Menon, J., & Kandasamy, A. (2018). Relapse Prevention. Indian Journal of Psychiatry, 60, 473-478.
Introduction
Addiction is conceptualised as a chronic relapsing brain disorder. Miller and Hester reviewed more than 500 alcoholism outcome studies and reported that more than 75% of subjects relapsed within 1 year of treatment1. A study published by Hunt and colleagues demonstrated that nicotine, heroin, and alcohol produced highly similar rates of relapse over a one-year period, in the range of 80-95%. A significant proportion (40–80%) of patients receiving treatment for alcohol use disorders have at least one drink, a “lapse,” within the first year of after treatment, whereas around 20% of patients return to pre-treatment levels of alcohol use. Relapse prevention is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours.
The initial transgression of problem behaviour after a quit attempt is defined as a “lapse”, which could eventually lead to continued transgressions to a level that is similar to before quitting and is defined as a ‘relapse’. Another possible outcome of a lapse is that the client may manage to abstain and thus continue to go forward in the path of positive change, ‘prolapse’. Many researchers define relapse as a process rather than as a discrete event and thus attempt to characterize the factors contributing to relapse.
Relapse prevention (RP) is a cognitive– behavioural approach with the goal of identifying and addressing high-risk situations for relapse and assisting individuals in maintaining desired behavioural changes. RP has two specific aims:
- Preventing an initial lapse and maintaining abstinence or harm reduction treatment goals
- Providing lapse management if a lapse occurs such that further relapses can be prevented
Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies. The assumption of RP is that it is problematic to expect that the effects of a treatment that is designed to moderate or eliminate an undesirable behaviour will endure beyond the termination of that treatment. Further, there are reasons to presume a problem will re-emerge on returning to the old environment that elicited and maintained the problem behaviour; for instance, forgetting the skills, techniques, and information taught during therapy; and decreased motivation.
Cognitive Behavioural Model of Relapse
A high-risk situation is defined as a circumstance in which an individual's attempt to refrain from a particular behaviour is threatened. They often arise without warning. While analysing high-risk situations the client is asked to generate a list of situations that are low-risk, and to determine what aspects of those situations differentiate them from the high-risk situations. High-risk situations are determined by an analysis of previous lapses and by reports of situations in which the client feels or felt “tempted.” Appropriate responses are those behaviours that lead to avoidance of high-risk situations, or behaviours that foster adaptive responses. Seemingly irrelevant decisions (SIDs) are those behaviours that are early in the path of decisions that place the client in a high-risk situation. For example, if the client understands that using alcohol in the daytime triggers a binge, agreeing for a meeting in the afternoon in a restaurant that serves alcohol would be a SID
A number of less obvious factors also influence the relapse process. These covert accidents lifestyle factors, such as overall stress level, one's temperament and personality, as well as cognitive factors. These may serve to set up a relapse, for example, using rationalization, denial, or a desire for immediate gratification. Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse. It involves the degree of balance in the person's life between perceived external demands and internally fulfilling or enjoyable activities. Urges and cravings precipitated by psychological or environmental stimuli are also important.
Another factor that may occur is the ‘Problem of Immediate Gratification’ where the client settles for shorter positive outcomes and does not consider larger long term adverse consequences when they lapse. This can be worked on by creating a decisional matrix where the pros and cons of continuing the behaviour versus abstaining are written down within both shorter and longer time frames and the therapist helps the client to identify unrealistic outcome expectancies.
Marlatt, based on clinical data, describes categories of relapse determinants which help in developing a detailed taxonomy of high-risk situations. These components include both interpersonal influences by other individuals or social networks, and intrapersonal factors in which the person's response is physical or psychological.
Relapse Determinants
These can be classified as intrapersonal or interpersonal.
Intrapersonal determinants
- Self-efficacy
Self-efficacy is defined as the degree to which an individual feels confident and capable of performing certain behaviour in a specific situational context5. The RP model proposes that at the cessation of a habit, a client feels self-efficacious with regard to the unwanted behaviour and that this perception of self-efficacy stems from learned and practiced skills. The relationship between self-efficacy and relapse is possibly bidirectional, meaning that individuals who are more successful report greater self-efficacy and individuals who have lapsed report lower self-efficacy.
- Outcome Expectancies
Outcome expectancies can be defined as an individual's anticipation or belief of the effects of a behaviour on future experience. The expected drug effects do not necessarily correspond with the actual effects experienced after consumption. Both negative and positive expectancies are related to relapse, with negative expectancies being protective against relapse and positive expectancies being a risk factor for relapse. Those who drink the most tend to have higher expectations regarding the positive effects of alcohol9. In high-risk situations, the person expects alcohol to help him or her cope with negative emotions or conflict (e.g., when drinking serves as “self-medication”). Expectancies are the result of both direct and indirect (e.g., perception of the drug from peers and media) experiences.
- Emotional States
According to this affective model of drug motivation, excessive substance use is motivated by affective regulation, both positive and negative. Studies with alcohol-dependent patients have shown that on-going depression increases the risk of relapse during and after treatment, and sudden increases in negative affect have been shown to immediately precede nicotine relapse. In one study, alcoholic beverage presentation and negative affect imagery led to increased subjective reporting of desire to drink and predicted time to relapse after inpatient discharge. Negative mood states associated with relapse include anger, loneliness, boredom, fatigue (Daley et al., 2011).
- Craving
Craving has been described as a cognitive experience focused on the desire to use a substance and is often related to the expectancies for the desired effect of the drug, whereas urge has been defined as the behavioural intention to use a substance. Craving can be aroused either by interoceptive or exteroceptive cues, environmental situations associated with prior heavy drinking, or with the psychological and physical effects of prior withdrawal experiences. While craving may initiate drinking, relapse is facilitated through the complementary phenomenon of loss of control, a behavioural state characterized by the relative inability to respond to either internal or external cues which regulate alcohol consumption.
- Interpersonal determinants
Positive social support is highly predictive of long-term abstinence rates across several addictive behaviours. Among social variables, the degree of social support available from the most supportive person in the network may be the best predictor of reducing drinking, and the number of supportive relationships also strongly predicts abstinence. Further, the more non-drinking friends a person with an AUD has, the better outcomes tend to be. Negative social support in the form of interpersonal conflict and social pressure to use substances has been related to an increased risk for relapse. Social pressure may be experienced directly, such as peers trying to convince a person to use, or indirectly through modelling (e.g. a friend ordering a drink at dinner) and/or cue exposure.
While many families can find addiction difficult to deal with, negative family behaviours such as withdrawing from a family member with a substance use disorder or avoiding dealing with the substance use is actually associated with more drinking. In addition to familial, marital, friend, and co-worker relations, research also suggests that community-based support services, such as recovery communities, enhance outcomes for those struggling with cessation once treatment has been completed.
References
Daley, D.C., Marlatt. G. A., & Douaihy, A. (2011). Relapse Prevention. Lowinson and Ruiz’s Substance Abuse.
