High Risk Situations for Relapse

High Risk Situations for Relapse. Psychology Fanatic article header image
High Risk Situations for Relapse
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Addictions sneak into our lives, wreak havoc and then refuse to leave. Addictions aren’t just bothersome; they’re destructive. They rob lives of value, motivation, and perspective. We lose futures to the accumulating rubble of the insatiable need. The captives of addiction often desire freedom but fail to remain focused long enough to execute the escape. After detoxing, the victorious proudly proclaim, “I did it.” Their righteous joy exploding with hopeful futures. Their accomplishment is commendable, they rid themselves of a noxious poison; however, the final celebration must wait. A dark demon lurks, waiting to pounce, dragging prisoners back to the dungeons. Relapse is real. It threatens all that dance in newfound freedoms of sobriety.

Ramping up the motivation to begin recovery, fighting the lure of the next fix is a formidable challenge. Withdrawal symptoms curse well wishers for their efforts with agonizing sickness. It’s a paradox; we hurt, screaming for an end, but must refrain from the easy cure. Cruelly, the ache and the resolution arise from the same source.

Detox Isn’t Recovery

The physical aches are miserable (dopesickness); although excruciating, they last only a short time, with a distinct beginning and end (see Detox Isn’t Recovery). Recovery is a longer process. Recovering addicts must return to a life where temptations are present. The motivational pricks that pushed detox lose potency; motivation wanes and the decisional balance for sobriety adjusts. In the dark weeks and months of change, demons of relapse haunt the lonely halls. 

Withdrawal symptoms curse well-wishers for their efforts with agonizing sickness. It’s a paradox; we hurt, screaming for an end, but must refrain from the easy cure.

~T. Franklin Murphy

In Mary Addenbrooke’s fascinating book on addiction, she writes, “Unpleasant memories of detoxifying tend to fade over time and act less as a deterrent to lapses. Knowing and understanding the characteristics of addiction and the risk of relapsing are a vital part of recovery” (2011, p. 20).

Power of Addiction

Recovery is an epic struggle between motivation and temptation. The future teeters between success and failure, waiting to see which power prevails.  Drug and alcohol abusers must prepare for these challenges, planning tactics and escapes to combat the urges. The warrior must effectively respond to high-risk junctures for recovery to succeed.

Addiction dulls awareness. The first return to sobriety is frightening, unplanned events and feelings dot the landscape. The awakening frightens. Sobriety isn’t the paradise expected and the flustered recovering addict runs back to the predictable environment of addiction. Addenbrooke explains, “after stopping, anyone who has been addicted is extremely vulnerable.

​The addiction itself has taken a toll both physically and psychologically. They have forgotten how to deal with everyday life without the drug and they have to start learning how to cope. A radical turnaround starts with simple steps in mastering life skills, as well as filling the gap left by the absence of drug-determined activities” (p. 96).

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A Lapse Isn’t the Same as a Relapse

A lapse isn’t the end of the game. Lapses provide wisdom. Above all, a lapse can quickly be addressed, preventing a backward slide. It’s a short term slip that breaks the abstinence goal. A relapse, on the other hand, “is . . . a return to previous pattern of substance use (Kadam, et al., 2017). Many researchers define relapse as a process, instead of a definable event (Menon & Kandasamy, 2018).

An Example of a Lapse

In the early morning hours of a cold winter night, a man sat shivering on a bus bench. He wore dirty jeans and a stretched t-shirt, exposing his chest. He sat alone. The transit system cuts service to this line after midnight. Homeless encampments stretch along the railroad tracks only a few short yards behind the stop. It’s not uncommon for camp residents to seek shelter here from harsh weather. On this night, the man sat alone—crying. His sobbing cut through the crisp air.

“I can’t do it,” he stammered. “I smoked some shards, man.” Earlier in the week, his grandmother that raised him died. After the funeral, he met up old friends, and found emotional escape in old habits—crystal methamphetamine. He lapsed. A single event. A setback. But he viewed the lapse as a failure. He saw his entire year of sobriety lost. His number of ‘days clean’ vanished. The thought of starting over frightened him. His year in recovery was exhausting, the thought of it being for naught, struck deep. “I can’t do it. I can’t go through it all again.” He lost hope.

Days clean is a faulty measurement of progress; it’s incomplete, missing major milestones. We can absorb the setback of a lapse without failing the wider purposes—namely, living again. A year of sobriety includes successes in relationships, cognition, and life management. After a lapse, the accomplishments remain; only the accumulations of “days clean” reset.

Avoiding Complete Relapse

To achieve a sustained recovery, drug and alcohol abusers must avoid devastating relapses, not with magical thoughts, but with effective preparation. Carlos DiClemente, famous for his theories on change, wrote, “patterns of behavior are not usually created, modified, or stopped in a single moment in time or with a single flick of a switch. There are steps or segments to the process . . .” (2005, p. 25). The inevitable struggles of the first year of recovery is a necessary step in the process. Leaving a habitual pattern is uncomfortable—painful and full of anxiety.

Addenbrooke comments about early recovery, “immediately after a person stops. . . they probably have no idea what their expectations of themselves should be. In their addiction people lose track of who they are. The first, tentative steps without the drug have to be taken with this as a starting point.” (2011, p. 116) This is applicable to any major changes. We move from familiar to the unfamiliar. Our role in the new dynamics is undefined. The unpredictableness challenges newly detoxed individuals as they adjust. Small stresses magnify fear and prompt a return to abandoned habits.

Studies repeatedly cite high relapse rates during the first year of recovery, often reaching as high as 90 percent. (Anton, et al., 2006; Dawson, et al., 2005; Smyth, et al., 2010). Threat of relapse is significant. We can’t ignore this menacing risk. Over simplistic advice, “just don’t do it” is insufficient. Lapses loom, destroying unprepared revelers. The delicate moments of early sobriety are vulnerable to countless temptations.

Preparing for Lapses by Identifying High Risk Situations

We must address lapses before they explode into a relapse. A lapse doesn’t need to be disheartening. A momentary slip doesn’t demand a discouraging resignation, “the hell with it. I can’t do this.”

DiClemente warns, “the new behavior must be sustained over time in order to create the new habit. A behavior cannot simply be done several times and automatically become established. The old pattern retains its attraction and returning to it is often easier than sustaining a new pattern. It takes a long time to establish a new pattern of behavior” (2005, p. 29).

Art Markman, author and professor of psychology, wrote, “the problem you face when changing your behavior is that every behavior you want to change now is one that your brain is trying hard to maintain“ (2015, location 140). DiClemente refers to addiction as a position of stability. On the opposite end of the spectrum, sustained recovery is also a position of stability.

Drug and Alcohol Use a Conditioned Response to Adversity

​Moving towards addiction or sustained recovery is transitory and difficult. “Once it is well maintained, the addiction becomes integrated into the entire life context of the individual.” (2005, p. 56). Life builds around the addiction, interpreting everything from that context. Change phases are unstable. We are still programmed to react from the recently left past. During the first months of recovery, our brain defaults to problem behaviors that were connected to the addicted lifestyle.

We lapse. We are programmed to return to the mire when the going gets tough. Author of Games Alcoholics Play, Claude M. Steiner, remarked, “It has been my experience that every alcoholic, after some months of sobriety, drinks again” (1984, location 2091).

Conditioned Responses and Stress

​Old behaviors spontaneously occur in response to stress. “Often the addiction becomes prepotent in the life of the individual and an integral part of the individual’s way of life and coping (DiClemente, 2018, p. 4). While in addiction, intoxication is the answer to everything. In recovery, we can’t rely on untested self-efficacy to resist the continuous urges. Our willpower is finite, eventually weakening, when depleted we lapse. Over reliance on self-control is foolishness. We must set protective new patterns to avoid overwhelming temptations.

Addenbrooke adds, “It is a time of unique vulnerability for the person who has just stopped, for they plummet into a time of radical readjustment without the familiar prop of the drug. If the pitfalls of relapse are avoided successfully, the experience of meeting the challenges successfully can form a basis for building confidence” (2011, p. 89).

In the Classic, The Art of War, Sun Tzu taught that, “If equally matched, we can offer battle; if slightly inferior in numbers, we can avoid the enemy; if quite unequal in every way, we can flee from him” (2007, pp. 10-11). His wisdom is applicable to personal battles in addiction.

Relapse Prevention Model and High Risk Situations

Marlatt’s and Gordon’s relapse prevention model has influenced addiction theory, research and treatment for over 35 years. Relapse Prevention (RP) provides timeless wisdom to prepare warriors for battle by identifying threats and developing skills. The relapse prevention model, through painstaking research, has identified the foes likely to precipitate lapses (Donovan & Marlatt, 2005, p. 3). By being familiar with the hostile assailant, we can act with confidence, deciding whether to go to battle, avoid conflict or run like hell. Envisioning future threats and making appropriate adjustments in advance requires a cognitive process we refer to as episodic foresight.

Three high risk Situation we must identify to prevent relapse are:

Negative Emotional States

The primary enemy is negative emotional states. Research found that negative emotional states are associated with the highest rates of relapse (Larimer, et al., 1999).

When we feel sad, angry, or bored, our bodies seek resolution. We are driven to balance, reestablishing homeostasis. During addiction, abusers typically numb the pain. Drugs and alcohol are negative reinforcers, rewarding use by removing the negative (discomforting emotion). Even though we detoxified and freed our physical system from dependence, our psychologically conditioned responses remain—difficulties ignite urges. In a recent study, the most common reason cited for relapse was the desire for a positive mood (Kadam, et al., 2017).

A heroin drug user explained, “it’s like a total explosion that blocks you out from your surroundings. You just instantly forget everything that bothers you. You just feel a total peace with yourself. . . It’s like nothing can put you in the troubles, no matter how difficult your problems are (Nasir & Rosenthal 2009) While dousing emotional pain with chemicals softens the impact, the intoxication leaves troubles intact. Healthy coping manages emotions while addressing the woes.

Relationships and Recovery

Relationships are necessary for recovery. Overall, we can’t recover privately. We need others to regain independence. In recovery, we discover the vulnerability of trust. During recovery, needs are substantial, magnifying vulnerabilities. We need others to support the journey.

However, along with relationships comes conflict. Social struggles often play a primary role in addiction. In recovery we must face our social incompetence. These demons remain and must be overcome.

Interpersonal conflict exaggerates fear, giving rise to intense emotions. These conflicts create high-risk situations, warning of an approaching lapse. An alert warrior takes heed. Old friends do what old friends have always done together. Social connections maintained during addiction typically share drug and alcohol dependency.

When addictions take control, we find social circles that are accepting, alleviating friction and guilt. The addicted crowd lovingly shares wounds of bondage and scars of oppression, complaining in bitterness, frustration and resentment about the outside world. However, these friends accept the “addicted” you, not the “recovering” you. A person in recovery ignites their guilt. Their trepidation creates discomfort, creating dangerous shifts in the decisional balance against continuing in recovery.

DiClemente warns, “breaking away from the addicted world either geographically or symbolically” is crucial for recovery, with the final stage of change being “a transformation of social identity” (2005, p. 178). During change, we don’t fit in. We’re not “normal,” and we’re not “addicted.”  Hence, recovery groups help, reminding us we’re not alone on this unnerving journey.

The addicted crowd lovingly shares wounds of bondage and scars of oppression, complaining in bitterness, frustration and resentment about the outside world.

~T. Franklin Murphy

Old social circles contain countless triggers, generating cues to use, extended exposures overwhelm, we weaken and fall.

Old Environments Cue Old Behaviors

Maslov is famous for his “salivating dogs” experiments. A staple of basic psychology courses. He conditioned dogs to salivate at the sound of a bell by repeatedly pairing the bell with food. DiClemente explains the operant conditioning of addiction, “Otherwise neutral sights, sounds, scenes, and behaviors that tend to occur with the drug taking become capable of producing by themselves the drug’s physiological reaction. Many behaviors and situations that previously were unrelated to the addictive behavior become potent signals that arouse physiological and psychological states that feed desire and temptation” (2005, p. 46).

In recovery, constant bells are ringing, and we salivate for our drug of choice. Cues permeate everything.  In serious addictions, drug and alcohol abusers construct entire worlds around consumption. Eventually, the potency of cues weakens. We must mindfully be aware of cues, identify them, know their strength, and prepare appropriately.

Seemingly Insignificant Decisions and Relapse

​We overlook pressures that lead to a fall, forecasting presupposes a clear distinct choice—I will, or I will not use. Consequently, the newly detoxified abuser declares they would never use again because they envision a simple choice. The return to bondage is unthinkable. However, the simple choice is never encountered. Relapse is the final scene at the end a of a sequence of Seemingly Irrelevant Decisions (Menon & Kandasamy, 2018).

Marlatt explained, “Seemingly insignificant changes in one risk factor (e.g., an undetected reduction in self-efficacy) may kindle a downward spiral of increased craving, positive outcome expectancies, and intensified negative affect. These small changes may result in a major relapse, often initiated by a minor cue” (Donovan & Marlatt 2005, p. 20).

Dragged to the Dramatic Conclusion

Famous philosopher and author, Erich Fromm believes that small justified choices drag the actor to the dramatic conclusion. He suggests that by the time of the final choice, the decision has already been made (2010, location 1871). Accordingly, we must vigilantly watch for seemingly insignificant movements, slowly shifting attitudes and eroding strength.

Jim Orford, renown in the field of addiction, concurs. He believes consumption habits are not “simply discrete, isolated behavioural acts,” he continues, “but rather as whole sequences and chains of actions which. . . lead up to consumption . . . accompanied by a host of cues, prompts and encouragements” (2013, p. 54).

The lapse follows a string of insignificant choices. Accordingly, the disastrous path becomes increasingly difficult as we slide down inviting slopes. Surprise! the seemingly insignificant decisions were actually woefully significant. At the crescendo, Fromm argues, freedom is no longer available. “But since his desire makes him blind . . .he does not make the right choice when he still would have the possibility of doing so. At the last point of the chain . . . he is no longer free. . .” (Fromm, 2010, location 1892).

As Sun Tzu warned, we are “quite unequal” to match some enemies and should avoid battle. Orford states that in addiction “ability to govern” is compromised (2013, p. 38). We must structure defenses that compensates for diminished power. We must avoid battles by recognizing dangers early. Basically, relapse prevention brings high-risk situations to awareness, moving choice to a position where we can intervene, where we are “still free to act according to reason . . .” (Fromm, location 1892).

A Few Words By Psychology Fanatic

We must prepare action plans that prevent high-risk situations from developing into irresistible temptations. Markedly, we remain in a position of power by finding new forms of restraint, borrowing power from external resources. We can call a sponsor, practice new coping skill, get lost in new passions, or simply run away. But these must be planned and used early in the sequence of seemingly insignificant decisions. If our planned action plan works, keep it; if it doesn’t, scrap it and try something else.

When we feel discomforting emotions, argue with a spouse, stumble on powerful cues, we can reach into our bag of tricks and activate the preventative plan, building confidence and increasing self-efficacy as we establish new habits in sobriety.

The beauty of relapse prevention is that countless people have made it through the pangs of addiction, reestablished life in sustained recovery. Eventually, the dungeons of addiction become a distant memory from the past. Through persistence, supportive others, and vigilance, the successful destroy the daunting enemies, move forward, and stand as a shining example. We can recover from lapses, learn important lessons, strengthen our resolve, and prevent a devastating relapse. We can recover. Accordingly, We can make it to a place where life settles and find peace and joy.

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Addenbrooke, Mary (2011) Survivors of Addiction: Narratives of Recovery. Routledge; 1 edition.

Anton RF, O’Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, et al. (2006) Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA 2006; 295:2003-17.

Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. (2005) Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction 2005; 100:281-92.

DiClemente, C. C (2005) Addiction and Change, Second Edition: How Addictions Develop and Addicted People Recover. The Guilford Press; Second edition.

Donovan, D. M., & Marlatt, G. A. (2005) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. The Guilford Press.

Fromm, E. (2010) The Heart of Man: Its Genius for Good and Evil. American Mental Health Foundation Books.

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). Retrieved from Questia.

Larimer, M. E., Palmer, R. S., & Marlatt, G. A. (1999). Relapse Prevention: An Overview of Marlatt’s Cognitive-Behavioral Model. Alcohol Research, 23(2), 151.

Markman, A. (2015). Smart Change: Five Tools to Create New and Sustainable Habits in Yourself and Others. TarcherPerigee; Reprint edition.

Menon, J., & Kandasamy, A. (2018). Relapse Prevention. Indian Journal of Psychiatry, 60(8). Retrieved from Questia.

Nasir, S., & Rosenthal, D. (2009). The social context of initiation into injecting drugs in the slums of Makassar, Indonesia. International Journal of Drug Policy, 20(3), 237-243.

Orford, J. (2013) Power, Powerlessness and Addiction. Cambridge University Press. 

Smyth BP, Barry J, Keenan E, Ducray K. Lapse and relapse following inpatient treatment of opiate dependence. Ir Med J 2010;103:176-9.

Steiner, C.M. (1984) Games Alcoholics Play. Ballantine Books; Reissue edition.

Tzu, S (2007) The Art of War. Filiquarian; First Thus edition.

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