RELAPSE PREVENTION

RP

Addiction is considered a chronic, relapsing brain condition. Miller and Hester evaluated over 500 alcoholism outcome studies and found that over 75% of participants relapsed within a year of treatment.

Hunt et al. found that nicotine, heroin, and alcohol have similar rates of relapse over a year, ranging from 80-95%. Within the first year of treatment, 40-80% of individuals with alcohol use disorders experience a "lapse," with around 20% returning to pre-treatment levels of alcohol consumption. Recurrence prevention (RP) is an approach that reduces the frequency and severity of recurrence after addressing harmful habits.

After attempting to quit, the initial transgression of problem behaviour is referred to as a "lapse," which can progress to further infractions to a level comparable to before quitting, known as a "relapse". A lapse can lead to abstinence and continued progress towards good transformation, sometimes known as "prolapse". Researchers often view relapse as a process aiming to identify the components that contribute to it. Relapse prevention (RP) is a cognitive-behavioural technique that aims to detect and address high-risk scenarios for relapse while also aiding clients in maintaining desirable behavioural improvements.

(a) RP attempts to prevent first lapses, sustain abstinence, and achieve harm reduction therapy goals.

(b) Manage lapses to prevent future relapses. Relapse prevention emerged as a deliberate response to the long-term failures of conventional treatments.

RP assumes that the effects of a therapy intended to reduce or eradicate an undesired behaviour may not last beyond the treatment's discontinuation. Returning to the old environment that aroused and supported the issue behaviour may lead to a re-emergence of the problem, such as forgetting the skills, strategies, and information provided during therapy and experiencing decreased motivation.

In a high-risk situation, an individual's attempt to refrain from a specific action is endangered. They frequently appear without warning.

When assessing high-risk circumstances, clients must identify low-risk situations and discover what distinguishes them from high-risk situations. High-risk circumstances are determined by reviewing previous lapses and customer complaints of being "tempted." Appropriate reactions involve avoiding high-risk circumstances or promoting adaptive responses. Seemingly irrelevant decisions (SIDs) occur early in the decision-making process and put the customer at risk. A variety of factors beyond the apparent influences relapse. Covert antecedents include lifestyle elements like stress, temperament, personality, and cognitive abilities. These behaviours, such as rationalisation, denial, or seeking quick gratification, might lead to a relapse. Research suggests that lifestyle factors are the most significant predictors of relapse. It refers to a person's ability to balance outward demands and interior fulfilment or enjoyment. Urges and cravings caused by psychological or environmental factors are also significant.

The Abstinence Violation Effect (AVE) is a crucial aspect of RP. It describes how a client may blame themselves after a relapse, leading to a loss of perceived control. When a client perceives no intermediary step between a slip and relapse, they may believe that by violating the abstinence rule, they might maximise the benefits of the lapse. During RP, these variables must be addressed. Individuals who blame themselves for a mistake are more prone to experience guilt and destructive emotions. This might lead to more drinking as a coping mechanism.

The Problem of Immediate Gratification can lead clients to prioritise short-term pleasant outcomes above long-term negative implications. To address this, create a decisional matrix outlining the benefits and drawbacks of continuing the behaviour versus abstaining across varying time frames. The therapist can assist the client in identifying unrealistic outcomes.

Marlatt uses clinical data to categorise relapse factors, resulting in a thorough taxonomy of high-risk circumstances. These components include interpersonal effects from others or social networks and intrapersonal aspects such as bodily or psychological responses.

  RELAPSE IS CATEGORISED INTO INTRAPERSONAL AND INTERPERSONAL DETERMINANTS.

RP

INTRAPERSONAL DETERMINANTS

Self-Efficacy

Self-efficacy refers to a person's confidence in their ability to do specified behaviours in a given situation. According to the RP model, when a habit is broken, a client feels self-efficacious about the unpleasant behaviour, and this impression of self-efficacy is based on taught and practiced abilities. In a prospective study of men and women being treated for alcohol dependency using the Situational Confidence Questionnaire, higher self-efficacy scores were associated with a longer interval between relapses to alcohol use. The association between self-efficacy and relapse may be bidirectional, meaning that more successful persons report higher self-efficacy and individuals who have slipped report lower self-efficacy. Chronic stressors may overlap with self-efficacy and other areas of intrapersonal determinants, like emotional states, by presenting more adaptational strain on the treatment-seeking client.

Outcome Expectancies

Outcome expectations are an individual's beliefs about how their actions will affect their future experiences. The expected drug effects do not always correlate to the actual impact felt after consumption. Operant conditioning motivates behaviour depending on an event's expected positive or negative reinforcement value. Negative expectancies protect against relapse, while positive expectancies increase the likelihood of recurrence. Individuals who consume alcohol frequently tend to have higher expectations for its benefits. In high-risk settings, individuals may rely on alcohol to cope with bad feelings or conflicts.

Emotional states

The affective model of drug motivation suggests that excessive substance use stems from both positive and negative emotional regulation. Baker and other academics created the negative reinforcement hypothesis of drug addiction, which suggests that addictive drug usage stems from the need to avoid undesirable emotions. Research indicates that ongoing sadness among alcohol-dependent patients increases the chance of relapse during and after treatment. Additionally, rapid spikes in negative affect have been linked to nicotine relapse. One study found that presenting alcoholic beverages with negative affect imagery boosted the subjective urge to drink and predicted relapse following inpatient discharge. Negative emotional states linked to relapse include anger, loneliness, boredom, and exhaustion.

Coping

Efficient coping techniques in high-risk settings are a crucial predictor of recurrence. Coping refers to how individuals manage stressful events through their thoughts and behaviours. Effective coping methods, such as leaving a situation or practicing positive self-talk, are associated with lower recurrence rates than those lacking these skills. Successfully navigating high-risk circumstances is linked to increased self-efficacy. There are several types of coping outlined. Shiffman and colleagues define stress coping, in which substance use is seen as a coping response to life. They assume that there is a difference between stress coping skills, which are coping mechanisms meant to address everyday stress, and temptation coping skills, which are coping mechanisms tailored to circumstances when there are substance temptations that may lead to relapse. While avoidance coping may involve avoiding stimuli or diverting attention to other activities, approach coping may entail attempts to accept, confront, or reinterpret as a coping mechanism. While those with avoidance-based coping may emphasise their surroundings more than their behaviour, approach-oriented participants may believe they are more accountable for their actions, including lapses. Inaction can also be seen as coping. Generally speaking, inaction has been understood to mean "letting go" and not responding to an impulse or accepting material cues. Effective coping mechanisms include "staying in the moment" and being aware of cravings.

Desiring

While urge has been characterised as the behavioural intention to use a substance, craving has been defined as a cognitive experience centred on the desire to use a substance and is frequently connected to expectations for the desired effect of the drug. Interoceptive or exteroceptive cues, contextual factors linked to past heavy drinking, or the psychological and physical repercussions of previous withdrawal episodes can all trigger cravings. While yearning may lead to drinking, loss of control, and a behavioural condition marked by a relative incapacity to react to internal or external cues that regulate alcohol consumption, it is a complementing phenomenon that facilitates relapse. The process of associative learning, which occurs when environmental cues are repeatedly associated with drug consumption, acquires incentive-motivational value, evoking the expectation of drug availability and memories of past drug euphoria.

Environments linked to past drug use appear to be more conducive to substance use or relapse. This link has been investigated using the cue-reactivity paradigm, which tracks their responses to drug-related stimuli. Craving is triggered by cues connected to drugs, but cue reactivity is not a reliable indicator of relapse.

Inspiration

According to the Oxford English Dictionary, motivation is "the conscious or unconscious stimulus for action towards a desired goal provided by psychological or social factors; that which gives purpose or direction to behaviour. " Motivation can be linked to relapse in two ways: motivation to participate in problematic conduct and motivation for positive behaviour change. This exemplifies the problem of ambivalence that many patients encounter while trying to modify an addictive activity. Motivational interviewing can aid the process of change.

INTERPERSONAL DETERMINANTS

Long-term abstinence rates from a variety of addictive activities are strongly predicted by positive social support. The number of supportive relationships also highly predicts abstinence. The level of social support from the most supportive individual in the network may be the best predictor of lowering drinking among social variables. Furthermore, a person with an AUD tends to do better if they have more friends who do not drink. Relapse risk has been linked to negative social support in the form of interpersonal conflict and peer pressure to take drugs. Social pressure can come from peers trying to persuade someone to use it or indirectly through cue exposure and modelling (e.g., a friend ordering a drink at dinner). Negative family behaviours, like avoiding dealing with a family member who has a substance use disorder or withdrawing from them, are linked to increased drinking, even though addiction can be challenging for many families. Along with relationships with friends, family, spouses, and coworkers, research indicates that community-based support programmes, including recovery communities, improve results for individuals having trouble quitting once treatment is ended.

Emotion, coping, and expectations are intrapersonal processes that significantly impact interpersonal relationships and support networks.

Dynamic model

Previous models proposed several relapse-related parameters developed in a step-by-step, linear fashion. According to a revised model, the abovementioned determinants are dynamic and multifaceted. Changes in one risk factor that seem trivial could start a downhill spiral that leads to relapse. Relapse is ultimately caused by a combination of events acting simultaneously and to differing degrees.

Relapse factors can be considered proximal factors, the different determinants of relapse acting, and distal risk factors: vulnerability in temperament, personality, family loading, and environment, including social and economic background. These factors interact intricately with one another to cause relapse. Therefore, the dynamic model proposes a non-linear path to relapse.

Particular Relapse Prevention Intervention Techniques

The therapist must examine past events and relapse triggers to help the client identify and manage high-risk scenarios. Both internal and exterior clues are possible. For the client to self-monitor thoughts, feelings, or behaviours before a binge, they are also urged to maintain a current journal. Following this, two tactics might be used. One is to assist clients in recognising warning indicators, such as persistent stress, decisions that appear pointless, and notable beneficial outcomes utilising the substance so they may steer clear of the high-risk circumstance. The second is evaluating the client's coping mechanisms and teaching them general techniques like mindfulness, relaxation, positive self-talk, or employing drink refusal to deal with the circumstance.

Increasing Self-Efficaciousness

In RP, the client and therapist are treated as equal partners, and the client is urged to participate actively in problem-solving. The client is taught that developing new abilities is more critical for addressing problematic conduct than willpower. Another tactic is to divide the path to abstinence into more manageable goals so that the client can quickly become proficient and boost their self-efficacy. Additionally, therapists might compliment their clients on their accomplishments in other areas of their lives.

Getting rid of placebos and misconceptions

Examining the client's cultural background and outcome expectations might help uncover myths about substance use. After that, a decisional matrix can be created in which clients' views may be questioned, and the benefits and drawbacks of continuing or abstaining from substance use are elicited.

Management of lapses

Lapse management includes

• creating a contract with the client to restrict use,

• contacting the therapist immediately and

• assessing the circumstances for any contributing factors to the lapse.

Restructuring the mind

The abstinence violation effect is one cognitive error that can be addressed with cognitive restructuring. Clients are trained to change the way they think about lapses and see them as essential teaching moments that arise from the combination of many relapse drivers, both of which may be changed in the future rather than failures. Statements such as "I can't relapse," "I'll never use alcohol or drugs again," "I can control my use of alcohol or other drugs," "a few drinks, pills, won't hurt," "recovery isn't happening fast enough," "I need alcohol or other drugs to have fun," "my problem is cured," and "I can control my use of alcohol or other drugs" are some of the other common cognitive errors that have been identified. As in CBT, these ideas are enumerated, their reliability is questioned, and clients must formulate alternative thoughts to replace them.

A healthy way of living and constructive addiction

A vital component of the global self-management strategy is motivating clients to resume their previously fulfilling, alcohol-free leisure pursuits. Clients can also benefit from time management, relaxation training, and daily planning to attain better balance in their lifestyles. A balanced lifestyle can also be achieved by assisting clients in acquiring healthy addictions or substitute pleasures (such as running, meditation, relaxation, exercise, hobbies, or creative endeavours).

Techniques for controlling stimuli

These methods encourage the client to clear up everything in their house or place of business that is directly related to substance use. They should get rid of everything related to drug usage, including needles, mirrors, pipes, glasses, and bottles. The client's favourite chair or the music they listened to while drinking are examples of more subdued objects. A brief adjustment to seating or listening practices could be beneficial in these situations. Likewise, some social gatherings have come to be linked to binge drinking; the client might have to turn down these invites.

Techniques for managing urgency

Marlatt created the concept of urge surfing. Urge surfing is a visualisation approach that uses a wave metaphor to help clients resist their temptations to take drugs or alcohol. This method teaches the client to first identify internal feelings and mental concerns as urges and then cultivate a detached mindset from those urges. Instead of acting on the urge or trying to resist it, the emphasis is on recognising and embracing it.

Over the past decade, mindfulness-based relapse prevention (MBRP) has gained popularity for treating addictive habits. MBRP emphasises nonjudgmental attention to thoughts and desires.

To your health,

Nwabekee.

Reference

Kandasamy, A. and Menon, J. (2018) ‘Relapse prevention’, Indian Journal of Psychiatry, 60(8), p. 473.