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What Is an Alcohol Relapse Prevention Plan? And Will Mine Work?

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Only 2.3 million people in the United States receive addiction treatment each year, despite an estimated 21.6 million people needing treatment.1 Even with potentially critical treatment, some studies indicate that 40-80% of individuals relapse within 1 year, with many relapsing within the first 3 months.2, 3

How Does Relapse Happen?

Relapse is a longer process than you may realize. It can start weeks or months before you consume alcohol again. This process of relapse can be broken down into 11 distinct phases. However, these 11 phases boil down to 3 components:4

  1. Emotional
  2. Mental
  3. Physical

Emotional

Alcohol relapse prevention accounts for emotions.Emotional signs and symptoms that can lead into or point to an increased risk of relapse include:4

  • Denying or bottling up emotions
  • Isolating from others OR only focusing on others
  • Developing poor sleep hygiene
  • Developing disordered eating behaviors, such as forgetting to eat or routinely overeating until you feel ill
  • Changing how you participate in recovery activities, such as suddenly reducing the number of Alcoholics Anonymous (AA) meetings you attend, canceling regular therapy sessions, or not sharing in peer support meetings or group therapy

Mental

Both recovery and relapse can be conceptualized as states of mind. A person can be abstinent from alcohol and not be “in recovery” because they have no intention of staying sober.

Similarly, a person can be abstinent from alcohol, but simultaneously be getting closer to relapse when their mindset shifts away from their alcohol relapse prevention plan and toward:4

  • Cravings
  • People, places, and things associated with your alcohol use
  • Minimizing the consequences of your past use or relapse
  • Glamorizing alcohol
  • Bargaining or giving yourself permission to use under specific rules (e.g., only one drink or only to celebrate a friend’s wedding)
  • Using other substances as a replacement for alcohol
  • Being dishonest about the shift in your mindset
  • Thinking about or planning of ways to control your alcohol use if you started drinking again
  • Looking for or planning opportunities for relapse, including thinking about how you would explain the relapse to other people after the fact (e.g., your AA sponsor or your partner)

Physical

The “physical” occurs when you actually interact with alcohol again. This can include toying with the decision one or more times before taking a drink, such as having a bartender pour you a drink or leaving unopened alcohol in your home.

The smell of alcohol and other sensory cues can be extremely triggering when you encounter them by accident. If you introduce them back into your life intentionally, they raise the risk of relapse dramatically.

Most people when relapsing, will look for an opportunity and window in which they feel they would be able to “get away with it” without others knowing.4

You may experience a lapse—which is typically a single drink or brief instance of alcohol use that is not repeated—or you may relapse into a pattern of alcohol use where you feel you cannot control how often or how much alcohol you drink.4

What Are the Risk Factors of Relapse?

To help maintain your recovery and assist with alcohol relapse prevention, it may be helpful to identify risk factors that lead to emotional changes, mental obsessiveness, or physical action related to relapse.

The AA acronym HALT is one of the quickest ways to recognize some of the most basic risk factors to relapse. HALT stands for:4

  • Hungry
  • Angry
  • Lonely
  • Tired

Additional relapse risk factors include:3

  • Boredom
  • Negative mood states
  • Frustration
  • Sadness
  • Sleep problems
  • External pressures to use
  • Decreased cognitive vigilance
  • Inability to concentrate
  • Craving
  • Lack of support
  • Unemployment and financial problems
  • Co-occurring mental health conditions

Importantly, research indicates that there are a number of protective factors that reduce the risk of relapse, including:5

  • Supportive social networks
  • Increasing self-efficacy
  • Longer duration of abstinence
  • Increasing insight
  • Seeking help
  • Having goals
  • Increasing motivation
  • Reducing the availability of alcohol
  • Finding a purpose or meaning to your life

What Is Relapse Prevention Therapy?

Relapse prevention is more than a concept—it’s also a component of addiction treatment. The theory and treatment approach known as “relapse prevention” was introduced in the 1980s. Today, the principles of this theory have been adapted and are often an key part of alcohol addiction treatment plans.4

The relapse prevention program is complemented by other common therapies used in alcohol addiction treatment.

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Relapse Prevention Plan

Relapse prevention is a self-management program that enhances the maintenance stage of alcohol addiction recovery. The program teaches individuals how to anticipate and cope with potential relapse.

Relapse prevention incorporates:2, 3, 4

  • Cognitive interventions, including learning to tolerate cravings and respond to triggers (approach-based goals)
  • Behavioral skills training, including learning to avoid triggering situations (avoidance-based goals)
  • Lifestyle change procedures, including increasing self-efficiency, strengthening social support, and participating in psychoeducation about addiction

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) for individuals and groups has consistently demonstrated effectiveness in treating and reducing the risk of relapse.

Therapists who utilize CBT focus on identifying the thought patterns that lead into specific behaviors. CBT also focuses on learning coping skills for real-life situations. The the development and utilization of these skills that have been shown to impact recovery outcomes.4

Medication-Assisted Therapy

A combination of medication and cognitive-behavioral therapy is seen as the first line treatment for alcohol addiction.6

The FDA-approved medications for treating alcohol addiction are:6

  • Antabuse
  • Naltrexone
  • Acamprosate

Several classes of psychotherapeutic medications, such as certain antidepressants, can also be beneficial and indirectly reduce the use of alcohol.6

Mindfulness-Based Relapse Prevention

Mindfulness-based relapse prevention incorporates evidence-based practices and mind-body relaxation to decrease the probability and the severity of relapse.2

An example of a mindfulness-based relapse prevention technique is sitting meditation. This technique allows the participant to increase their awareness and behavioral flexibility within their daily life.2

What Are the Four Concepts of Relapse Prevention?

Generally, four concepts go along with relapse prevention and recovery. Namely, that relapse prevention and addiction recovery:4

  • Are a gradual process with distinct stages
  • Are a process of personal growth and development
  • Include cognitive therapy and mind-body relaxation to assist in the enhancement and/or development of healthy coping skills
  • Can be explained in a few basic rules
    • Change your life
    • Be completely honest
    • Ask for help
    • Practice self-care
    • Don’t bend or break the rules

How Is a Relapse Prevention Plan Developed?

Alcohol relapse planYour relapse prevention plan is designed to increase your awareness of the factors that could contribute to a possible relapse. It must include a plan of action when you face high-risk situations such as:3

  • Emotional states
  • Urges to use
  • External pressures to use

The plan should include various strategies that increase your self-efficacy in these situations and strengthen your support system.3 When developing your alcohol relapse prevention plan, your treatment team will suggest some strategies and encourage you to decide on other specific to the stressors you think could come up in your recovery.

Relapse happens gradually, typically it begins weeks, sometimes months, before you actually use the substance. The goal of your plan is to help you recognize early warning signs and remind you of helpful coping skills to prevent the lapse/relapse.4

It can be challenging to identify high-risk situations on your own so part of the plan can be to talk through emotional changes, your mindset, and actions you question with your treatment team, therapist, AA sponsor, or another trusted person.

How Does “True” Recovery Happen?

Recovery is defined as a process of personal growth, sometimes divided into the following three stages.4

Abstinence

The abstinence stage typically follows you immediately after you have stopped using and lasts approximately 1-2 years. The main focus of the abstinence stage is to deal with your cravings to drink. A number of tasks during this stage assist with recovery:4

  • Accepting you have an addiction
  • Practicing honesty
  • Developing coping skills
  • Becoming active in self-help groups
  • Practicing self-care and saying “no”
  • Understanding the stages of relapse and of cross-addiction
  • Saying “goodbye” to friends who are still using
  • Dealing with post-acute withdrawal
  • Developing healthy alternatives to using
  • Recognizing yourself as a non-user

It’s important to note that not all research supports equating recovery with lifelong abstinence. Some find that a harm reduction or moderation model provides long-term stability, peace, and healing. Your treatment team can help you find your definition of recovery: a definition that reduces the risk of relapsing into harmful alcohol misuse or misuse of other substances.

Repair

The repair stage has a main focus on repairing damage in your life caused by addiction. This stage usually lasts 2-3 years.4

The main focus is to confront the damage and overcome the guilt and negative self-labeling that often accompanies addiction. Tasks of this stage include:4

  • Using cognitive therapies to dismantle cognitive distortions such as negative self-labeling and negative thinking patterns
  • Understanding that individuals—including you—are not their addiction
  • Repairing relationships and making amends
  • Starting to feel comfortable being uncomfortable
  • Improving your self-care practices
  • Developing a balanced lifestyle that supports recovery
  • Continuing to develop healthy coping skills as alternatives to using substances
  • Continuing to engage in recovery activities, such as peer support groups, specialized therapy, or sober group activities

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Growth

Last is the growth stage, where you develop skills that you may have never learned before. This stage can last 3-5 years in length and includes:4

  • Identifying and repairing negative thinking and self-destructive patterns
  • Understanding how negative familial and other relationship patterns may have influenced you
  • Challenging fears
  • Setting healthy boundaries
  • Beginning to give back and help others

How Should You Respond to a Relapse?

Relapse is not uncommon and normalizing this can help with feelings of shame and guilt. Relapse is also multifactorial, meaning that no one factor is to blame. There are 5 generally accepted rules of recovery:3, 4

  1. Changing your life—Changing your life consists of creating a new life where it is not easy to use alcohol. For most people, only a few things need to change dramatically, but those changes can be critical for reducing the risk of relapse.
  2. Being completely honest—Practice telling the truth, especially to yourself. This also includes honesty with your recovery circle, which includes supportive family and friends, counselors, peer support group members which may include a sponsor, and any other treatment professionals.
  3. Asking for help—Isolation is often part of addiction and part of relapse. Asking for help can mean seeking treatment, joining a peer support group, or asking a friend to be your “sober buddy” at a high-pressure event. Importantly, this also means asking for help with anything that might affect your recovery before it becomes a relapse factor.
  4. Practicing self-care—Self-care in a recovery context is not about bubble baths or indulgent purchases. This kind of self-care is prioritizing your needs, such as using the HALT evaluation, as well as giving yourself time for practices that improve your emotional and mental well-being.
  5. Not bending or breaking the rules—Adhering to the rules means not looking for loopholes or ways to get out of any aspect of recovery.

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Resources

  1. National Institute on Drug Abuse. (2020). Principles of drug addiction treatment: A research-based guide (Third edition).
  2. Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., Carroll, H. A., Harrop, E., Collins, S. E., Lustyk, M. K., & Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders. JAMA Psychiatry, 71(5), 547-556.
  3. Kadam, M., Sinha, A., Nimkar, S., Matcheswalla, Y., & De Sousa, A. (2017). A comparative study of factors associated with relapse in alcohol dependence and opioid dependence. Indian Journal of Psychological Medicine, 39(5), 627-633.
  4. Melemis, S. M. (2015). Relapse prevention and the five rules of recovery. Yale Journal of Biology and Medicine, 88(3), 325-332.
  5. Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97-115.
  6. Rose, G., Skelly, J., Badger, G., Naylor, M., & Helzer, J. (2012). Interactive voice response for relapse prevention following cognitive-behavioral therapy for alcohol use disorders: A pilot study. Psychological Services, 9(2), 174-184.
  7. Spanagel, R., & Vengeliene V. (2013, March 03). New pharmacological treatment strategies for relapse prevention. Current Topics in Behavioral Neurosciences: Behavioral Neurobiology of Alcohol Addiction, 13(205), 583–609.
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