Relapse – Can it be avoided?
Relapse – Can it be avoided?
I observe so many people who suffer with addictive disorders and eating disorders successfully complete their treatment, only to leave and at some point relapse. I believe that both good treatment and aftercare is necessary for the maintenance of recovery. However, it seems that during the treatment episode not enough time is given to the individual regarding relapse prevention. I believe that every person is different, and therefore needs tailor made relapse prevention plans that are realistic and therefore effective. I also believe that this needs to consist of a spiritual framework.
I particularly like the Cognitive-Behavioural Model of Relapse.
The Relapse Prevention Model (RPM) proposed by Marlatt and Gordon (1985) aims to address the problem of relapse and suggests that both “immediate determinants” (high risk situations, negative emotional states, outcome expectancies, coping skills and the abstinent violation effect), and “covert antecedents” (life style factors, urges and cravings) can contribute to relapse. That, three quarters of relapse are due to negative emotional states, interpersonal conflict and social pressure. This RPM suggests that a relapse is a complex process that develops over time. This gives a wider framework for identifying warning signs and making earlier interventions in order to prevent a relapse. The RPM has two main goals. The first is to identify the individual’s high-risk situation, and to help enhance skills for coping with those situations that can result in an increase in their own self-efficacy. The second is to help individuals who do lapse with coping strategies so that the lapse does not develop in to a full-blown relapse.
Immediate Determinants of relapse
High Risk Situations
A high-risk situation is defined as any situation that poses a threat to the individual’s sense of control (self-efficacy) and increases the risk of potential relapse. The RPM (1985) suggests that high-risk situations can often cause a person who has achieved abstinence to relapse. This model suggests that once a person has achieved abstinence their self-efficacy will increase helping them to maintain their change. Dangerous situations or places can be difficult for the person and may trigger specific stimuli and memory that can increase cravings and result in relapse. Overcoming addiction is linked to the individual’s beliefs that he/she can do the necessary actions to achieve or maintain abstinence. Self-efficacy is the level of a person’s confidence in their abilities to achieve their goals. Research has shown that higher levels of self-efficacy are predictive in improved alcoholism treatment outcomes (Annis & Davis 1988). If an individual has low self-efficacy and confidence in the high-risk situation it may result in relapse (Bandurra & Adams 1977). The cognitive process of whether to continue to use the substance is then determined by the individual’s outcome expectancy for the effects of the substance use.
Numerous other studies (Greenfield, Hufford, Vagge, Muenz, Costello & Weiss 2000) have also showed that self-efficacy was an important factor in maintaining abstinence.
Emotional States
Marlatt and Gordon’s (1980) original study of relapse episodes showed that negative emotional states such as anger, anxiety, depression, boredom, and loneliness were the strongest predictors of relapse. These feelings are also known as intrapersonal high-risk situations, factors that do not involve other people. 37% of this study sample reported that negative effects were the primary relapse trigger. These emotional states may be caused by a person’s perception of a certain situation (e.g., feeling lonely when they are at home alone).
Situations that involve another person or group, resulting in arguments or conflict are referred to as interpersonal high-risk situations. These situations can also result in negative emotions that can precipitate relapse. Both intrapersonal negative emotional states and interpersonal conflict situations were triggers for more than half of all relapse episodes in Marlatt’s 1978 study. There have been numerous studies (Brandon, Tiffany, Obremski, & Baker, 1990) that have shown that there is a strong link between negative effect and relapse. Additionally, positive emotional states (e.g. celebrations) were also identified as high-risk situations that could precipitate relapse. Another study of factors of relapse (McKay, Merikkle, Mulvaney, Weiss & Koppenhaver 2001) showed that 62.1% of cocaine addicts reported loneliness, 55.8% reported depression, 55.8% reported tension, 40% reported anger on the day of relapse, 37.9% reported feeling good and 37.9% reported feeling excited.
Outcome Expectancies
Outcome expectancies are the imagined effects that an individual expects will happen when drugs or alcohol have been consumed. Research (Connors, Tarbox & Faillace 1993) has shown that individuals in treatment who have positive outcome expectancies for e.g. ‘a drink would be relaxing’ are linked with poorer treatment outcomes than individuals with negative outcome expectancies for e.g. ‘I will be discharged from treatment’ (Jones & McMahon 1996). A person may feel that if they use a substance or behaviour he/she will feel more relaxed, happier and outgoing. The actual reality may be increased stress, anxiety, sadness and anger. Positive expectations may cause the individual to consume alcohol, while negative expectations may provide motivation to abstain from alcohol (Cox & Klinger1988). Research (Carey 1995) among college students have shown that those who drink the most tend to have higher expectations of the positive effects of alcohol, and may think about only the immediate effects while disregarding the potential negative consequences.
Marlatt and Gordon (1984) suggest that all addicts have several stimuli (cues) for their addictive behaviour. If the person in recovery comes in to contact with a cue he/she may be at higher risk to relapse. This cognitive process, whereby, the cue can trigger positive outcome expectancies can then motivate the person to use a substance. Studies (Connors, Tarbox & Faillace 1993) have shown that positive outcome expectancies are associated with poorer treatment outcomes while negative outcome expectancies are associated with improved treatment outcomes (Jones & McMahon 1996).
Abstinence Violation Effect
If a person in twelve steps based treatment or in recovery consumed alcohol or a drug, the person may feel anger, guilt and shame and that they have failed or ‘blown it’. These feelings along with the acceptance of the disease concept could develop in to a full-blown relapse, which is known as the ‘Abstinent Violation Effect’. If the same individual learns to view a lapse as external and controllable then the person’s lapse may not develop in to a full-blown relapse. If the individual makes the lapse or relapse a learning experience, their awareness of their warning signs and coping strategies could lead to more effective coping responses in the future. A study by Collins & Lapp (1991) proved the ‘abstinent violation effect’ was an important factor in predicting relapse in alcoholics.
Social Support
Social support can provide a sense of belonging, identity and being connected to people. It can help a person to feel cared for, loved and valued which can increase self-esteem. The addict/alcoholic’s thinking may be distorted or irrational and by receiving honest feedback from friends can help the person to change their thoughts and behaviour.
“People are adapted and motivated to belong in groups, that people need strong, stable relationships with other people.” Alcoholics Anonymous (AA) was formed in 1935 by two men struggling to remain sober. The idea of helping each other to stay sober originated from AA’s founding members called Bill Wilson and Bob Smith. From their friendship and support for each other came the AA philosophy that one member can be of help to another during periods of stress. An AA meeting is a place where a group of alcoholics meet to share their experience, strength and hope to enable them to abstain from alcohol. The core of the AA programme involves the twelve steps. These are intended to act as a personal guide to recovery and the twelve traditions act as the guiding principles. AA describes addiction as a spiritual disease and suggests that spirituality is a vital part of recovery. The acceptance of ‘Powerlessness’ and ‘Unmanageability’ as outlined in the first step is considered to be the foundation of recovery (Alcoholics Anonymous 2001).
Individuals with long attendance at Narcotics Anonymous meetings tended to have lower trait anxiety and higher self esteem scores (Christo & Sutton 1994). Meeting attendance is thought to be beneficial for a variety of reasons. Attending Narcotics Anonymous is associated with a range of good outcomes and some of those benefits for addicts/alcoholics are: – new associates and friends for aiding the goal of abstinence, improved confidence and self esteem, the opportunity for spiritual development, role modelling, sponsorship and “the therapeutic value of one addict helping another is without parallel” (Narcotics Anonymous Basic Text 1988). Positive social support predicts long-term abstinence across a range of addictive behaviours.
On contrast, negative social support such as peer pressure to use chemicals or/and interpersonal conflict has been linked to increased risk for relapse. Social pressure to use a substance both verbally direct and indirect led to more than twenty per cent of relapse episodes in Marlatt’s (1996) study.
Covert Antecedents
Cravings
Marlatt and Donovan (2005) have defined an urge as “the behavioural intention or impulse to consume alcohol or drugs,” and a craving as “the subjective desire to experience an addictive substance.” The same processes may mediate both urges and cravings. The two processes are conditioning and positive expectancies. Cravings can lead to obsessive thoughts of the addictive behavior or substance. The experience of craving can be understood by which a person is obsessed. The individual can then feel driven to obtain and use their behavior/substance.
Lifestyle factors
A person in recovery needs to have a balanced lifestyle between what they feel they ‘should’ be doing and enjoyable activities that they want to do. If a person in recovery is only doing what they feel they ‘should’ be doing can generate stress and negative emotional states. If this behaviour continues a person could be at a higher risk of relapse and may begin to rationalize their potential lapse (e.g. ‘I deserve a drink’).
Relapse
Originally, the term relapse derived from the medical model, indicating a return to a disease state after a period of remission. There are two main definitions of relapse. One suggests that a relapse is “a recurrence of symptoms of a disease state after a period of improvement” (Webster’s New Collegeiate Dictionary 1983) which refers to an outcome with the view that a person is either well or ill. The second definition is “a breakdown or setback in a person’s attempt to change or modify any target behaviour” (Marlatt & Gordon 1985). This refers to a relapse being a process. Marlatt and Gordon (1985) suggest that a lapse may best describe this process. One definition of lapse is a “slight error or slip” (Webster’s New Collegiate Dictionary 1985). A lapse can be a single event that may or may not develop in to a full-blown relapse. If a person addressed the lapse immediately they may still have some control in their situation and could prevent a relapse (Marlatt & Gordon 1985).
Daley (1987) suggests that a relapse is a process and not an event and that there are indicators that take place prior to the relapse itself. When a person attempts to change a problematic behaviour a lapse is likely to happen. The person may then return to their problematic behaviour (relapse) or they may stop and continue with their recovery.
Many individuals relapse following a period of drug/alcohol treatment. Studies (Simpson, Joe & Lehman 1986) have shown that 54% of alcohol and drug abuse individuals can be expected to relapse, 61% will have multiple episodes of relapse and 47% will relapse in the first year after treatment. Although many individuals do relapse, it can be prevented. A factor in preventing relapse is improved social adjustment and the identification of warning signs and coping strategies. For an individual leaving treatment following discharge, the person may be vulnerable to a potential relapse back to their addictive disorder and 90% of individuals do not change their behaviour on their first attempt (Witkiewitz & Marlatt 2004). Marlatt and Gordon (1985) highlighted similar relapse factors in many addictions.
Other studies (Hunt, Barnett & Branch 1971) have also demonstrated that there was a similarity between the relapse rates of alcohol, heroin and smoking. This highlights the need for a therapeutic environment so that, an individual, throughout this period of heightened vulnerability can be supported through the stages of change (Prochaska & Diclemente 1984).
Relapse and Spirituality
By the time an individual seeks recovery, their living skills and ability to meet even their basic human needs may be impaired. They may be unable to comprehend or consider higher states of consciousness. Behaviors and thoughts such as self will, control, resentment, arrogance and self-pity are often present in a person seeking recovery. Gorski (2001) suggests that there is a relationship between spirituality and relapse. An individual may relapse because of their shame and guilt and so do not believe in a higher power being open to them or because they cannot find a higher power to believe in. A person who presents with grandiosity may see themselves as superior and of higher intellect than anyone, and when faced with problems may be cut of from sources of courage, strength and hope.
It therefore follows that in order to maintain recovery; an individual would be best placed to succeed if the relapse prevention plan is tailored to the individual. Along with an understanding and willingness to change the negative character traits that are present. Well-being is likely to be facilitated by a commitment to operating in a less self-seeking, more ‘spiritual’ way. Long-term recovery is likely to be less fraught and more manageable if acceptance, forgiveness, humility and gratitude are present.
