Relapse prevention is a critical aspect of addiction treatment, and individuals often seek help because they’ve struggled to quit on their own. This article provides a practical approach to relapse prevention, suitable for both individual and group therapy, focusing on the vital role of self-care tools.
There are four core principles in relapse prevention. Firstly, relapse is a gradual process occurring in distinct stages. Effective treatment aims to help individuals identify these early stages, maximizing the chances of successful intervention [1]. Secondly, recovery is a journey of personal development with specific milestones, each stage presenting unique relapse risks [2]. Thirdly, cognitive therapy and mind-body relaxation are essential tools in relapse prevention, fostering healthy coping mechanisms and altering negative thought patterns [3]. Finally, most relapses can be understood through a few fundamental rules [4]. Educating individuals about these rules empowers them to concentrate on crucial aspects of recovery. These rules include: 1) life transformation towards a substance-free existence; 2) unwavering honesty; 3) seeking support; 4) prioritizing self-care; and 5) strict adherence to recovery principles.
This article will delve into these principles, offering an overview of relapse prevention and highlighting the significance of self-care tools in addiction medicine.
The Gradual Nature of Relapse: Recognizing the Stages
Understanding that relapse unfolds gradually is fundamental to prevention [6]. It often begins weeks or even months before actual substance use. Treatment focuses on equipping individuals to recognize early relapse warning signs and develop coping strategies to intervene effectively at the earliest stages, where success is most likely. This approach has proven to significantly decrease relapse risk [7]. While Gorski outlines 11 relapse phases [6], a simplified model of emotional, mental, and physical relapse stages can be more accessible and helpful for clients [4].
Emotional Relapse: Neglecting Self-Care
Emotional relapse is characterized by behaviors and emotions that, while not involving thoughts of substance use, pave the way for future relapse. Individuals in this stage recall their last relapse and are determined to avoid repetition. However, denial is a significant component of emotional relapse, as individuals are not consciously considering substance use.
Signs of emotional relapse include: 1) suppressing emotions; 2) social isolation; 3) avoiding support meetings; 4) attending meetings but remaining silent; 5) excessive focus on others’ problems or perceived impact of others; and 6) neglecting healthy eating and sleeping habits [1]. The unifying factor in emotional relapse is inadequate self-care, encompassing emotional, psychological, and physical well-being.
What Does Self Care Tools Mean In Addiction at this stage? Self-care tools are strategies and practices individuals use to nurture their emotional, psychological, and physical health. In early recovery, especially during emotional relapse, these tools are crucial for stability. For some, self-care tools may start with basic physical needs like ensuring enough sleep, maintaining hygiene, and eating nutritious food. For many, it involves emotional self-care tools, such as dedicating time for oneself, practicing self-compassion, and allowing oneself to enjoy pleasurable activities. Therapy often revisits these topics: “Are you feeling drained again? Are you being kind to yourself? How are you incorporating fun into your life? Are you making time for yourself, or are you getting overwhelmed by daily demands?”
A useful reminder of basic self-care needs is the acronym HALT: Hungry, Angry, Lonely, Tired. Recognizing and addressing these states can be a fundamental self-care tool.
Another therapeutic goal at this stage is to help individuals recognize their denial. Comparing current behaviors to those during past relapses can illuminate whether self-care is improving or deteriorating.
Prolonged neglect of self-care and continued emotional relapse naturally lead to mental relapse. Living in emotional relapse for an extended period causes discomfort and unease, eventually leading to restlessness, irritability, and discontent, which can trigger thoughts of substance use as an escape.
Mental Relapse: The Internal Battle
Mental relapse is characterized by internal conflict. A part of the individual desires substance use, while another part resists. As mental relapse progresses, cognitive resistance weakens, and the urge to escape intensifies.
Signs of mental relapse include: 1) cravings for drugs or alcohol; 2) dwelling on people, places, and things associated with past substance use; 3) minimizing negative consequences or romanticizing past use; 4) bargaining with oneself about substance use; 5) lying about cravings or thoughts of use; 6) devising schemes to control future use; 7) seeking out relapse opportunities; and 8) actively planning a relapse [1].
Avoiding high-risk situations is a crucial therapeutic objective. However, individuals often underestimate their high-risk situations and the actual danger they pose, sometimes perceiving avoidance as weakness.
Bargaining involves creating justifications for substance use, such as permitting use during holidays or vacations. Airports and all-inclusive resorts, for instance, are frequently high-risk environments in early recovery. Another form of bargaining is contemplating controlled relapse, perhaps once or twice a year, or substituting one addictive substance for another.
Occasional, fleeting thoughts of use are normal in early recovery and differ from mental relapse. Individuals entering treatment often express a desire to never think about substance use again. Discovering persistent cravings can be distressing, leading to feelings of failure and disappointment. Reluctance to discuss these thoughts due to embarrassment is common.
Normalizing occasional thoughts of use in therapy is essential. They do not signify impending relapse or recovery failure. Addiction leaves lasting memories, but effective coping skills can enable individuals to quickly dismiss these thoughts.
Clinicians differentiate mental relapse from occasional thoughts by monitoring behavioral trends over time. Warning signs include changes in the nature of thoughts of use, such as increased insistence or frequency.
Physical Relapse: The Act of Using
Physical relapse occurs when substance use resumes. Some researchers differentiate between a “lapse” (initial use) and a “relapse” (return to uncontrolled use) [8]. However, emphasizing the amount used during a lapse can diminish the perceived consequences of even a single instance. One drink or drug use can rapidly lead to a relapse of uncontrolled use and, more immediately, to mental relapse characterized by obsessive thoughts about substance use, ultimately increasing the risk of physical relapse.
Most physical relapses are “relapses of opportunity,” happening when individuals perceive a window where they believe they won’t be caught. Relapse prevention includes rehearsing these scenarios and developing healthy exit strategies.
Without relapse prevention understanding, individuals may believe it’s about resisting use at the last moment. However, this late stage is the most challenging to stop, explaining why relapses occur. Prolonged mental relapse without adequate coping skills increases the likelihood of turning to substances to escape emotional turmoil.
Cognitive Therapy and Relapse Prevention: Restructuring Thought Patterns
Cognitive therapy is a primary tool for modifying negative thinking and building healthy coping mechanisms [9,10]. Its effectiveness in relapse prevention is well-documented [11].
Negative thought patterns that hinder recovery and are addressed in cognitive therapy include: 1) blaming others for their problems; 2) believing inability to cope without substances; 3) considering occasional controlled use; 4) fearing life will be unenjoyable without substances; 5) worrying about personality changes in recovery; 6) feeling incapable of making necessary changes, like changing social circles; 7) fearing abandonment of family; 8) perceiving recovery as too demanding; 9) fearing overwhelming cravings; 10) anticipating relapse as inevitable due to past failures; 11) believing relapse can be kept secret; and 12) doubting the possibility of recovery due to addiction-related damage.
Underlying addictive thinking are often patterns like all-or-nothing thinking, dismissing positives, catastrophizing, and negative self-labeling [9]. These thoughts can generate anxiety, resentment, stress, and depression, all contributing to relapse risk. Cognitive therapy and mind-body relaxation help break old habits and rewire neural pathways, fostering healthier thought patterns [12,13].
Fear: A Common Obstacle
Fear is a prevalent negative thought pattern in addiction [14]. Categories of fearful thinking include: 1) fear of inadequacy; 2) fear of judgment; 3) fear of being exposed as a fraud; 4) fear of navigating life without substances; 5) fear of success; and 6) fear of relapse.
A fundamental fear in recovery is self-doubt in one’s recovery capacity, believing it requires extraordinary willpower lacking in oneself. Past relapses are often seen as proof of this inadequacy [9]. Cognitive therapy helps reframe recovery as skill-based, not willpower-dependent.
Redefining Fun: Shifting Perspectives
Therapy plays a key role in redefining “fun.” Under stress, individuals may romanticize past substance use, viewing recovery as arduous and addiction as enjoyable, while minimizing recovery gains. The cognitive challenge is to acknowledge recovery’s difficulties but recognize addiction’s greater hardships. If addiction were truly easy, quitting wouldn’t be necessary or desired.
Continuing to label using days as “fun” downplays addiction’s negative impacts. Expectancy theory shows that anticipated fun often materializes, and anticipated lack of fun usually does too [15]. Initially, substance use can be a positive experience for predisposed individuals. Later, even when it becomes negative, the expectation of positivity often persists. Addicts often chase past “highs.” Conversely, they anticipate discomfort and boredom from abstinence, which they initially sought to escape. Cognitive therapy addresses both these misconceptions.
Learning from Setbacks: Reframing Perceptions
How setbacks are handled significantly impacts recovery. A setback is any behavior increasing relapse risk, such as neglecting boundaries, help-seeking, high-risk situation avoidance, or self-care. Setbacks, even without leading to relapse, are valuable therapy discussion points.
Recovering individuals often view setbacks as failures due to self-criticism [9], creating a vicious cycle reinforcing negative self-views and feelings of inability to cope, potentially leading to further substance use and deeper failure feelings. Progress is overlooked, and the future appears overwhelming [16].
Setbacks are normal progress components, not failures. They stem from insufficient coping skills or planning, which are correctable [8]. Encouraging clients to acknowledge past successes and strengths challenges negative thinking and counters global negative self-statements like “This proves I’m a failure.” All-or-nothing thinking regarding recovery increases feelings of being overwhelmed and abandoning long-term goals for short-term relief, known as the Abstinence Violation Effect [8].
Embracing Discomfort: A Key to Long-Term Recovery
Recovering individuals need to become comfortable with discomfort. They often assume non-addicts don’t experience similar negative emotions, justifying substance use as an escape. The cognitive challenge is to present negative feelings as normal, not failures, but opportunities for growth. Accepting discomfort reduces the urge to escape into addiction.
Stages of Recovery: A Developmental Perspective
Recovery is a developmental journey where each stage presents unique relapse risks and developmental tasks [2]. Stage durations vary, but they provide a useful framework for understanding and teaching recovery. Broadly, there are three stages, originally termed “transition, early recovery, and ongoing recovery” [2], and more descriptively, “abstinence, repair, and growth.”
Abstinence Stage: Establishing Sobriety
The abstinence stage, typically lasting 1-2 years, begins immediately after cessation of substance use [1]. The primary focus is managing cravings and maintaining abstinence. Tasks include:
- Accepting addiction
- Practicing honesty
- Developing craving coping skills
- Engaging in self-help groups
- Practicing self-care and assertiveness (“saying no”)
- Understanding relapse stages
- Disconnecting from substance-using peers
- Recognizing cross-addiction risks
- Managing post-acute withdrawal
- Developing healthy substance-free alternatives
- Adopting a non-user identity
Risks at this stage include physical cravings, self-care neglect, urges for “one more time,” and internal struggles with addiction acceptance. Clients may be eager for major life changes early on, but it’s generally advised to postpone significant changes for the first year to gain perspective and avoid solely blaming external factors.
The core tasks are enhanced physical and emotional self-care. Clients often rush to bypass these, but it’s crucial to emphasize that neglecting self-care contributed to addiction and will likely lead back to relapse.
Post-Acute Withdrawal: The Lingering Effects
Managing post-acute withdrawal is a key task of the abstinence stage [1]. Post-acute withdrawal begins after acute withdrawal and is a common relapse trigger [17]. Unlike acute withdrawal’s physical symptoms, post-acute withdrawal syndrome (PAWS) primarily presents psychological and emotional symptoms, which are often similar across different addictions, unlike addiction-specific acute withdrawal symptoms [1].
PAWS symptoms include: 1) mood swings; 2) anxiety; 3) irritability; 4) fluctuating energy levels; 5) low enthusiasm; 6) variable concentration; and 7) sleep disturbances [1,18,19]. Many symptoms overlap with depression, but PAWS symptoms are expected to gradually improve.
Understanding PAWS’s prolonged duration, potentially up to 2 years, is crucial [1,20]. Symptoms tend to fluctuate, with symptom-free periods followed by recurrences, increasing relapse risk if individuals are unprepared for this protracted nature. PAWS can lead to catastrophizing and perceived lack of progress. Encourage clients to measure progress monthly rather than daily or weekly.
Repair Stage: Addressing the Damage
The repair stage, typically lasting 2-3 years, focuses on repairing addiction-related damage [2]. While the abstinence stage often brings initial improvement, the repair stage can temporarily feel worse as individuals confront damage to relationships, careers, finances, and self-esteem. Guilt and negative self-labeling from addiction must be addressed. Clients may doubt their capacity for joy, confidence, or healthy relationships [9].
Developmental tasks of the repair stage include:
- Using cognitive therapy to overcome negative self-labeling and catastrophizing
- Understanding separation of self from addiction
- Repairing relationships and making amends
- Cultivating comfort with discomfort
- Enhancing self-care as an integral recovery component
- Developing a balanced, healthy lifestyle
- Continuing self-help group engagement
- Expanding healthy substance-free alternatives
Common relapse causes in this stage are self-care neglect and self-help group disengagement.
Growth Stage: Moving Forward
The growth stage, typically beginning 3-5 years into recovery and continuing lifelong, focuses on developing skills possibly never learned, which may have predisposed individuals to addiction [1,2]. The repair stage was about catching up; the growth stage is about moving forward.
This is the time to address family-of-origin issues or past trauma, issues clients are sometimes eager to tackle prematurely. However, these can be stressful, and early engagement without adequate coping skills can lead to relapse.
Growth stage tasks include:
- Identifying and modifying negative thinking and self-destructive patterns
- Understanding intergenerational negative family patterns to release resentments and move forward
- Challenging fears using cognitive therapy and mind-body relaxation
- Setting healthy boundaries
- Engaging in giving back and helping others
- Periodically re-evaluating lifestyle to maintain recovery trajectory
These tasks mirror life skills needed by everyone. For non-addicts, lacking these skills may lead to unhappiness; for recovering individuals, it can lead to unhappiness and relapse.
Late-Stage Relapse Causes
Late-stage recovery presents unique relapse risks:
- Desiring to put addiction behind them, leading to reduced focus on recovery and less meeting attendance.
- Improved life quality leading to self-care neglect, increased responsibilities, and attempts to compensate for lost time, reverting to old patterns without substances, and abandoning healthy recovery practices.
- Feeling meetings are no longer providing new insights, leading to less frequent attendance. It’s important to remember meetings reinforce understanding of the “addiction voice,” which is easily forgotten.
- Feeling “beyond the basics” and embarrassed to discuss fundamental recovery aspects, like cravings or questioning the reality of past addiction.
- Believing improved understanding of substances enables controlled relapse or avoidance of negative consequences.
The Five Rules of Recovery: Practical Guidelines
Based on over 30 years of clinical experience, most relapses can be explained by a few basic rules [4]. These rules simplify recovery and highlight its attainability: 1) change your life; 2) be completely honest; 3) ask for help; 4) practice self-care; and 5) don’t bend the rules.
Rule 1: Transform Your Life
Recovery isn’t just about abstinence; it’s about creating a new life where sobriety is easier. Without life changes, addiction-contributing factors will resurface.
Clients and families often hope to avoid change, desiring their “old life back, without the using.” It’s crucial to reframe change as an opportunity, not a negative. Necessary changes can lead to greater happiness than before addiction—the “silver lining,” forcing life reevaluation and changes non-addicts may avoid.
Change can feel overwhelming. Emphasize that often only a small portion of life needs changing and that common changes are often needed.
Examples of Necessary Changes
Three categories of change include:
- Modifying negative thinking patterns (discussed earlier)
- Avoiding substance-related people, places, and things
- Incorporating the five rules of recovery
Developing a healthy aversion to substance-related cues is vital but requires mental retraining as these were previously associated with positive emotions. Perceiving this aversion as weakness is a common misconception.
Rule 2: Embrace Complete Honesty
Addiction necessitates dishonesty—obtaining substances, hiding use, denying consequences, and planning relapses. Eventually, addicts lie to themselves. Inability to be completely honest signals emotional relapse. “Recovering individuals are as sick as their secrets.” Therapy helps practice truth-telling and immediate correction of misstatements.
How much honesty is appropriate without jeopardizing work or relationships? Introduce the concept of a “recovery circle”—family, doctors, counselors, self-help groups, sponsors—where complete honesty is encouraged. The circle can expand as comfort grows.
A common misinterpretation is honesty about others’ flaws. Honesty is self-directed. “Uncomfortably honest” sharing within the recovery circle is a good gauge, especially in self-help groups where participation can become rote.
Honesty about past lies is generally preferable, unless it harms others [14,21].
Rule 3: Seek Support
Most initially attempt solo recovery, wanting to prove control and challenge negative perceptions. Self-help group participation significantly boosts long-term recovery chances. Combining treatment programs and self-help groups is most effective [22,23].
Numerous self-help groups exist, including 12-step programs like Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and others, as well as alternatives like Women for Sobriety and SMART Recovery. Regular meeting attendance, sponsorship, 12-step literature engagement, and abstinence goals maximize 12-step group benefits [24,25].
Self-help group benefits include: 1) feeling less alone; 2) recognizing the “addiction voice” in others; 3) learning successful recovery strategies and coping skills; and 4) having a non-judgmental safe space.
Overcoming guilt and shame, common addiction-related emotions and recovery barriers, is a key benefit. Self-help groups demonstrate that individuals are not alone and that recovery is achievable.
Reasons for avoiding self-help groups include: 1) fear of admitting addiction; 2) desire for self-reliance; 3) dislike of groups; 4) self-perception as a “non-joiner”; 5) fear of public speaking; 6) fear of “AA addiction”; 7) fear of recognition; and 8) discomfort with religious aspects. Cognitive therapy can address the negative thinking underlying these objections.
Rule 4: Prioritize Self-Care
Understanding why people use substances highlights self-care’s importance. Escape, relaxation, and self-reward are primary substance use motivations [4]. Acknowledging these benefits in therapy motivates individuals to find healthy alternatives and understand the importance of what does self care tools mean in addiction.
Self-care, though vital, is often neglected. Without it, relapse can occur despite other recovery efforts. Self-care is challenging because recovering individuals tend to be self-critical [9], either overtly feeling undeserving of self-kindness or covertly claiming self-care while being ruthlessly self-critical. Self-care is particularly difficult for adult children of addicts [27].
Distinguishing selfishness from self-care is key. Selfishness is taking more than needed; self-care is taking what’s needed. Addicted individuals often take less than needed, leading to exhaustion, resentment, and substance use for escape or relaxation. Challenging addictive thinking involves recognizing that self-care is not selfish; you cannot effectively care for others if you neglect yourself.
Substance use is not only for escaping negative emotions but also for reward and enhancing positive emotions [11]. Self-care neglect plays a role here too. For example, after achieving a goal, celebration is desired, but all-or-nothing thinking might lead to denying small rewards during work, making substance use the only “sufficient” reward at completion.
Self-Care: Mind-Body Relaxation Techniques
Mind-body relaxation significantly reduces substance use and is effective for long-term relapse prevention [28,29]. Relapse prevention therapy and mind-body relaxation are often combined into mindfulness-based relapse prevention [30].
Mind-body relaxation’s roles in recovery include: 1) stress and tension reduction, common relapse triggers; 2) facilitating release of negative thoughts like rumination and worry, also relapse triggers; and 3) practicing self-kindness. Self-care during relaxation extends to self-care in daily life. Finding time for relaxation is part of creating a new recovery life.
Rule 5: Adhere to Recovery Principles
This rule reminds individuals to avoid resisting or undermining change by insisting on “doing recovery their way.” Looking for loopholes in recovery is a sign of rule-bending. Consistently ignoring professional advice while seeking help is another warning sign.
Long-term recovery clients can be categorized as non-users or denied users. Non-users acknowledge past substance use enjoyment but recognize its recent negativity and are ready for a new chapter.
Denied users cannot fully acknowledge their addiction’s extent or imagine life without substances. They secretly plan future substance use. Recovery milestones can be seen as justifications for use. Alternatively, reaching milestones can create a false sense of recovery completion, leading to beliefs about controlled future use. Relapses after years of sobriety often stem from this.
Identifying as a non-user or denied user is crucial. Denied users are in chronic mental relapse and high-risk. Early recovery often starts with being a denied user; the goal is to transition to becoming a non-user.
Conclusion: Embracing a New Life Through Self-Care
Recovery is not just about stopping substance use; it’s about creating a new, supportive life. Without life changes, addiction triggers persist. Many begin recovery hoping to reclaim their old life without substances, but relapse is a gradual process starting long before actual use. Emotional, mental, and physical stages characterize relapse, with self-care neglect being the common thread in emotional relapse. Insufficient self-care leads to discomfort and seeking escape, relaxation, or reward, often through substances. Treatment aims to foster early relapse sign recognition and coping skills for early intervention. Most relapses are explained by simple rules. Understanding these rules, especially the importance of self-care tools, helps individuals focus on essential aspects: 1) life transformation; 2) honesty; 3) help-seeking; 4) self-care practice; and 5) rule adherence.
Abbreviations
HALT Hungry, Angry, Lonely, and Tired
AA Alcoholics Anonymous
NA Narcotics Anonymous
MA Marijuana Anonymous
CA Cocaine Anonymous
GA Gamblers Anonymous
ACA Adult Children of Alcoholics
PAWS post-acute withdrawal syndrome
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