and behavioral learning perspectives described addictions as overlearned behaviors that were supported by contextual forces. More recently, addiction has also been described as a reward deficit disorder in which an individual progresses from impulsivity to compulsivity and from positive reinforcement to negative reinforcement in the development of their addiction. This model focuses more on how substances affect brain functioning, emotion regulation, and stress management, creating behaviors that are difficult to stop and maintain cessation. Of interest, all models arrived at some similar relapse-prevention strategies.

Medical and Mutual Help Model

In the Medical Model, addiction is viewed in terms of the changes that are made in the neurochemistry of the addicted individual, which causes physiological dependence. The perspective is that the addiction acts as a disease and changes biological processes which, in turn, pose significant barriers for change for the addicted individual. The physiological changes that result from prolonged substance abuse manifest themselves in craving, which continually pushes the addicted individual to return to the addictive behavior. For the addicted individual, their normal biological state is inherently resistant to behavior change. Medical Model–oriented interventions to prevent relapse include periods of hospitalization that focus on breaking the physiological and psychological connections to addiction as well as using medications that decrease cravings.

In the Medical/Mutual Help or Twelve-Step Model, addiction is also described as an illness or disease that addicted individuals are powerless to control. One analogy for the disease is an allergy such that the individual cannot have contact with the substance without a loss of control. This perspective supports the view of relapse as any contact with addictive substance or behavior. The addicted individual is seen as someone who has a defect such that willpower cannot be the solution for recovery. Preventing relapse must include an admission of powerlessness and a reliance on a higher power, whether that is seen as a spiritual power or the power of the mutual help network that is created by associating with Alcoholics Anonymous and working the 12 steps of recovery. The program includes a number of strategies (e.g., approach recovery, one day at a time, you are always an alcoholic and must always be vigilant, meeting attendance) and support systems (e.g., sponsors, fellowship of Alcoholics Anonymous) for the prevention of relapse.

Reward Deficit Model

Addiction, particularly a severe alcohol use disorder, has been conceptualized as a reward deficit disorder. It is a chronically relapsing disorder that, like in the medical model, is defined by a loss of control in limiting one’s intake. It is also characterized by a compulsion to use the substance driven also by the negative affectivity in the form of dysphoria, anxiety, or irritability occurring as a result of withdrawal from the substance. When an individual initiates substance use, impulsivity, a predisposition to quick unplanned actions without considering negative consequences, is the dominant precipitant to substance use. Later in the addiction cycle, once negative affectivity and withdrawal has begun, substance use becomes compulsive, meaning one continues to use the substance in the face of negative consequences. When substance use is more of an impulsive behavior, it is positively reinforced by the pleasurable effects of the drug. Use becomes compulsive as the motivational force changes to negative reinforcement and use becomes necessary to relieve a negative affective state. This model asserts that it is the reward deficit caused by neurobiological changes in the brain that is the chief vulnerability for relapse. Interventions based on this model often include use of a pharmacological agent to assist in breaking the addiction cycle and in supporting behavioral strategies that will enable abstinence and avoidance of relapse.

Cognitive-Behavioral Models

In 1980, G. Alan Marlatt and Judith Gordon developed the Relapse Prevention Model, an extensive, empirically focused conceptual model that we use as the basis of our discussion of relapse in this chapter. Their cognitive-behavioral model of the relapse process is based on social cognitive and learning models of behavior and posits that addiction stems from maladaptive habit patterns. Relapse is conceptualized as resulting from a series of predictable cognitive and behavioral events that lead to a return to substance use. This relapse prevention model hypothesizes that common cognitive, behavioral, and affective mechanisms underlie the process of relapse for a variety of problem behaviors. This view of recovery is based on learning theory and differs from the disease model in many ways, although it does share some theoretical precipitants of relapse.

The model assumes that a complex array of determinants is involved in the development of an addiction and the ability to successfully change addictive behaviors. Some influential factors include genetics, environmental/situational factors, family history of addiction, peer influence, early use of substances, and expectancies of the effects of the substance. During periods of abstinence, individuals must engage in cognitive and behavioral coping activities that lead to successful behavior change. Along the way, they are likely to face situations that put them at risk for relapse. High risk situations that become triggers for relapse are at the center of the cognitive-behavioral model of relapse.

The most recent refinement to this model emphasizes that relapse processes are interactive, dynamic, and nonlinear. They also define two sets of processes that contribute to relapse. More stable (called tonic) processes encompass risks for relapse that include background factors like genetics, social support, and dependence; cognitive processes include global self-efficacy, outcome expectancies, craving and motivation; as well as physical withdrawal. More immediate processes (called phasic) processes include the individual’s affective states and coping behaviors (including cognitive/behavioral strategies and self-regulation). The more stable tonic processes determine one’s vulnerability for relapse, but the more immediate phasic responses determine how and when that happens.

Research has elucidated several experiences that lead to relapse, which have been incorporated into the cognitive-behavioral relapse model. Cummings et al. found that the most frequently reported precipitants of relapse included negative emotional state (35% of relapses), social pressure (20%), interpersonal conflict (16%), and urges and temptations (9%). Factor analysis of the Reason for Drinking Questionnaire revealed three major factors that differentiated the types of relapses people experienced: (1) negative emotions, (2) social pressure and positive emotions with others, and (3) temptation and craving.

According to the cognitive-behavioral relapse model, individuals who use effective coping responses and have high self-efficacy are less likely to relapse. Moreover, successful use of this coping behavior increases self-efficacy, which should reduce the probability of subsequent relapse in similar high-risk situations. If an individual fails to use effective coping behaviors, the lure of the substances will increase while self-efficacy to abstain decreases, thereby escalating the likelihood that the individual will use the substance in that particular situation. Guilt and low self-esteem can occur if the substance is used during this period of abstinence. These feelings can propel an individual from the initial use of alcohol, often termed a “lapse,” into a full-blown relapse.

Marlatt and Gordon describe the onset of guilt and lowered self-efficacy as a possible effect of a lapse from an initial goal of abstinence. They label this reaction the Abstinence Violation Effect. This reaction is related to the individual’s causal attribution for the slip. For example, when drinkers attribute the lapse to their own personal failure, they tend to experience guilt and negative emotions that can lead to increased drinking in an attempt to avoid or escape those feelings. When people attribute the lapse to stable, global factors that are beyond their control, they are more likely to avoid a full-blown relapse. A subsequent relapse is more likely for persons who attribute the lapse to a personal inability to cope with high-risk situations. It is the individuals who are able to learn from the mistake and avoid future relapses that are better able to develop effective coping skills to deal with triggers. Of interest, research has found that contrary to the proposed inevitable loss of control that occurs after a lapse, some people are able to slip or engage in a first use and then regain control. If an individual is able to reinstate abstinence after a slip, they have achieved a prolapse or positive lapse experience.

Review of Relapse Prevention and Substance Abuse Studies

Since the advent of a focus on relapse and maintenance and, in particular, the response to the detailed, conceptual perspective of the Relapse Prevention Model, interventions designed to prevent relapse have been developed as clinical applications of Marlatt and Gordon’s model. The conceptual foundations of this model and a review of its applications have been updated by Marlatt and Donovan and Hendershot and colleagues. These interventions are designed to enhance the maintenance stage tasks of sustaining and integrating change into the person’s lifestyle and emphasize self-management and coping skills in order to withstand the challenges presented by relapse precipitants. The goals of relapse prevention are twofold: to prevent an initial lapse and to provide lapse management to prevent a complete relapse if a lapse does occur. Most controlled studies that administered relapse prevention treatment measured outcome success based on the goal of abstinence, although treatment goals based on harm reduction and decreasing substance use have also been attempted.

The effectiveness of relapse prevention as an intervention has been reviewed for different substances and compared to a number of alternative interventions. Relapse prevention programs have been designed specifically for smoking, alcohol, marijuana, cocaine, and other drug use. Although early reviews concluded that there was little evidence for differential effectiveness of relapse prevention across classes of substance abuse, later reviews found some support for the greater effectiveness of relapse prevention when applied to alcohol or polydrug use disorders in combination with medication treatment.

In terms of comparative efficacy, relapse prevention has been found to be superior to no-treatment control groups, and equally as effective as other treatments, such as supportive therapy, social support groups, and interpersonal psychotherapy. Another review found that relapse prevention has a greater impact on improving psychosocial functioning than on reducing substance use. In addition, relapse prevention was more effective when combined with the use of prescribed medication. Although results were based on a small number of studies and should be interpreted with caution, Irvin et al. concluded that individual, group, and marital modalities were equally effective in preventing relapse in cohorts of substance abusers. What follows is a brief review of the literature on the efficacy and use of relapse- prevention strategies with different types of addictive behaviors. A detailed presentation of the standard elements is included in the section entitled “Strategies for Relapse Prevention.”

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