Warning Sign and Triggers Relapse Prevention

Relapse is usually caused by a combinations of factors. Some possible factors and warning signs might be: * Stopping medications on one’s own or against the advice of medical professionals * Hanging around old drinking haunts and drug using friends – slippery places * Isolating – not attending meetings – not using the telephone for support * Keeping alcohol, drugs, and paraphernalia around the house for any reason * Obsessive thinking about using drugs or drinking

* Failing to follow ones treatment plan – quitting therapy – skipping doctors appointments * Feeling overconfident – that you no longer need support * Relationship difficulties – ongoing serious conflicts – a spouse who still uses * Setting unrealistic goals – perfectionism – being too hard on ourselves * Changes in eating and sleeping patterns, personal hygiene, or energy levels * Feeling overwhelmed – confused – useless – stressed out * Constant boredom – irritability – lack of routine and structure in life * Sudden changes in psychiatric symptoms

* Dwelling on resentments and past hurts – anger – unresolved conflicts * Avoidance – refusing to deal with personal issues and other problems of daily living * Engaging in obsessive behaviors – workaholism – gambling – sexual excess and acting out * Major life changes – loss – grief – trauma – painful emotions – winning the lottery * Ignoring relapse warning signs and triggers

Relapse Prevention
Preventing relapse requires that we develop a plan tailored to maintaining new behavior. The plan involves integrating into our behavior diversion activities, coping skills, and emotional support. Our decision to cope with cravings is aided by knowing: (1) there is a difference between a lapse and a relapse; and (2) continued coping with the craving while maintaining the new behavior will eventually reduce the craving. Coping Skills for Relapse Prevention

These coping skills can make the difference when cravings are intense: * Ask for help from an experienced peer and use relaxation skills to reduce the intensity of the anxiety associated with cravings. * Develop alternative activities, recognize “red flags,” avoid situations of known danger to maintaining new behavior, find alternative ways of dealing with negative emotional states, rehearse responses to predictably difficult events, and use stress management techniques to create options when the pressure is intense. * Reward yourself in a way that does not undermine your self-caring efforts. * Pay attention to diet and exercise to improve mood, reduce mood swings, and provide added strength to deal with stressful circumstances and secondary stress symptoms, including loss ofsleep, eating or elimination problems, sexual difficulties, and breathing irregularities. Steps for Relapse Prevention

There are nine steps in learning to recognize and stop the early warning signs of relapse. Step 1: Stabilization:
Relapse prevention planning probably won’t work unless the relapser is sober and in control of themselves. Detoxification and a few good days of sobriety are needed in order to make relapse prevention planning work. Remember that many patients who relapse are toxic. Even though sober they have difficulty thinking clearly, remembering things and managing their feelings and emotions. These symptoms get worse when the person is under high stress or is isolated from people to talk to about the problems of staying sober. In early abstinence go slow and focus on basics. The key question is “What do you need to do to not drink today?” Step 2: Assessment:

The assessment process is designed to identify the recurrent pattern of problems that caused past relapses and resolve the pain associated with those problems. This is accomplished by reconstructing the presenting problems, the life history, the alcohol and drug use history and the recovery relapse history. By reconstructing the presenting problems the here and now issues that pose an immediate threat to sobriety can be identified and crisis plans developed to resolve those issues. The life history explores each developmental life period including childhood, grammar school, high school, college, military, adult work history, adult friendship history, and adult intimate relationship history. Reviewing the life history can surface painful unresolved memories. It’s important to go slow and talk about the feelings that accompany these memories. Once the life history is reviewed, a detailed alcohol and drug use history is reconstructed. This is be done by reviewing each life period and asking four questions: (1) How much alcohol or drugs did you use?

(2) How often did you use it?
(3) What did you want alcohol and drug use to accomplish?
(4) What were the real consequences, positive and negative, of your use? Finally, the recovery and relapse history is reconstructed. Starting with the first serious attempt at sobriety each period of abstinence and chemical use is carefully explored. The major goal is to find out what happened during each period of abstinence that set the stage for relapse. This is often difficult because most relapsers are preoccupied with their drinking and drugging and resist thinking or talking about what happened during periods of abstinence. Step 3: Relapse Education:

The education needs to reinforce four major messages:
First, relapse is a normal and natural part of recovery from chemical dependence. There is nothing to be ashamed or embarrassed about. Second, people are not suddenly taken drunk. There a progressive patterns of warning signs that set them up to use again. These warning signs can be identified and recognized while sober. Third, once identified recovering people can learn to manage the relapse warning signs while sober. Fourth, there is hope. A new counseling procedure called relapse prevention therapy can teach recovering people how to recognize and manage warning signs so a return to chemical use becomes unnecessary. Step 4: Warning Sign Identification:

Relapsers need to identify the problems that caused relapse. The goal is to write a list of personal warning signs that lead them from stable recovery back to chemical use. There is seldom just one warning sign. Usually a series of warning signs build one on the other to create relapse. It’s the cumulative affect that wears them down. The final warning sign is simply the straw that breaks the camel’s back. Unfortunately many of relapsers think it’s the last warning sign that did it. As a result they don’t look for the earlier and more subtle warning signs that set the stage for the final disaster. Most people start by reviewing and discussing The Phases And Warning Signs Of Relapse (available from Independence Press, PO Box HE, Independence MO 64055, 1-800-767-8181).

This warning sign list describes the typical sequence of problems that lead from stable recovery to alcohol and drug use. After reading the warning signs they develop an initial warning sign list by selecting five of the warning signs that they can identify with. These warning signs become a starting point for warning sign analysis. Since most relapsers don’t know what their warning signs are they need to be guided through a process that will uncover them. The relapser is asked to take each of the five warning signs and tell a story about a time when they experienced that warning sign in the past while sober. They tell these stories both to their therapist and to their therapy group. The goal is to look for hidden warning signs that are reflected in the story. warning sign management.

Understanding the warning signs is not enough. We need to learn how to manage them without resorting to alcohol or drug use. This means learning nonchemical problem solving strategies that help us to identify high risk situations and develop coping strategies. In this way relapsers can diffuse irrational thinking, manage painful feelings, and stop the self-defeating behaviors before they lead to alcohol or drug use. This is done by taking each relapse warning sign and developing a general coping strategy. For example the following management strategy for dealing with the job related stress. Warning Sign: I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress.

General Coping Strategy: I will learn how to say no to taking on extra projects, limit my work to 45 hours per week, and learn how to use relaxation exercises and meditation to unwind. The next step is to identify ways to cope with the irrational thoughts, unmanageable feelings, and self-defeating behaviors that accompany each warning sign. Jake developed the following coping strategies: Irrational Thought: I need to try harder in order to get things under control or else I will be a failure. Rational Thought: I am burned out because I am trying to hard. I need to time to rest or I will start making more mistakes. Unmanageable Feelings: Humiliation and embarrassment.

Feeling Management Strategy: Talk about my feelings with others. Remind myself that there is no reason to embarrassed. I am a fallible human being and all people get tired. Self-defeating Behavior: Driving myself to keep working even thought I know I need to rest. Constructive Behavior: Take a break and relax. Ask someone to review the project and see if they can help me to solve the problem. recovery planning.

A recovery plan is a schedule of activities that puts relapsers into regular contact with people who will help them to avoid alcohol and drug use. They must stay sober by working the twelve step program and attending relapse prevention support groups that teach them to recognize and manage relapse warning signs. This is why relapse prevention planning is a “Twelve Step Plus” approach to recovery inventory training.

Most relapsers find it helpful to get in the habit of doing a morning and evening inventory. The goal of the morning inventory is to prepare to recognize and manage warning signs. The goal of the evening inventory is to review progress and problems. This allows relapsers to stay anticipate high risk situations and monitor for relapse warning signs. Relapsers need to take inventory work seriously because most warning signs are deeply entrenched habits that are hard to change and tend to automatically come back whenever certain problems or stresses occur. If we aren’t alert we may not notice them until it’s too late. family involvement.

A supportive family can make the difference between recovery and relapse. We need to encourage our family members to get involved in Alanon so they can recover from codependency. With this foundation of shared recovery we can beginning talking with our families about past relapses, the warning signs that led up to them, and how the relapse hurt the family. Most importantly we can work together to avoid future relapse. follow-up.

Our warning signs will change as we progress in recovery. Each stage of recovery has unique warning signs. Our ability to deal with the warning signs of one stage of recovery doesn’t guarantee that we will recognize or know how to manage the warning signs of the next stage. Our relapse prevention plan needs to be updated regularly; monthly for the first three months, quarterly for the first two years, and annually thereafter. RP Intervention Strategies

The RP model includes a variety of cognitive and behavioral approaches designed to target each step in the relapse process (see figure 2). These approaches include specific intervention strategies that focus on the immediate determinants of relapse as well as global self-management strategies that focus on the covert antecedents of relapse. Both the specific and global strategies fall into three main categories: skills training, cognitive restructuring, and lifestyle balancing. Specific Intervention Strategies The goal of the specific intervention strategies—identifying and coping with high-risk situations, enhancing selfefficacy, eliminating myths and placebo effects, lapse management, and cognitive restructuring—is to teach clients to anticipate the possibility of relapse and to recognize and cope with high-risk situations. These strategies also focus on enhancing the client’s awareness of cognitive, emotional, and behavioral reactions in order to prevent a lapse from escalating into a relapse.

The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process. For example, the therapist can use the metaphor of behavior change as a journey that includes both easy and difficult stretches of highway and for which various “road signs” (e.g., “warning signals”) are available to provide guidance. According to this metaphor, learning to anticipate and plan for high-risk situations during recovery from alcoholism is equivalent to having a good road map, a well-equipped tool box, a full tank of gas, and a spare tire in good condition for the journey. Identifying and Coping With HighRisk Situations. To anticipate and plan accordingly for high-risk situations, the person first must identify the situations in which he or she may experience difficulty coping and/or an increased desire to drink. These situations can be identified using a variety of assessment strategies. For example, the therapist can interview the client about past lapses or relapse episodes and relapse dreams or fantasies in order to identify situations in which the client has or might have difficulty coping.

Several self-report questionnaires also can help assess the situations in which clients have been prone to drinking heavily in the past as well as the clients’ self-efficacy for resisting future drinking in these situations (Annis and Davis 1988; Annis 1982a). Furthermore, clients who have not yet initiated abstinence are encouraged to self-monitor their drinking behavior—for example, by maintaining an ongoing record of the situations, emotions, and interpersonal factors associated with drinking or urges to drink. Such a record allows clients to become more aware of the immediate precipitants of drinking. Even in clients who have already become abstinent, self-monitoring can still be used to assess situations in which urges are more prevalent. Once a person’s high-risk situations have been identified, two types of intervention strategies can be used to lessen the risks posed by those situations. The first strategy involves teaching the client to recognize the warning signals associated with imminent danger—that is, the cues indicating that the client is about to enter a high-risk situation. Such warning signals to be recognized may include, for example, AIDs, stress and lack of lifestyle balance, and strong positive expectances about drinking.

As a result of identifying those warning signals, the client may be able to take some evasive action (e.g., escape from the situation) or possibly avoid the high-risk situation entirely. The second strategy, which is possibly the most important aspect of RP, involves evaluating the client’s existing motivation and ability to cope with specific high-risk situations and then helping the client learn more effective coping skills. Relevant coping skills can be behavioral or cognitive in nature and can include both strategies to cope with specific high-risk situations (e.g., refusing drinks in social situations and assertive communication skills) and general strategies that can improve coping with various situations (e.g., meditation, anger management, and positive self-talk). Assessing a client’s existing coping skills can be a challenging task. Questionnaires such as the situational confidence test (Annis 1982b) can assess the amount of self-efficacy a person has in coping with drinking-risk situations. Those measures do not necessarily indicate, however, whether a client is actually able or willing to use his or her coping skills in a high-risk situation.

To increase the likelihood that a client can and will utilize his or her skills when the need arises, the therapist can use approaches such as role plays and the development and modeling of specific coping plans for managing potential high-risk situations. Enhancing Self-Efficacy. Another approach to preventing relapse and promoting behavioral change is the use of efficacy-enhancement procedures— that is, strategies designed to increase a client’s sense of mastery and of being able to handle difficult situations without lapsing. One of the most important efficacy-enhancing strategies employed in RP is the emphasis on collaboration between the client and therapist instead of a more typical “top down” doctorpatient relationship. In the RP model, the client is encouraged to adopt the role of colleague and to become an objective observer of his or her own behavior. In developing a sense of objectivity, the client is better able to view his or her alcohol use as an addictive behavior and may be more able to accept greater responsibility both for the drinking behavior and for the effort to change that behavior. Clients are taught that changing a habit is a process of skill acquisition rather than a test of one’s willpower.

As the client gains new skills and feels successful in implementing them, he or she can view the process of change as similar to other situations that require the acquisition of a new skill. Another efficacy-enhancing strategy involves breaking down the overall task of behavior change into smaller, more manageable subtasks that can be addressed one at a time (Bandura 1977). Thus, instead of focusing on a distant end goal (e.g., maintaining lifelong abstinence), the client is encouraged to set smaller, more manageable goals, such as coping with an upcoming highrisk situation or making it through the day without a lapse. Because an increase in self-efficacy is closely tied to achieving preset goals, successful mastery of these individual smaller tasks is the best strategy to enhance feelings of self-mastery. Therapists also can enhance selfefficacy by providing clients with feedback concerning their performance on other new tasks, even those that appear unrelated to alcohol use. In general, success in accomplishing even simple tasks (e.g., showing up for appointments on time) can greatly enhance a client’s feelings of self-efficacy.

This success can then motivate the client’s effort to change his or her pattern of alcohol use and increase the client’s confidence that he or she will be able to successfully master the skills needed to change. Eliminating Myths and Placebo Effects. Counteracting the drinker’s misperceptions about alcohol’s effects is an important part of relapse prevention. To accomplish this goal, the therapist first elicits the client’s positive expectations about alcohol’s effects using either standardized questionnaires or clinical interviews. Positive expectancies regarding alcohol’s effects often are based on myths or placebo effects of alcohol (i.e., effects that occur because the drinker expects them to, not because alcohol causes the appropriate physiological changes). In particular, considerable research has demonstrated that alcohol’s perceived positive effects on social behavior are often mediated by placebo effects, resulting from both expectations (i.e., “set”) and the environment (i.e., “setting”) in which drinking takes place (Marlatt and Rohsenow 1981). Subsequently, the therapist can address each expectancy, using cognitive restructuring (which is discussed later in this section) and education about research findings.

The therapist also can use examples from the client’s own experience to dispel myths and encourage the client to consider both the immediate and the delayed consequences of drinking. Even when alcohol’s perceived positive effects are based on actual drug effects, often only the immediate effects are positive (e.g., euphoria), whereas the delayed effects are negative (e.g., sleepiness), particularly at higher alcohol doses. Asking clients questions designed to assess expectancies for both immediate and delayed consequences of drinking versus not drinking (i.e., using a decision matrix) (see table, p. 157) often can be useful in both eliciting and modifying expectancies. With such a matrix, the client can juxtapose his or her own list of the delayed negative consequences with the expected positive effects. Lapse Management. Despite precautions and preparations, many clients committed to abstinence will experience a lapse after initiating abstinence.

Lapse-management strategies focus on halting the lapse and combating the abstinence violation effect to prevent an uncontrolled relapse episode. Lapse management includes contracting with the client to limit the extent of use, to contact the therapist as soon as possible after the lapse, and to evaluate the situation for clues to the factors that triggered the lapse. Often, the therapist provides the client with simple written instructions to refer to in the event of a lapse. These instructions reiterate the importance of stopping alcohol consumption and (safely) leaving the lapse inducing situation. Lapse management is presented to clients as an “emergency preparedness” kit for their “journey” to abstinence. Many clients may never need to use their lapse-management plan, but adequate preparation can greatly lessen the harm if a lapse does occur. Cognitive Restructuring. Cognitive restructuring, or reframing, is used throughout the RP treatment process to assist clients in modifying their attributions for and perceptions of the relapse process.

In particular, cognitive restructuring is a critical component of interventions to lessen the abstinence violation effect. Thus, clients are taught to reframe their perception of lapses— to view them not as failures or indicators of a lack of willpower but as mistakes or errors in learning that signal the need for increased planning to cope more effectively in similar situations in the future. This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future. This reframing of lapse episodes can help decrease the clients’ tendency to view lapses as the result of a personal failing or moral weakness and remove the selffulfilling prophecy that a lapse will inevitably lead to relapse. Global Lifestyle Self-Control Strategies

Although specific intervention strategies can address the immediate determinants of relapse, it is also important to modify individual lifestyle factors and covert antecedents that can increase exposure or reduce resistance to highrisk situations. Global self-control strategies are designed to modify the client’s lifestyle to increase balance as well as to identify and cope with covert antecedents of relapse (i.e., early warning signals, cognitive distortions, and relapse set-ups). Balanced Lifestyle and Positive Addiction. Assessing lifestyle factors associated with increased stress and decreased lifestyle balance is an important first step in teaching global self-management strategies. This assessment can be accomplished through approaches in which clients self-monitor their daily activities, identifying each activity as a “want,” “should,” or combination of both. Clients also can complete standardized assessment measures, such as the Daily Hassles and Uplifts Scale (Delongis et al. 1982), to evaluate the degree to which they perceive their life stressors to be balanced by pleasurable life events. Many clients report that activities they once found pleasurable (e.g., hobbies and social interactions with family and friends) have gradually been replaced by drinking as a source of entertainment and gratification.

Therefore, one global self-management strategy involves encouraging clients to pursue again those previously satisfying, nondrinking recreational activities. In addition, specific cognitive-behavioral skills training approaches, such as relaxation training, stress-management, and time management, can be used to help clients achieve greater lifestyle balance. Helping the client to develop “positive addictions” (Glaser 1976)—that is, activities (e.g., meditation, exercise, or yoga) that have long-term positive effects on mood, health, and coping—is another way to enhance lifestyle balance. Self-efficacy often increases as a result of developing positive addictions,largely caused by the experience of successfully acquiring new skills by performing the activity. Stimulus control techniques are relatively simple but effective strategies that can be used to decrease urges and cravings in response to such stimuli, particularly during the early abstinence period. Simply stated, these techniques encourage the client to remove all items directly associated with alcohol use from his or her home, office, and car. This includes eliminating, at least temporarily, all alcohol supplies, including those typically kept for “guests,” as well as packing away wine or shot glasses, corkscrews, and similar items.

Clients who used to hide or stash alcoholic beverages should make a concerted effort to remember and remove alcohol from all possible hiding places, because these hidden or forgotten bottles can serve as a powerful temptation when found “accidentally” after a period of sobriety. Other, more subtle items that may serve as conditioned cues for drinking may include the favorite living room easy chair or the music the client typically listened to while unwinding in the evening with several of his or her favorite drinks. In these cases, a temporary change in seating or listening habits may be helpful while the client develops alternative coping strategies. Urge-Management Techniques. Even with effective stimulus-control procedures in place and an improved lifestyle balance, most clients cannot completely avoid experiencing cravings or urges to drink. Therefore, an important aspect of the RP model is to teach clients to anticipate and accept these reactions as a “normal” conditioned response to an external stimulus.

According to this approach, the client should not identify with the urge or view it as an indication of his or her “desire” to drink. Instead, the client is taught to label the urge as an emotional or physiological response to an external stimulus in his or her environment that was previously associated with heavy drinking, similar to Pavlov’s dog, which continued to salivate at the sound of a bell that had previously signaled food. In one clinical intervention based on this approach, the client is taught to visualize the urge or craving as a wave, watching it rise and fall as an observer and not to be “wiped out” by it. This imagery technique is known as “urge surfing” and refers to conceptualizing the urge or craving as a wave that crests and then washes onto a beach. Relapse Road Maps.

Finally, therapists can assist clients with developing relapse road maps—that is, cognitive behavioral analyses of high-risk situations that emphasize the different choices available to clients for avoiding or coping with these situations as well as their consequences. Such a “mapping out” of the likely outcomes associated with different choices along the way can be helpful in identifying AIDs. For example, if arguments with a former spouse are a high-risk situation, the therapist can help the client map out several possible scenarios for interacting with the ex-spouse, including the likelihood of precipitating an argument in each scenario. The therapist can then help identify coping responses that can be used to avoid a lapse at each point in the interaction.