CHAPTER-V

RELAPSE PHENOMENON, ITS CORRELATIONAL

MATRIX AND CURE*

Introduction

.The Webster's New Collegiate Dictionary (1983)_ defines 'relapse as a

~ecurrence of symptoms of a disease after a period of improvement.

Relapse is thus seen as an end- state the end of the road, the dead

end. According to some traditional theorists, relapse is the result of

"negative forces" that overpower the individual who has lost touch

with the protective influence of a ''higher power". Relapse thus

seems to be the result of a battle between one's ''higher power" and

unconscious negative forces emanating from kind of ''lower pov,'er"

(the Devil himself). Another alternative approach I definition

reflected as the second definition in Webster's is "Relapse is the act

or instance of backsliding, worsening, or subsiding (1993). It is best

defined as a return to drini:J.Lg or drugs after an intervening period

of abstinence. In the Relapse Prevention approach, relapse is viewed

as a transitional process, a series of events that may or may not be

followed by a return to baseline levels of the target behaviour. It

The material presented in this chapter is drawn from: our

own observations during the course of our field work in Delhi, and

also from a host of other sources, which are cited in the text.

2~2

views the occurrence of a lapse as a fork in the road, with one path

returning to the former problem level (relapse or total collapse) and

the other continuing in the direction of positive change.

Relapse is a critical issue often misunderstood even by the

professionals in the field of addiction treatment. Relapse is very ~

common among chemically- -dependent people. It can, and does

occur. It is a part of the disease of chemical dependence. Most of the

drug-dependent people are not able to recover inspite of their best

efforts. Treatment professionals also stand by, totally helpless,

because they feel guilty or angry that their treatment and

prevention Counselling (anticipatory guidance) have not been

successful.

Normally, relapse is understood as the act of taking a drink or a

drug after a period of abstinence, following treatment. Actually, it is

neither the mere EVENT of using the chemical nor the act of taking

alcohol or a drug after a period of abstinence. It begins much earlier.

Relapse is a PROCESS that creates, in stages, an overwhelming

need for the use of the chemical. This PROCESS is called 'Relapse

dynamic'. Chemical dependency, as a disease, has two sharp edges.

The first edge attacks the person while he is using the chemical.

While the patient gets addicted to the chemical and continues to use

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it, he faces unmanageable problems in many areas of his life. This is

the most easily noticeable and obvious part of the disease. The other

edge is that part of the disease, which attacks the person when; he is

struggling to recover. In other words, once the chemically dependent

person abstains from the drug, he may initially face several

problems. A strange set of physical and psychological d.l'ives becomes \

activated. The victims lose control over their thought process,

judgement and emotional reactions. Even though these conditions

are common during recovery and will disappear in course of time,

the chemically dependent person is unaware of it and is, therefore,

susceptible to it. At this stage, with proper support and help, he/she

will be able to cope with the Rituation. When this does not happen,

the addicts either go back to the chemical or in case they are

determined not to use the drug, acute mental stress may drive them

to attempt suicide. In fact, this abstinence-based edge can also be as

sharp and destructive as the chemical based edge.

What is Relapse?

A relapse always occurs following a slip or when a lapse is not

managed then it will result in the abstinence violation effect (AVE).

This effect creates intense anxiety, great confusion, profound guilt,

decreased self-esteem, embarrassment and a sense of shame. These

powerful negative states head to a words belief pattern of non-

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control and resumption of abusive patterns in order to manage the

negative emotional states occur prior to the violation and these

occurring because of strong social situation in which the recovering

addict finds himself/herself after treatment. The experience of a

relapse is to be seen in this broader context and not simply as the

lack of ex-addict's lack of determination to abstain even after ~ ~

treatment. '

We cannot understand the relapse phenomenon without including

social and economic factors, environmental factors and the

importance of significant individuals around the addict in the

development of aparticular abuse pattern.

A relapse or an uncontrolled return to drug or alcohol-use following

competent treatment is one of the greatest problem drug addicts and

the people who are involved in treatment and rehabilitation of

addicts face. Drug-dependency can be seen as the important factor

for relapse to occur, the duration of C1e drug-taking, the type of

substance abused during the period have to be seen to find out how

has the dependency rate increased and why the addict now feels

inclined to the substance-abuse all the more after the treatment.

Drug dependency can be purely physiological or can be purely

psychological, and it can be overlapping also.

245

The present work is supposed to explore as to why even after

treatment in the drug de-addiction centre or in hospital where

detoxification is the only method of treatment, the addict is not able

to recover from his I her habit. The problem of relapse has not

received sufficient attention. The focus of this study is more on

learning about relapse prevention; which are the most obvious goals

of drug-abuse treatment, counselling, and rehabilitation as well as

after-care services.

The kind of treatment, the nature of the treatment process, the

duration of treatment are very important factors which hav.e a direct

bearing on Relapse. Should the period of treatment be different for

different drugs used, or should it differ according to different age-

groups; should treatment programmes cater to different social

backgrounds or . should a homogeneous treatment package · be

offered? These are the questions for which people involved in

therapy and treatment find no one answers. Relapse prevention is

not a simple process.

Relapse is a phenomenon by itself and in itself and it reqmres

different techniques and approaches for exploration. The pattern of

drug-abuse, the qualitative and quantitative changes because of

multiple dl·ug-abuse along with cigarette and alcohol makes relapse

246

even more difficult to understand. Any addict initially begins with

one particular drug; he I she may continue with the same substance

or change the type of the drug itself, or increase the quantity or even

decrease the quantity, of one and increase the quantity of the other.

These variations in the pattern of drug-abuse are very interesting

and ··have to be recorded for every individual addict who has been \ \

abusing drugs for a period of time and after tre'atment that has a

relapse now.

Drug addiction is a compulsive habit, a physiological need or the

derivation of psychological satisfaction we will not be able to

conclude because drug addiction is not plainly any one of these. It is

only a combination of all the three even the doctors (clinical and

psychotherapists), counsellors and anti-drug therapists have given

special opinion on these matters through experience and interaction

with drug addicts. Relapse is not a complete failur-e on the part of

drug-addicts, or the entire t.reatment programme. Relapse is the

experience of an addict, which the addict and the people helping him

cannot avoid. Relapse is a reality and it can happen with every

addict, Relapses are often fatal also and all addicts are subject to

theoretical possibility of relapse. Relapse does not occur because of

any accident, we cannot pinpoint the reason in particular, but we

can say that the addict during treatment is given a choice to abstain

247

from drug, but if he I she does not or has not exercised his I her

choice of abstaining, then we cannot blame the treatment

programme as inefficient, or the duration of the treatment period as

in sufficient. Relapse can be a combination of various factors and it

also very much depends upon the reaction of the addict to the kind

of treatmemt given or voluntarily taken. Therefore, any ··addict who \ \

has undergone treatment in any de-addiction centre ·or undergone

detoxification for a short period of time has all the potentialities to

relapse. We cannot say that treatment for addicts is the only cure to

drug abuse. Treatment is not final, continuation of the treatment,

care and rehabilitation are also part of recovery for the addict. The

co-operation from the addict, his I her family members all determine

whether he I she will relapse or not. We cannot become pessimistic

about ev€ry treatment and rehabilitation; yet we cannot take it for

granted that relapse will not occur, however ? efficient

the treatment may be.

Relapsed addicts have already oriented themselves to de-learn their

psychological desire to take to drugs or alcohol, or at least as part of

treatment they were taught or trained how to adopt preventive

techniques in order to abstain from drugs, but they have relearnt to

go back to drugs. Relapse cannot be just a technical understanding

of going back to drugs. Recovery from addiction is not an overnight

248

process; to abstain from (!rugs completely reqmres not just

avoidance of taking drugs, but it also require changes in the attitude

of addict, his self-perception and the perception of the other.

The perception of the "self' and the "other" is very important for our

understanding of the relapse. From the desire not to take drugs and '\

the desire to take drugs-both can be understood studying the

relapsed addicts. We can see that thos·e who have relapsed

sometimes express their helplessness in going back to drugs, and at

the same time they are not confident about giving up drugs. Drug-

abuse can affect the individual to such an extent that his self-

perception and the perceptions about society-everything are

determined by the availability of drugs and its non-availability.

Drugs start controlling their attitude and recovery is not simply

abstinence from drugs. 1

Treatment and Recovery are continuous processes and relapse is

part of this process. The progression of drug addiction is an on-going

process, even during abstinence. Relapse does not mean that the

1. A.G. Billings, Stressful Life Events and symptoms (Los Angels,

1987) PP. 99-101

249

addict one-day could not resist his temptation and has got involved

in taking drugs again; it is not so simple, relapse is both a conscious

decision and can also be a spontaneous decision. Inspite of being

aware that going back to drugs can cause his dependency to

increase, the addict still takes to drugs again. At the same time, \

his treatment need not completely c,ome to a standstill with relapse.

Relapse is a part of the treatment. Relapse ·can lead to guilt, can

embarrass the addict, still the addict does not stop thinking that he

really wants to go back to it or should overcome his temptation.

Most of the addicts do not have a clear relapse, they become dl·ifters

and continue to take drugs, and they also undergo treatment, such

cases also become very difficult to analyse and understand.

Recovery from drugs or relapse into drugs should not be seen as

separately. They are part of the same process. The individual's

perception of himself I herself before treatment, after treatment,

short period of recovering and relapse all matters. The perception of

the individual towards the social milieu in which he I she is

studying, working or living, also changes during his I her taking

drugs, during his I her treatment and during his I her relapse.

Relapse is also a process with a history and a future and because of

this we have to be conscious about other dimensions of relapse.

250

Relapse need not necessarily happen immediately after treatment.

Relapse occurs when the addict consciously goes back to taking

drugs like he used to when he initially started the substance abuse.

There are stages, which the addict could go through before he

relapses completely, but there are cases where the relapse can be

straight and sudden also. The different stages, which the addict

experiences are unique and distinct, and we can examine these to

understand how relapse occurs finally.

There is a stage of "contemplation" where the addict thinks about

treatment, then a stage of "action" when he enquires about the

treatment centre, and the treatment methods. The next stage can be

the stage of "determination" where he decides to cooperate for

treatment. During all these stages, he needs constant counselling

and direction, which can sustain his determination. He then moves

into the stage of treatment itself during which he I she again goes

through different experiences depending upon the substance abuse.

Mter the treatment he I she cannot maintain his I her determination

in many cases because he I she gets exposed to an environment

which is not conducive to perpetuate abstinence from drugs, or to a

social milieu which might not accept him I her, due to various other

external pressures, his urge to take to drugs re-emerges and he can

have 'slip' or a lapse. This is just abusing a drug not constantly, but

251

at the same time not keeping completely away from it. This stage of

a slip or a slight lapse after treatment is very crucial because at this

stage, the addict has not relapsed or for that matter he is still

undergoing the treatment.

He can either go back to the same stage of" contemplation" in which

he started i.e. to think about complete abstinence or, he can move

directly into the stage of complete relapse where the return to the

stage of contemplation about treatment is not immediate. Rather, it

takes a long period because the addiction-urge has been rekindled

and to contemplate about another phase of treatment will not be \

immediate. Relapse, therefore, occurs when the addict after a

period of abstinence returns back to drugs completely. However, till

now it has been observed that Relapse process is part and parcel of

treatment.

However to prevent relapse, no definite strategy can be improved,

but after treatment, in order to maintain his I her determination to

abstain drugs, the appropriate rehabilitation and training after

treatment can be the effective support system for the addict who is

out of treatment. Mter exit-treatment, the addict instead of directly

coming in contact with the social environment, can undergo a

training or a vocational programme in which he /she can acqmre

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some skills to perform some kind of craft or a job. This can keep him

busy and can provide him economic sustenance also.

Generally, many of the addicts who come for treatment lack any

significant economic support or resource, and even when they have,

they are not able to work their way well; so there is a gap and ' '

especially after treatment the gap gets widened. In many cases we

have 'seen that the work place can either be very congenial for the

addict to have a relapse, or it can be such that the colleagues or the

employer do not provide him I her any direct or indirect opportunity

to consume drugs in the organisation. So, these are the factors,

which can make him more vulnerable to pressure, frustration,

loneliness, anxiety, fear, and finally produce relapse, which can also

be a sign of rebellion.

After treatment, the addict cannot easily adapt to the surroundings,

his perception towards others has changed, but others' perception

about him 'being an addict' remains the same. The ex-addict then

reacts to this gap between the two states by getting into relapse.

The rehabilitation is the transitional phase where the addict can

train himself to face the society outside, especially, after a long

period of treatment where he is protected and cared for. He does not

253

want to face the world, which does not have anything to offer him.

Rehabilitation is also a part of treatment and in this phase, the

recovering addict selects the particular training, which he wants to

do and which is offered by the rehabilitation, centres. During this

period he is given consistent counselling and he is prepared and

trained by therapists to be courageou~,-, and to accept the world as it

is. Motivational orientation, family counselling, group counselling,

leadership training, vocational training, training in counselling,

training and education to prevent drug abuse needs to be provided

to the recovering addicts. 2

These kinds of exercises can surely enhance the abilities of the

addict and with the suitable kind of vocational training if he is able

to establish a support-system for himself then he I she surely is

moving towards a stage where relapse need not be considered as

inevitable. A relapse cannot be avoided, but a good support system

can prevent a relapse.

Rehabilitation does not begin and end with vocational training,

because there are other psychological and social factors, which can

2. M.R. Goldfried, Behavioural Change Through Self-control (New

York, 1993) PP. 55-59

254

be overpowering and inspite of resourceful economic sustenance, the

recovered addict, can have a relapse. So, rehabilitation programmes

have to cater to build a better human being out of the addict so as to

maintain his determination to abstain and recover completely.

Characteristics of Relapse

In order to understand what causes a relapse m a chemically

dependent person, we should understand abstinence and relapse in

their mutuality and totality. It is a process; Relapse is not an

event but a process. An event is something, which has already

happened and therefore cannot be changed; on the other hand, a

'process' refers to an ongoing situation that can be interrupted and

changed at a given point in time.

The process of relapse occurs within the patient

The attitude, values and thought processes of the individual form

the 'relapse-patterns'. These processes lie placed within the mind of

the patient.

Relapse shows itself in a progressive pattern of behaviour.

Others can notice the thought-processes of the chemically dependent

person through his behavioural responses. It shows itself in the way

the person acts reacts and responds.

255

It is preventable

During recovery, the patient feels an overwhelming need to go back

to the chemical. At that time, the counsellor should intervene, help

the patient and alter the course of events to reinforce and

strengthen the process of recovery. '

Since a relapse is not uncommon in patients once or even more than

once during different stages of recovery, relapse and recovery should

be seen to go' side by side'. In other words, relapse and recovery

should be seen as two sides of the same coin.

Thre-e distinct stages which indicate the onset of a relapse

Nearly everyone close to the chemically dependent person is able to

recognise the behavioural changes that indicate a return to the old

addictive way of thinking, responding and behaving. They will

notice three distinct stages in that process.

(i) There is a change at the thinking level.

The recovering person gets back· to his old thought pattern. For

example, he thinks constantly about the chemical, and the same old

morbid preoccupation starts.

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(ii) Changes in external setting or life style

The person starts relating again to the set of people, places and

activities that centre on chemical abuse.

For example, he visits places which encourage drug-taking, or meets

chemically dependent friends; visits bars and does not attend \

Alcoholics Anonymous I Narcotics Anonymous He is over-confident

that he will not be tempted to take drugs. He keeps reassuring

himself that his chemical dependency is absolutely under control.

(iii) Return to chemical abuse

The previously stated changes will definitely lead him back to the

same chemical or to other substitute drugs, which are addictive. 3 .

These stages indicate the possibility of the chemically dependent

person unconsciously heading toward a relapse. If the patient is

made aware of the problems he is likely to face during abstinence,

he will be able to identify them and consciously recognise the slow

onset of 'relapse dynamic' and take necessary steps as directed, to

cope with the situation. Such advice and counsel

---------------------------------------------------------------------------------------

3. P. Karoly & Others, From Theory to Practice: Self-Management

and Behaviour Change (New York, 1985) P. 45

257

should be provided to the patient though a specific relapse

prevention programme. This should preferably be communicated

periodically, before the patient actually faces the acute problems

related to abstinence.

Initial Problems Associated with Abstinence

During chemical dependency, the body becomes so accustomed to

the use of the particular chemical, that as soon as its intake is

stopped, severe withdrawal symptoms appear. This condition is

handled by medical treatment. Apart from physical problem, during

the process of staying away from the chemical, there is a marked

increase in physical stress, leading to discomfort and fear, a total

loss of control resulting in behavioural problems like agitation,

restlessness, lack of sleep, instability etc. This is to be handled

through Behavioural Management

Behavioural management needs personal and individual attention.

This includes listening to the· patient talk about the pain caused by

stress and anxiety, and helping him with stress management

techniques, relaxation exercises. etc. The most important thing is to

reassure the patient that the stress caused to him is natural and

normal and will definitely come to an end.

258

Prolonged Abstinence Syndrome(PAS)

After the initial stages of abstinence the patient will be beset with

several other problems- thought process impairment, emotional

process impairment, overreaction to stress or numbness to stress.

Thought process impairment shows itself in confusion, in a narrow,

rigid and repetitive thought-pattern, in a lack of concentration, and-

an inability to remember or to transfer short-term memory to long

term memory etc. The chemically dependent is not able to do things

properly, come to conclusions or solve problems. All these are due to

the long-term effects of the chemical and the body's inability to

adapt itself to its absence. All these will have to get stabilised with

the passage of time, proper nutrition and ongoing psychological

reinforcement.

Short-term memory impairment.

The chemically dependent person gets confused because he is unable

to remember things. He struggles against his inability to retain

information even for a short time. This makes him feel he is going

crazy. Every recovering addict should be educated during recovery

that in the long run he will definitely get back to normalcy. - that

this problem improves with continued abstinence, proper nutrition

and rest.

259

Emotional process impairment

This leads to overreaction stress. There is a very low stress tolerance

and the person gets agitated and becomes aggressive in no time.

Stress is intensified during post-abstinence, and the severity of

abstinence also creates stress. Such acute stress keeps driving the

chemically dependent person back to the drug. The chemical is able

to temporarily set right these· damages. If a person uses the

chemical, he will be able to think clearly for a little while, experience

normal emotions for a little while and feel healthy for a little while.

But the patient should be told that any relief he may drive through

use of drugs is very temporary and it will inevitably lead him back

to the old drug-related unmanageable problems. He has to be

constantly reassured that his low tolerance to stress will diminish

over a period of time.

State Dependent Learning

What a chemically dependent person has learnt while using drugs

cannot be recalled during the initial stages of recovery. What a

person, is best recalled in the same emotional state in which it was

learnt. During the initial stages of abstinence, he is not able to

perform tasks at the office with the same efficiency and skill with

which he used to. This leads to confusion, embarrassment and a

feeling of incompetence during abstinence. It is very important that

260

the patient is reassured that this is normal. This inability to

perform is short-lived. These skills can be re-learned if the patient

recognises and accepts the impairment and participates in a process

of structured skill learning. This learning involves use of both

mental rehearsal and actuai role-play exercise. These can be taught, "

and if practised, they become habitual and can be assembled into

total action. 4

Denial during abstinence

Denial is common in chemical dependency. It continues during

abstinence also. But here 'denial' takes on a different form. The

person denies the presence of any personal weakness or personal ·

problems. He denies the need for a change in his life-style. This

denial will block the recovery process and, therefore, must be broken

in a supportive and understanding manner.

Structured programme of recovery

The most important thing is that the patient himseWherself must

make a total commitment to a daily structured programme of

recovery with a whole-hearted attempt to relearn proper thought

4. M.J. Nilsson, Self-Control: Power to the Person (California, 1984)

PP. 84-89

261

patterns, expression of feelings and behavioural control that have

been affected due to an excessive chemical intake. The patient who

makes a commitment to set a daily structured programme of

recovery has an excellent chance of regaining capabilities and

thereby leading a normal life. Patients can be taught skills with ~ ·.

which they can identify their source of stress and solve their

problems. This will help in reducing stress.

The following are a few practical hints, which he can try and

practice while coping with the problems associated with abstinence:

Physical * Taking care of health

* Good eating habits with a high protein diet

* Relaxation exercises

* Regular sleep

Psychological *Building self-esteem

* Living by values

* Feeling good

Behavioural *Getting into a structured and planned activity

*Going to work on time

* Taking up responsibilities and managing them

Social * Relatinq with family and friends

* Taking on specific roles

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These adjustments require change - and all changes create stress.

With this awareness, stress can be minimised and overcome in

course of time.

Recovery Carries with it the Responsibility to Change

Personality Styles

The recovering addict i~ likely to develop any one of the three types

of personality styles mentioned below. These prevent him from

maintaining a successful recovery programme.

(i) Extremely independent person

Unable to accept any help, he always wants to face life all alone. He

is unable to accept the reality of his powerlessness.

(ii) Totally dependent person ·

Always dependent on others for everything, he does not recognise

any of his personal strengths. His reaction will always be "take care

of me or I will drink or go back to drugs".

(iii) Counter dependent person

He appears to be independent, but always depends on somebody

else. He feels terribly insecure. He wants to project himself as a

strong and confident person, but in reality he feels weak and totally

helpless. As stated above, all these three types are 'RELAPSE-

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PRONE'. 5 Recovery demands a FUNCTIONALLY INDEPENDENT

PERSONALITY, i.e. a person who

- recognises that he can function independently' but needs

others for a balanced life.

- recognises his strengths and abilities·. •.

- is willing to undertake the responsibility for his recovery.

- accepts help from the proper people and from a 'Higher

Power'

In order to recover, a person must develop a functionally

independent personality.

To sum up,

- Relapse is a process, not an event

- Relapse and recovery are two sides of the same coin.

- Some problems are associated \vith initial abstinence

- The problems associated with abstinence are short-lived and

can be overcome by proper structured planning and

implementation.

- Recovery demands change; and the change is definitely worth

the rewards.

5. G. A. Marlatt, Relapse Prevention: Self-Control programme for

the Treatment of Addictive Behaviours (New York 1982) PP. 109-

112

26-l

Staying Off

Many people can get off their dr·ug - whatever it is - for a few days,

a week, even a month or two. But inevitably, cravings, denial, and

addictive thinking return and- despite well-intentioned vows and

promises - these people somehow end·. up using drugs again. '

Staying off, it seems, is even more challenging than getting off.

Still, despite the high stakes of relapse and the fact that it is

preventable, the topic itself remains something of a taboo. Many

newly recovering people seem to think that if they let themselves

consider the possibility of relapse, it will become a self-fulfilling

prophecy. Even addiction treatment professionals have avoided

talking about relapse for fear of communicating an expectation of

failure.

Ironically, it is this mistaken notion - that relapse is synonymous

with failure- that contributes more than any other factor to high

relapse rates. Because relapse is viewed as something to be

ashamed of and treated as taboo subject matter, many people do

not learn how to recognise th.eir addictive attitudes and behaviours,

avoid high-risk situations, identify the warning signs of a relapse

and cut one short if it occurs. These skills are the essence of relapse

prevention.

265

The most important concept to understand to prevent relapse is

that abstinence is not synonymous with recovery. In the absence of

active, concrete prevention efforts, a tendency to relapse emerges

automatically. Why should p.ot it? When an addict stops 'using',

nothing insid.e has changed. The same 'pull' back to the adpj.ctive

substance - the compelling urge to anaesthetise feelings whe~ they

become too uncomfqrtable - is still going to be there. In other .

words, there is no 'standing still' in recovery. If addicts are not

moving away from the drug, they are automatically moving toward

it. It is like standing on a down escalator. If they just stand there,

they are going to go down, in this case back into addictive thinking

and behaviour. They have got to keep walking. upward to

counteract the escalator's- or addiction's downward pull.

The good news IS that with a conscientious relapse prevention

effort, chances of recovery from addiction - arresting the

compulsion and living a full, satisfying life- are very good. But as

with any illness, just getting the diagnosis is not enough. A person

will need to put his own effort into prescribed step in order to see

improvement, for recovery is active, not passive. In this chapter we

will present many of the tools for avoiding relapse that have

worked for others. But first, we shall try to segregate some myths

about relapse.

266

MYTHS ABOUT RELAPSE

Let's clear up some of the mistaken beliefs about relapse that

abounds and contribute to its high incidence.

MYTH# 1: Relapse is a sign of recovery failure.

FACT: Having a relapse is not a sign that you are a failure or that

your recovery is flawed. It simply means you have made a mistake,

which you can learn to avoid with greater awareness. Having a slip

can be compared to falling on ice. If you slip and fall once, it doesn't

mean that you are ''hopelessly clumsy" or doomed to fall all the

time; it means you need to take more precautions when walking on

1ce.

MYTH# 2: Relapse is a sign of poor motivation.

FACT: A tendency to relapse is a natural part of addictive disease,

and even people who are highly motivated and sincere about their

recovery can slip. No one is guaranteed a lifetime of total

abstinence simply by embarking on recovery.

MYTH# 3: Relapse starts the instant you "pick up".

FACT: Relapse begins long before you actually return to drug use.

A relapse starts when you "stuff' uncomfortable feelings or deny

stressful circumstances in your life, return to addictive thinking,

stop taking actions to cope effectively with problems, stop getting

267

support, use another mood-changer, put yourself in a high-risk

situation, and so OIL Picking up your drug is actually the end point

of the relapse, not the beginning.

MYTH # 4: Relaps~ is unpredictable and, therefore, unavoidable: lt

.. hits you out of the blue.

\

FACT: Since relapse begins well before you actually return to

use, there are many warning signs and chances to short-circuit the

process before it culminates in use. Having an addictive disease

means you have no control over its use once you re-expose yourself

to the drug, because you escalate rapidly out of control. But you do

have control over it in case you do not put yourself in situations in

which your vulnerability is raised, and that's where relapse

prevention comes in.

MYTH# 5: Relapse applies only to your drug of choice.

FACT: Use of any substance, activity, or person that you use to

anaesthetise your feelings is a relapse, whether you have had a

problem with that particular mood-changer in the past or not.

Other mood-changers such as money-gambling, sex or other drugs

can trigger cravings, lower your resistance to your drug of choice, or

become new addiction.

268

MYTH# 6: relapse cancels out all progress made up to that point.

FACT: Having a relapse does not mean that all progress is lost. If

you were abstinent for two months or two years before having a

slip, you still have that experience in recovery. Those months or

years don't cease to exist. A slip can be a temporary setback that "

ultimately serves as a reminder that you are still vulnerable. If you

return as quickly as possible to abstinence, recovery can continue.

MYTH# 7: If a relapse is not the end of recovery, then it is OK to

have one.

FACT: While a relapse is no reason to condemn yourself, it is

always dangerous. Relapse is a return to the insanity and

unnianageability of your addiction. Because of the progressive

nature of addiction; the negative consequences of a relapse can be

even more devastating than those prompted you to quit in the first

place. Some people never make it back.

Relapse Prevention Planning

Relapse tendencies are a normal and natural part of the recovery

process. However, clear and accurate thinking helps to overcome

relapse tendencies. Relapse and Recovery are closely related and a

chemically dependent cannot recover form addiction without

experiencing a tendency towards relapse. Recovery from chemical

269

dependency starts with the acceptance of the fact that the person

cannot safely use various drugs or any other mood-altering

chemicals. Abstinence from mood-altering drugs allows the recovery

process to begin. Total recovery, however, requires much more than

mere abstinence. It is necessary· to correct the physical,

psychological and social damages .caused by addiction. It is also

necessary to learn to live a healthy and pToductive life without

feeling the need for alcohol or other drugs.

Recovery from addiction goes through the following distinctly

defined stages

Developmental Period

1. Pre-treatment Recognition of addiction

2. Stabilisation Handling withdrawal

symptoms and

Crisis Management

• 3. Early Recovery Recovery from Post-Acute

Withdrawal

4. Middle Recovery Balance Living

5. Late Recovery Positive Personality Changes

6. Maintenance Growth and Development

270

One of the major problems in recovery from chemical dependency is

relapse or a return to alcohol or drug use after a period of abstinence

following treatment. The dependent must be made aware that

, relapse is a distinct possibility which could ha~pen to him. Recovery

from addiction is an ongoing process requiiing both abstinence from

mood-altering substances and a change in thinking patterns,

attitudes, behaviour and life-style.

There are certain specific problems experienced during abstinence.

When these abstinence-based problems become severe, the person

begins to become dysfunctional even though he is not using

chemicals. These episodes of dysfunctionality constitute the Relapse

Syndrome. When these symptoms of the Relapse Syndrome make

life pmnful, many chemical dependants choose to use drugs to gain

temporary relief from the pain. Some others do not drink I take

drugs; but develop serious problems related to the relapse

syndrome. 6 What are the problems experienced during the initial

stages of abstinence?

6. J. R. Kazdin, Detenninants of Relapse: Implications for the

maintenance of Behaviour Change (Michigan, 1994) PP. 82-85

271

The Relapse Syndrome

-Internal and external dysfunction

-Thought Process Impairment

- Emotional Process Impairment

- Problems with remembering things

_ .. High level of Stress

- Difficulty in sleeping restfully

- Difficulty with physical co-ordination

- Denial Returns

- Avoidance and Defensiveness

- Crisis Building

- Immobilisation

- Confusion and Over-reaction

- Loss of Control

- Depression

- Loss of Behavioural Control

- Recognition of Loss of Control

- Option Reduction

- Relapse Episode

Thus, relapse is not merely the act of taking a drink or using drugs.

It is a process or progression that creates an overwhelming need for

the use of alcohol or drugs.

272

What are the different stages in the progression of relapse?

The relapse progression goes through the following stages: -

Change

Stress

Denial

Post Acute Withdrawal

Behaviour Changes

Breakdown of one's place and placement in Social Structure

Loss of Control of Judgernent

Loss of Behavioural Control

Option Reduction

Acute Degeneration

Addictive Use

It 1s possible to interrupt the relapse progressiOn before serious

consequences set in by bringing the warning signs of relapse into the

chemical dependant's consciOus awareness. This is Relapse

Prevention Planning.

The Relapse Prevention includes educating the patient about the

relapse process and devising a plan to help him understand the

warning signs of relapse so that he can prevent a return to drug use.

The chemical dependent can be in a relapse before he actually uses

273

alcohol or drugs. It is possible to build up to a relapse over a period

of days, weeks or even months. Many alcoholics and chemical

dependants have reviewed their relapse experiences and identified

clues, which preceded their return to the use of chemical. Relapse

clues or warning _signs may relate to changes in attitude, thougl;lts,

feelings, behaviour, or a combination of these. The dependent shotild

be made to understand that he must be on the alert when changes

occur so that he can avoid a return to chemical use. The following

are some examples of "relapse clues".

1. Changes in attitude

- Not caring about subriety;

- Becoming too negative about life.

2. Changes in thought

- Thinking that he "deserves" drugs because he had been

sober for quite some time;

- Thinking that he can use substitute drugs;

- Thinking that his problem is "cured" since he had been

abstaining for sometime;

3. Changes is feelings

- Increased moodiness or depression;

- Strong feelings of anger and resentment;

- Increased feelings of boredom and loneliness;

4. Changes in behaviour

274

- Increased episodes of arguing with others;

-"forgetting'' to take anti-abuse;

- Skipping AA INA meetings;

- Stopping in a bar just to socialise and drink soda or

other soft (!rinks;

- Increased stress symptoms such as smoking more

cigarettes;

- Threatening to use drugs to have his way;

- Talking repeatedly about the pleasures associated with

chemicals.

These are just a few examples. The important point to remember is

that negative changes in attitudes, thoughts, feelings and behaviour

indicate that the relapse process has set in motion.

After the identification of warning signs, the chemical dependent is

helped to explore healthier ways to replace them. He is helped to

lower the risk of experiencing relapse through guided, focussed,

structured exercises, relapse prevention planning. Planning for

relapse prevention minimises its destructive potential. This

planning will give him a sense of security. He will be able to identify

early warning signs and develop a plan for interrupting the relapse

275

syndrome if it appears. Relapse prevention Planning should be an

essential part of his recovery programme.

There are various steps that together constitute Relapse Prevention

Planning.

Stabilisation

Get back in control of himself and his behaviour

Stabilisation is the method of regaining control over thoughts,

emotions, judgement and behaviour, when a person is in the relapse

process. This will be a time of crisis for him and his family. He may

feel frightened, angry, disappointed and guilty. At this point he

needs help. Vitamins and other medicines to help regain his norm.al

physical health may be his immediate requirements in the process of

getting physically stabilised. This is the time the counsellor could

reassures him and helps him to take necessary steps "I must find

out with the help of others, what is causing my relapse episodes." to

re-establish his sobriety. 7

7. F.H. Gawin, Relapse Prev~ntion: A Self-Control Programme for

the TreatTnent of Addictive Behaviours National Institute on drug

Abuse Research Monograph Series 63. (Washington DC,1986) US,

govt. Print off, PP. 55-57

276

Assessment

The second step in Relapse Prevention Planning is to identify the

factors that set his relapse in motion. This can be traced by

reviewing his history of addictive use, as well as finding out the

specific warning signs that Oefurred during each period of attempted

abstinence. This information will provide valuable clues as to what

went wrong and how it can be rectified to improve chances of the

dependant's permanent sobriety.

Prasad, 40 years old, was running his own departmental stores. He underwent treatment for his addiction. He was responding well during the initial phase and maintained abstinence for one year. Mter 12 months, he went back to multi-drug abuse again. He was again detoxified and tr:eated. This one-year mark became his relapse pattern. On the third year, after three relapses, he started thinking - "My God! What is happening to me? Why is it I am not able to abstain? I should definitely do something about this." He approached the counsellor and an open discussion and analysis revealed that his drug use was triggered by the stress he experienced during every "year-end' on the period of closing of accounts. Now that he identified ·the episode, which caused his relapse, he was able to work out a practical plan with the help of the counsellor and start implementing it straight away.

Relapse Education

''I must learn about the process of relapse, and methods to prevent it."

The more infonnation the chemjcally dependent gets about addiction,

recovery and relapse, the more tools he will have at his disposal to

nwintain sobriety. He has to understand post-cute withdrawal

277

symptorns, what puts hirn in high-rish of developing them, what

m,ight trigger them and what it tahes to prevent or manage them. The

counsellor should help him review and apply this information. The

education progranune will be com.plete only when he is capable of

honestly and openly applying information to his own life and his

current life ~ircurnstances. Addiction is a disease of denial; and, his

denial may prevent him front recognising what is really h'appening to

him. Raj Kumar was a 35-year-old ganja addict with a history of

heavy drug tahing and related problems for the past 8 years. He had

been hospitalised quite a number of times and participated in many

recovery programmes. H'hile reviewing his relapse history, he stated

that he usually built up to drug-tahing over a period of about 5

weeks. His relapse clues included decreased interest in taking care of

his nutritional needs which was evident when he shipped breakfast

and dinners.

1. Increased thoughts of smoking ganja such as ''I can have a few

puffs."

2.Stopping in the den where he used to smohe ganja in order to

"see old friends."

Raj Kumar with the help of the counsellor devised the following

relapse prevention plan.

278

- "When I notice that my food habits are clwnging, I must

find out why this is happening and whether something is

bothering 1ne which needs attention.

- I nwst see my counsellor I NA sponsor to review my current

feelings.

- I m.ust go regularly to gym.nasiwn to regain m.y physical

fitness.

- I must write in detail why stopping in the den is not in my

interest.

- I m.ust review the benefits of sobriety which I have already

written, in order to reinforce the importance of my recovery."

Warning Sign Identification

"I must make a list of my personal relapse warning signs."

Relapse Warning Signs identification is the process of identifying

the problems and symptoms that can lead to a return to chemical

use. Problems may be situations outside of the chemically dependent

or within. Symptoms may be health problems, thought problems,

emotional problems, memory problems or problems with judgement

and behaviour.

It is necessary for the patient to draw up a list of personal warning

signs from past relapse experiences. He should be helped to develop

27!.)

a list of clear and specific indicators that denote that he is beginning

to move towards drug-use again.

Sudhakar, 50 year old, addict, widower, employed, has had sober periods upto 2 years. However, since his wife died, he had been abusing drugs very heavily with only short periods of abstinence. His high-risk situ?tion was his "painful memories" of his wife's untimely death and related feelings of sadness and depressior""'.

\

Sudhakar usually experienced these memories and feelings on certain holidays; the anniversary of his marriage, and sometimes during the weekend when he was at home all alone.

In working out his relapse prevention plan, he decided to utilise

professional Counselling to . assist him in working through his

sadness, depression and grief. Should painful memories or feelings

regarding his wife make him feel like using various drugs, .he will

discuss these immediately with his counsellor I AA member or his

sister. Prior to the holidays and other times associated with his

negative feelings, he decided to make plans to become more active in

AA and visit his elder sister and her family and take their children

out.

Warning Sign Management

"I must have concrete plans to interrupt the warning signs before I

lose control." Addiction is a disease with a tendency towards relapse.

Once the chemically dependent knows and accepts that fact, he can

plan for the inevitable. Each warning sign is a problem he has to

solve once it occurs. He will need to review each warning sign and

answer the question, "How can I prevent this problem from

happening?"

~

The chemically dependent is supposed to keep a daily record to

review his recove1'Y process and monitor for relapse warning signs.

This helps him to see whether he is making progress in his recovery.

Just knowing what the warning signs are, may not necessarily help

him. It is essential for him to establish new responses to the

identified warning signs. He has to be guided to determine what he

is going to do when he recognises a specific warning sign, which

shows itself again and again in his life. He should be helped to get

clarity on the following questions:

"How can the relapse syndrome be interrupted?"

"What positive action can I take to deal with the warning sign?"

He should list several options or possible solutions for tackling these

problems in his life. Listing several alternatives will give him better

chance of choosing the best solution and provide him with

alternatives in case his first choice does not work. The chemical

dependent should be made to understand that he has to practise

each new response until it becomes a habit. If the new response is to

281

be applied in times of high stress, he can practise it in times of low

stress. If the new response fails to interrupt the warning sign, he

has to establish a more effective plan. He cannot afford to put off

developing a plan to interrupt his warning signs as and when they

occur. If he does not have a ready plan~. he will not be able to

interrupt any warning signs at all.

Warning Signs

Meeting a drug user

Loneliness

Boredom

An urge to take drugs

Management Techniques

Immediately leave the place and

Meet a NA member.

Get involved in some collective activities

Going with the children for a walk

-Visit a temple

-Get something to eat

-Postpone use of drug till the next day

-This method can be renewed again the following day.

- Go through the already prepared list of all the bad things that

happened during active drug taking days

282

- Think of how good I feel and how people respect me when

I do not use drugs.

- Think of slogans like "Things changes, today in not yesterday

"or "This too will pass". 8

Inventory Training

Any successful recovery programme involves a daily inventory. This

is necessary to help the addict identify relapse-warning signs before

his denial gets reactivated. Any relapse warning sign is serious

because it can be the first step towards his getting back to drug use.

'Without a daily inventory, the chemical dependent is likely to ignore

early warning signs, and then be unable to interrupt the relapse

syndi·ome when it becomes obvious. The chemical dependent should

be helped to develop a way to incorporate these inventory systems

into his day-to-day living. For the daily inventory to become a habit,

the establishment of two daily inventory systems can be

recommended to him. "he must do an inventory twice daily, so that

he can notice the first warning signs and correct the problems before

8. J.H. Harwood, Treating Drug Problem .. Vol.l; A study of the

Evolution, Effectiveness and Support to Drug Treatment Systems,

(Washington DC, 1990) National Academy Press, PP 32-36

283

they go out of his control." The first can take place in the morning.

He should plan activities for the 24 hours of that day. He should ask

himself whether he is prepared for that day and what action he is

going to take physically and emotionally to meet the challenges of

that day and maintain sobriety.

The second inventory can take place in the evening. Now he has to

review the tasks he had undertaken and identify those, which he

handled well, and those in which he needed improvement. He can

list the strengths he displayed in meeting the challenges and find

out methods to reinforce and build upon his strengths. He can also

think about his weaknesses ~nd find out methods to overcome his

shortcomings.

Anil, a 35 year old employed man, got treated for his drug addiction. Six months after completing the programme, four of his old 'friends' came to meet him. In the course of conversation, one of them suggested that they go on a picnic to a nearby place on the New Year eve. Anil was immediately thrilled with the idea and enthusiastically said he would join them. When they had left, after about an hour, he suddenly realised he was getting into their trap. "My God! How silly I have been! Their only source of enjoyment is drugs. How is it that I forgot about it and got thrilled with their idea! No! I will not go. If I go, I may not be able to resist the temptation of chugs," He decided to inform them that he would not be able to accompany them. How could he do it? He thought of a few ways.

- Straightaway say that he had a problem with drugs;

-Politely refuse to come, without giving any explanation;

28-'1

- Offer an alternative activity. For example tell them "

I am not taking drugs, let us enjoy going to temple.

He finally decided that the second option was the best and immediately rang them up and politely declined their offer.

~Review of the Recovery Programme

The counsellor can help the chemical dependent find out whether

his pre~ous recovery programme had been working well for him or

whether it can be improved upon. For every problem, symptom or

warning sign that he had identified, he should ensure that there is

something in his recovery programme to help him cope with it. " He

must review his current recovery programme to make sure that he

is managing his warning signs well.

Involvenwnt of "Significant Others':·

It is not possible for a chemical dependent to recover in isolation.

Total recovery involves the help and support of a variety of people.

As the relapse process sometimes happens at the unconscious level,

inspite of the daily inventory, the chemical dependent may not be

able to see what is actually happening to him. That is why it is

important to involve other people in Relapse Prevention Planning.

Family members, co-workers and fellow AA/NA members can be

extremely helpful in recognising warning signs.

285

Sometimes people even when they recognise the warning signs may

find it difficult to tell the recovering person that he is relapsing.

They may be afraid that in case they openly tell him, he will become

angry and show his resentment by taking drugs. They will be more

comfortable in informing the counsellor so that the counsellor, in

' turn, tells the patient without arousing his resentment. In order to

facilitate this, the counsellor may hold weekly meetings with the

family members and other significant people so that they openly

discuss the relapse warning signs, which they have observed in the

chemical dependent. "He must get feedback from others as to

whether they are able to identify any warning signs of relapse in

me." The chemical dependent must be made aware that he should

allow the network of 'significant' people to participate in his

recovery. He should encourage them to verbalise their feedback as to

whether he is showing any warning signs.

Follow-up and Reinforcement

Chemical dependency is a life-long chronic condition; and recovery

from addiction is a way of life. Since Relapse Prevention Planning is

a part of recovery, therefore, it must become a way of life. This

planning should be integrated into the addict's entire life, and must

be compatible with AA/NA and other support groups he is using to

286

maintain sobriety. "He must revise his Relapse Prevention Plan as

he grows and develops in his recovery."

The recovering person has the freedom to carefully choose methods

that will help him grow and develop. He must be willing to revise

and updatc~his plans at regular intervals and be willing to i'ecognise

' ' new problems that pose a threat to his sobriety. In short, Relapse

Prevention Planning is a process that should become an integral

part of his recovery. For him, the outcome will be freedom to enjoy a

comfortable sobriety and assurance that he has an action plan to

manage any warning sign if it develops.

Additional information

A model relapse prevention planning programme

Following is a treatment model, which allows the counsellor and

client to recognise forces that maximise the potential for recovery.

This can be done by

- obtaining information about the patient's current level of

functioning

identifying positive and negative forces m relation to

sobriety

- identifying problems and developing goals

- treatment strategies

287

- evaluation 9

This model is applicable within an-y treatment facility where there is

an emphasis on individualised treatment planning.

Ramesh, a 25-year-old electrician, married, had problems with Brown Sugar for t~e past 5 years. His drug taking was stress- .. related and occurred. when peers were around. His wife refused to , allow him to live in the house when he was using drugs. During those days, he stayed with his old ru·ug taking 'friend'. Ramesh recognised his problem and got admitted in the After-care Centre since he wished to achieve sobriety and was afraid of losing his wife. After discharge, Ramesh maintained abstinence ranging from 3 to 6 months with NA participation.

Recently, Ramesh had some problem at the office, which demanded overwork, and this caused stress. As a result, he could not attend NA meetings. When he met some of his ru·ug taking 'friends' he was almost on the verge of going back to drugs. He immediately consulted the counsellor at the After­Care Centre to prevent a relapse.

Obtaining Information

The purpose of this step is to gather information about the chemical

dependent in order to asses,s his current level of functioning. A

comprehensive assessment is obtained by gathering information

about the client's behaviour in different areas - emotional,

environment, family, vocational, physical and interpersonal.

9. Ibid, PP 59-61

288

Such information can be obtained through interviewing,

psychological testing etc. In the above case, the counsellor should

spend time with Ramesh, his wife, parents and employer. During

this process, the counsellor establishes a therapeutic relationship

with Rames_h and explains the purpose of obtainin_g this

information. Once this information is obtained Ramesh and his

counsellor will begin to organise information into a system that

allows them to understand the impact of various forces on his

sobriety.

Identifying Positive and Negative Forces in Relation to Sobriety.

Forces are feelings, thoughts, needs or behaviour of the chemical

dependent and I or in the person's environment which enhance

sobriety (positive forces) or those forces which jeopardise his

sobriety (negative forces). It is necessary to understand these forces

operating for or against a client so as to maximise successful

rehabilitation outcome. Once these forces are identified, positive

forces can be strengthened to facilitate sobriety; negative forces may

be weakened to enhance the person's potential for achieving

sobriety.

A review of Ramesh's experience indicates the following positive and

negative forces:

289

Positive Negative

Previous NA participation; Difficulty in handling stress;

Previous periods of abstinence; Drug-taking influenced by

Recognition of the drug problem peers.

Desire to achieye sobriety.

Identifying Problems and Developing Goals

When each problem is clearly stated, specific goals can be

formulated. The following format, which can be applied to each

significant force, is presented as a guide for the development of

problem statements, goals, and Counselling activities.

Let us examine Ramesh 's case.

Problem statement

Ramesh did not maintain and follow through his NA meetings.

Force which can

bring about the change

Goal

Counselling activity

Previous NA

involvement

Ramesh will become reinvolved

With NA on a regular basis.

a) Explore with his help,

previous involvement with

NA and the nature of

assistance he gained from it.

290

b) Discuss with him the

reasons why he stopped

going to NA meetings.

c) Help him identify a sponsor in

NA

d) Discuss with him the number of

'

weekly NA meetings he feels he

needs to attend.

e) Explore with him reinforcers,

which would assist him in

following through with NA

Treatment Strategies

The purpose of this step is to identify strategies so that the

goal is accomplished. These strategies should be realistic and

attainable. In Ramesh's case, the following can be the

treatment strategies.

(a) Meet Ramesh twice a week for individual sessions to

explore goal areas.

(b) Establish a written contract with him for his weekly

attendance of NA

© Talk with his wife and parents to determine their interest

and willingness to attend AI-Anon and family

291

counselling sessions in order to increase their

understanding of how to help Ramesh.

Goals and treatment strategies need to be established to address

his stresses. It will be helpful to involve him in group therapy

sessions. Mter Ramesh has established a stable ·.period of sobriety ~ ~

and his wife has received help for herself, mmjtal counselling may

be necessary to improve their communication and support system.

Evaluation

The final step evaluates the process and outcome of the assessment,

goal-setting and treatment/ planning. The following points may be

assessed as an evaluative measure to assure the comprehensiveness

and quality of treatment efforts.

1) Is the assessment information comprehensive, and

clear?

2) Have all the positive and negative forces been

identified? Are those the correct forces?

3) Are the specific problem- statements, goals, and

counselling activities for each force realistic and

attainable?

4) Have effective treatment strategies been outlined to

accomplish goals?

292

This model allows the coun.sellor and client to become actively

involved in a process to maximise the potential for recovery. This

process includes identifying the forces, enhancing sobriety and the

forces jeopardising; sobriety, and utilising the counselling process to

develop action plans necessary to increase and decrease appropriate

forces.,

This Relapse Prevention Planning Model can be easily integrated

into the existing treatment structure of any Mter-Care treatment

facility. 10

An implementation Tool for the Counsellor

Following is a tool which can be effectively used by the counsellor

when he I she is guiding the chemical dependent towards relapse

prevention. The purpose of this questionnaire is to help the

chemical dependent understand relapse as it relates to his

situation.

10. H.M. Boudin, Behaviour~ Treatment of Drug Abuse in M.c.

Sobell (ed.) Clinical Behaviour Therapy and Behaviour

Modification (New York, 1986). Garland Press PP. 82-83

293

This will-

· Provide him information on important topics related to

relapse.

· Give him some practical ideas which will help him

minimise the chances of relapse. '\

• Help him take respdnsibility for identifying specific high

risk relapse factors, which could lead to his drug, abuse

a gam.

· Help him begin to make specific prevention plan based on

his life situations.

Following are questions, which the counsellor can ask the chemical

dependent to answer, so that he is assisted in devising his own

relapse prevention plans.

I. Understanding the Relapse Process

If you have experienced a period of recovery in the past, prior to a

relapse, answer the following:

1. What specific clues or warning signs preceded your relapse?

2. How much time elapsed between the emergence of relapse clues

and the actual use of alcohol or drugs?

294

3. If these warning signs were to occur again, what specific steps

will you take to prevent a return to drug/alcohol use?

II. Identifying and managing the Warning Signs

During recovery, especially during the initial stages, it is very

common to experience an uncontrollable urge to use alcohol or

'

drugs. Have you experienced such urges? If so, think over and

answer the following:

1. What triggered your urge to take alcohol I drugs?

2. What was the physical discomfort, which made you, think

of going back to drinking/drug use?

3. Describe briefly your mental condition, which triggered

your thought of drinking/d.Tug taking again?

4. List the specific steps you have decided to take from now

on to prevent a return to alcohol/drug use.

III. Involving Significant Others

It is difficult to achieve sobriety without the help of others,

therefore, it becomes essential to get others seriously involved in

your Relapse Prevention Planning. Have you planned such a

network? If so, answer the following:

295

1) Who are the sponsors you have identified?

2) Are those significant people aware of the entire

relapse? warning signs?

3) In case they identify any warning signs in you, what is

the method by which they are going to bring it to your

notice? "

Relapse Prevention

Preventing relapse is a challenging enterprise. Usually, relapse

takes place after patients have left the treatment units and

laboratories. Thus, the crucial events leading up to a relapse, and

the episode itself, ~emains outside the arena of observation and

influence. Nevertheless answers to basic questions about relapse are

crucial if we are to prevent it. Although we have knowledge about

some of the variables that predict and control relapse, many puzzles

still remain.

What is relapse? Relapse is a 'resumption of substance-abuse

following a period of abstinence', yet the extent of drug-use that

constitutes full-blown relapse is a matter of debate. To adherents of

a strict abstinence model, a single self-administration of any

abusable drug (usually excluding nicotine) would qualify as relapse.

296

A return to baseline use of one's problem dl·ug(s) is another common

criterion. There is also no consensus regarding the length of time an

individual must be dl·ug-free before he or she can be said to have

"relapsed". Forty-eight hours appears to be an acceptable criterion.

' ' Whatever level of resumed use is agreed to_constitutes relapse, three

stages in the relapse process are usually of interest: (1) the first

lapse, or "slip", after a quit episode; (2) relapse itself, defined as

some level of continuing use; and (3) the transition between the two.

Seemingly few individuals, having slipped, avoid returning to pre-

treatment levels of dl·ug use, at least temporarily. 11

Many characteristics of the relapse process have been insufficiently

studied through insignificantly. Yet we know little about which

variables are important at which time. Another issue is change over

time in an individual's level of risk. Clinically, it appears that the

risk of dl·ug use of successful ex-drug users eventually reaches a

plateau, becoming similar to the risk faced by those who have never

used drugs. We know little about the intermediate phases of

11. B.S. Rosenthal, Detenninants of Initial Relapse Episodes among

Drug Addicts (Chicago, 1993) PP. 68-71

297

abstinence, the length of time individuals spends in various phases,

or whether these phenomena differ by drug of abuse.

Explaining Relapse: Main theoretical Models:

Despite lack of an agreed-Qn marker for relapse and inadequate

data on the relapse process, there are two classes of models for

explaining how relapse occurs; cognitive-behavioural and

conditioning models ..

Cognitive-Behavioral Models

The cognitive-behavioural model that has received the most

attention is that of Marlatt and Gordon (1985). The model focuses on

situations in which there is a high risk of relapse and on the ex-drug

user's responses to them. Marlatt and Gordon suggest that the

relapse process begins when the ex-drug user confronts a high-risk

situation for which he or she has no effective coping response.

According to the model, high-risk situations can occur for many

reasons, including social pressure to use drugs, negative emotions,

and, less frequently, 'withdrawal' symptoms and positive emotions.

The lack of a coping response, combined with positive expectancies

for the initial effects of the drug. The situation greatly heightens the

298

risk of a slip. 12

According to Marlatt and Gordon, a first slip may lead to a full-

blown relapse via the abstinence-violation effect (AVE), a core

construct in tht model. The AVE is said to occur in individual~ who

are committed to absolute abstinence. It has two compon.ents: (1) a

causal attribution of responsibility for the slip emphasising internal,

stable, global, and uncontrollable factors and, (2) a negative

affective reaction. This affective reaction is said to be similar to

cognitive dissonance. The individual believes that drug use IS

unacceptable, yet he or she has just used a drug. This conflict-state

is aversive, and individuals may attempt to reduce it as they have

customarily dealt with negative states in the past, that is, by

continuing to use the drug this may resolve the conflict by.

redefining themselves as he~pless addicts. This may lead to the

cessation of all efforts to control drug use. 13

12. G.A. Marlatt & J.R. Gordon, "Relapse, Rates in Addiction

Progrmmnes : Process and outconre", in Journal of Clinical

Psychology (London) VolA3, April 1991, PP. 41-43

13. Ibid, PP. 45-47

299

Conditioning Models

Conditioning models emphasise ' . ' cravmg. In the classical

conditioning model, ru·ug cravmg is assumed to reflect the

conditioning of withdrawal symptoms and drug effects with both

environmental and interceptive stirr...uli. A variant is the opponent-

process or compensatory response model. In this model, responses

opposite to the drug effects are conditioned to ru·ug cues via a

homeostatic process. These opposmg responses presumably

compensate for the "impending pharmacological assault" of the

drug. For example, a cocaine user might initially use the drug to

increase his or her energy level in social situations. Over time, the

presence of these social stimuli would elicit a compensatory response

of decreased arousal. This withdrawal-like state would be

experienced as aversive and interpreted as craving.

Status of Key Variables

Models of relapse suggest a plethora of variables that may be

important in relapse prevention. Although only a few have been well

explored in empirical studies, the literature on these does offer some

direction for improving relapse prevention treatment.

300

Commitment and Motivation

The importance of a strong initial and long-term commitment to

abstinence has been emphasised repeatedly in the addiction

literature. Several dimensions of commitment to abstinence may be

important for preventing relapse. A central one is abstinence goal, ..

the degree to which one's aim is total and permanent abstinence

versus a less restrictive goal, for example, periods of abstinence with

occasional slips. In our own work(see the next chapter) , we found

that a goal of absolute abstinence at the end of treatment predicted

better short-term outcomes in opiate addicts, smokers, and

alcoholics than did less stringent goals. However, all our subjects

were dTawn from programs that endorsed strict abstinence. 14

As with any resolution, enthusiasm for abstinence may decay over

time. Early in treatment, drug users may be highly motivated

toabstain because of real or threatened aversive consequences of

continued use, but as potential negative consequences are averted or

forgotten, the positively reinforcing aspects of drug-use may become

more salient e.g. the "euphoric recall" of heroin and cocaine users. A

decision to slip or relapse may be the ultimate result. This shift in

the perceived costs and benefits of habit- change suggests that post-

---------------------------.--------------~-----------------------------------------------------

14. M.R. Goldfried, n.2, PP. 62-63

301

sess10n motivation for abstinence should be continually monitored

and bolstered. A setback may be likely if the perceived costs of

change begin to outweigh the perceived benefits.

Coping Shills

Coping skills training for negotiation of high-risk situations has

been highly touted, but the results have been mixed. Skills tr·aining

have been effective sometimes with alcoholics and, less consistently,

with drug addicts. Comparable research with opiate and other illicit

<hug users is scanty and, so far, not encouraging. There are several

possible reasons for the equivocal results of skills training. The

skills needed for relapse-prevention may be so elementary that

skills training are superfluous. If so, more emphasis may be needed

on a patient's ever motivation to use the skills that he or she has.

Also, the discrete situations in which drug is available (e.g. is being

offered as a drug) may be insufficient causes of relapse. The

complex, chronic life problems that predispose ex-users to be in

these situations may be more important. Examples are chronic

unemployment and failure to develop drug-free networks, both of

which predict relapse. Skills training oriented toward more complex

targets, like job seeking, has been shown to be effective. Other

302

relevant skill areas may include job-holding skills, parenting skills,

and general social skills for developing non-drug-using networks.

Social Support

Social support has been demon.strated to be related to health '

outcomes and to mortality. Two major dimensions of social support

have been identified. Structural support concerns the existence of

relationships with others, for example, marital status and group

memberships. Functional support is the degree to which these

relationships provide emotional, informational, and material

resources. Recently there has been increased attention to social

support variables in drug tr.eatment programme with general social

support being distinguished from support specific to abstinence.

Across addictions, intriguing correlation has been

discovered between levels of support (primarily structural)

and drug treatment outcomes. Nevertheless, formal

interventions to increase levels of support usually have been

ineffective in preventing relapse. Encouraging results also

have been obtained using marital therapy with addicts and

alcoholics. It appears that successful treatment

interventions (compared with those that have failed) have

been distinguished by intensive intimate engagement with

303

the primary social system, compared with less intensive

methods, such as spouse training, or involvement of less

intimate systems such as work groups etc.

Clinical lore indicates that involvement in non-familial social

support programmes that emphasise abstinence also helps prevent

relapse. Although 12-steps self-help recovery organisations, such as

Narcotics Anonymous, can address this need, they may not be

palatable to substance abusers that find the spiritual orientation or

the meeting context evasive or offensive. Development and

evaluation of support prog"Tams offering alternative philosophies are

crucial. A promising alternative is Recovery Training and Self-Help

created for treated opiate addicts. 15 Research on social support

points to gender differences, and not surprisingly, correlation

evidence primarily from the alcoholism literature suggests that

social support may be particularly important for ch·ug-abusing

women. Investigators have found that alcoholic women have less

social support than non-alcoholic women do; familial support is

absolutely essential in successful tre.qtment for women. Some

clinical reports indicate that women not only fail to receive active

15. M.M. Glatt, A Guide to Addiction and its Treatment~ancaster,

1979) PP. 22-23

304

support for abstinence but also actually may encounter opposition to

entering treatment from family and friends. Reasons for this include

the shifting of child-care responsibilities to other family members

and the spouses' reliance on other women for meeting their day-to­

day needs. The impor~ance of providing adequate childcare to

remove this major treatment barrier has often been emphasised.

Negative Affect

Drug abusers have high rates of current and historical maJor

depression. In treatment research, both negative moods and a

history of depression predict poorer initial treatment outcomes and

higher relapse rates. Thus, depressed patients in treatment systems

should be identified. For some patients, especially those with

current major depression, psychoactive medications have been

shown to be useful. Many patients who do not have diagnosable

mood-disorders may still be dysphoric much of the time, and

psychological interventions to modify to prevent such dysphoria are

promising tools for preventing relapse.

Cue Reactivity

Conditioning models suggest that internal responses conditioned to

environmental cues can lead to relapse. Exposure techniques for

reducing cue-responsiveness may, therefore, prolong abstinence.

305

Relevant strategies have included practising di·ug-avoidance in

selected real-life situations and administration of priming doses

followed by response prevention. Although these laboratory

procedures have proved effective in reducing conditioned responses,

it is still unknown whether better long-term outcomes will result. It .. is plausible that, although the treatment model is a good one, '

successful clinical implementation will require modifications such as

booster sessions and structured implementation in the natural

environment. 16 The role· of other drugs as conditioned cues

deserves special mention. For example, many clinicians believe that

alcohol consumption is an important precursor to cocaine relapse.

Also, clinical lore suggests that, for individuals whose use of a

specific drug has been linked to other di·ugs, total abstinence from

all di·ugs may be necessary. There is intriguing laboratory research

about the effects of one drug on another. Yet we know little about

why, how, or even whether use of one drug causes use of another in

the natural environment. There can be improvement in drug

treatment by obtaining such knowledge.

In addition to the key variables already discussed, two others seem

intuitively important: "stress" and the abstinence violation effect. In

16. Ibid. PP.25-27

306

contrast to the previous areas, however, there are as yet insufficient

data to suggest potential interventions.

Stress

Stress has long bee~ implicated in drug abuse. The term "stress" h~s ~ ~

been applied to objective situations, such as to major life-events, as

well as to chronic minor irritants. Relevant research has been

largely retrospective, as in studies in which users are asked to

describe the events leading to a recent lapse. Whether the stress-

relapse link is real or artificial is unclear. A critical question is: to

what extent does post-lapse retrospection colours the perception of

antecedent e·vents? For example, if one has lapsed and seeks to

understand or interpret the lapse, a previously neutral-seeming

situation preceding the lapse may be reinterpreted as stressful. A

second issue is the extent" to which observed correlation is illusory.

Addicts tend to experience high-level stressful events. One of these

events may precede a lapse yet still not be causative. Actual

causative variables may be subtle and not easily verbalised. In case

of Alcoholics, addicts and smokers, retrospective analyses showed

stress to be linked significantly to relapse. Prospective examination

of the same data showed no relationship. Thus, our findings support

the belief that the "true" relationship between stress and relapse

may not be strong and equivocal.

307

But this is not to suggest that " stress" may have no bearing on

relapse , at all. Instead a better understanding of the role of stress

in relapse is needed. Additional prospective research employing a

fine-gained <i:pproach (i.e. assessing stress on a day-to-da~. basis)

should help illuminate the stress-relapse relationship. Without

additional knowledge, it is difficult to suggest answers to relevant ' '

treatment questions such as whether stress-reduction training is

advisable.

Abstinence Violation Effects

As appealing as Marlatt and Gordon's (1985) formulation of the AVE

may be, an is empirical evidence of its role in relapse phenomenon

and its consequences still awaits demonstration across drug-using

populations. Still, the AVE remains intriguing. It would seem

worthwhile investing in studies establishing the importance of the

AVE in relapse and then seeking ways to address it in drug

treatment. 17

17. G.A. Marlatt & J.R. Gordon, "Detenninants of Relapse:

Implications for the· Maintenance of Behaviour Change", in P.O.

Davidson & S.M. Davidson (Eds.) Behavioural medicine: Changing

Health Lifestyles (New York, 1982) P. 45.

308

SUMMARY

Although knowledge about relapse prevention is still at an early

stage, the extant data highlight the importance of several

constructs.

1. Moiivation for abstinence remains central. The cortstruct itself is

'

often clouded because of its association with mystical notions such

as willpower and self-control. We know that manipulation of

environmental events can increase motivation. These interventions

are effective, however, only as long as the contingencies are in effect.

We need to develop and evaluate strategies for transferring

contingency management to the natural environment, that is, to

institutions and groups that can perpetuate them for the long term.

Also, clarification of the kinds of abstinence goals needed to prevent

relapse is important.

2. Several investigators have studied coping skills, but research on

these, except for job-finding skills, is not encouraging. The skills

usually taught may be too basic; skills training oriented to complex

targets, such as building non-drug-using networks, may be useful

and should be further explored.

3. Social support is clearly important, yet we do not know how best

to use it to promote abstinence. The little research available

suggests that both familial and non familial systems or both formal

309

and informalities should be mobilised; we need to define abstinence­

promoting supportive behaviours, identify and engage important

support systems in treatment, and help patients expand their non­

drug-using contacts.

4. Negative affect may be causally related"to relapse. We need to

continue efforts to identify dysphoric patients and develop

interventions to ameliorate dysphoria concurrent with drug abuse

treatment.

5. Drug cue reactivity and extinction of drug cues have been

demonstrated in the laboratory. What is needed in this promising

line of research are (1) investigation of cues and cue-reactivity

phenomena in the natural environment and (2) extinction methods

that transfer from the treatment setting to the outside world.

Other phenomena are not well understood but it seems Abstinence

Violation Effects are important. Maladaptive ways of responding to

lapses, such as the AVE, are included here. Another is stress, which

patients and clinical intuition tell us must play a role in relapse. Its

exact role is far from clear.

310