Relapse Prevention – How the Counselors Do It

In this article I will tell you about the techniques that professional addictions counsellors use to prevent relapse, what the latest research science tells us about relapse prevention, and we’ll boil it all down into actionable stuff that we can do on a day-to-day basis to avoid relapse.

We'll discuss "brain hygiene," “urge surfing,” the “empty chair” and other techniques used by the professionals, and how we can apply the same techniques in our own recovery.

Is a Relapse Always a Relapse?

Not all relapses are on the same scale. I have run into many cases where a relapse was very brief. This usually happens with alcohol, I have not seen it happen quite so much with opiates and stimulants (cocaine, crystal meth, etc.).  Just the other day a guy (“Guy A”) who was three years into recovery from drugs and alcohol got into a bitter argument, and marched down to the bar. He ordered a beer, and took a few sips and then walked away from it. I know he was being truthful, because I had been seeing him regularly, and I know that he hadn’t been out on a full-out relapse. 

I also saw a guy (“Guy B”) recently who went on a three-day drinking binge and checked himself into a detox house. However, even though he was only back out drinking for three days, he had returned to his full-blast drinking levels even though he had been sober for more than five years.

In addictions lingo, we distinguish between a lapse and a relapse. A lapse means the person in recovery breaks the commitment to abstinence but does not return to previous levels of use. Relapse involves an activation of the addiction where the person resumes drug use at previous levels. So, Guy "A" had a lapse, Guy "B" had a relapse. A relapse is a lapse that has gotten out of control.

Is Relapse a Normal Part of Recovery?

We must be careful about considering relapse to be a normal part of recovery, as many counsellors and people in recovery do. This view can actually end up enabling alcohol and drug use by the underlying message that “everybody relapses in recovery.” When our alcoholic/addict mind is trying to talk us into using or drinking, this will come up as an excuse: “come on, it’s a normal part of recovery.”

It's more appropriate to look at it this way: “relapse may happen but does not have to happen.” It should be everyone’s goal in recovery to never relapse. However,  if it does happen, it’s important to remember that it’s not the end of recovery. Relapse does not mean that treatment is not working, the person is not trying, or the person will never be able to live in recovery.

How Does Relapse Play Out?

One big problem with relapse is that it can be fatal. A common theme that I have heard from hundreds of people who have come back from relapse is that they are amazed at how quickly they end up right back where they were before. Within a day or a few days they are drinking or using obsessively again, in the same amounts as before, with their life rapidly falling apart. They are also amazed at how quickly they end up drinking or using the same amounts as they were the first time around, even if they had been in recovery for many years.

People who have been in recovery from drug use for a significant period of time have lost their tolerance for the drugs, so when their doses quickly escalated in relapse they are in danger of overdosing. This was a problem even before Fentanyl hit the streets.

Now that Fentanyl and Carfentanil have made their way into the drugs, the death toll from relapse has gone way up. People never know what they are getting. Many active users say that with each hit they don’t know if they’ll survive or not. The ultra-potency of these synthetic drugs makes over-dose ever more a risk for those who relapse.

Worse, the Fentanyl and Carfentanil have found their way into cocaine. Fentanyl and Carfentanil are opioids, and cocaine is not; it’s a stimulant, like crystal meth or Ritalin. So, cocaine users have no tolerance to opioids, even if they have a high tolerance to cocaine, and they are extra susceptible to overdose from exposure to Fentanyl and Carfentanil.  I heard a cocaine dealer explain how he was making fake cocaine: he would put Fentanyl in a powder that had the same crystalline appearance as cocaine, and then add the same stuff the dentists use to numb your teeth so that people would get the same numbing feeling in their nose as they get with real cocaine.  I am sure there were many overdoses from his “product” when opioid-naïve people were unknowingly snorting the most powerful opioids known to science.

What Makes People Relapse?

Surveys of people who have relapsed showed the following common reasons: “stress, negative mood and anxiety, drug-related cues, temptations and boredom, and lack of positive supports (e.g., job, family relationships, responsibilities).”

An awareness of the common dangers of relapse has been shown to be an effective measure for relapse prevention, and is therefore a technique used by counsellors. The U.S. National Institute on Drug Abuse lists the “Ten Most Common Dangers:”

1. Being around familiar drugs, drug users, or drug-related settings.
2. Experiencing negative feelings.
3. Celebrating positive feelings.
4. Experiencing boredom.
5. Getting high on any mood-altering substance.
6. Experiencing physical pain.
7. Focusing on getting high.
8. Having a lot of money all of a sudden.
9. Taking prescription medication that causes a high.
10. Believing that occasional drug use (without problems) is possible.

These are generalities, and some may be more of a danger than others for specific people. As well, there are others, such as feeling lonely, and untreated mental health symptoms. Each person in recovery should reflect on what his or her own triggers are.

Another tool for recognizing relapse triggers is the HALT acronym. HALT stands for Hungry, Angry, Lonely, or Tired. The purpose of HALT is to allow us to recognize these feelings when they occur, and act on them lest they become a trigger for relapse. These are all self-care issues that mean that we need to take a moment to take care of ourselves. We can even ask friends and family members to alert us if they notice we are edgy, or self-isolating, or not eating properly, or not getting enough rest.

Relapse Prevention Principles

There are basic principle that are seen throughout the various counselling techniques, and various recovery support groups, and that some people have learned by experience.

The first of these is that people must realize that relapse is a process, not an event. One study found that people who were questioned admitted that their relapse had been developing over a period of at least three weeks, often longer. So, to recognize and arrest the process of relapse before it plays out is key. We will discuss exactly how to do that.  We will also discuss how these actions can be planned out and practiced in advance as part of an effective relapse prevention program.

Another important principle for relapse prevention is realizing that recovery requires much more than just quitting drinking or using. If you don’t address all the mental stuff that put you there in the first place and worsened during your active drinking and using, then you will be at very high risk of relapse. Addiction counseling, treatment centers (inpatient or outpatient), and recovery support groups (especially the 12 Step program) are very good at helping you do this. For more info about these, see the articles in the Alcoholism / Addiction Treatment Options section (click here).

Developing Healthy Coping Skills

When we are addicts or alcoholics we cope with stress by drinking or using drugs. It’s what we do. So, in order to stay in recovery we need to develop new, healthy coping mechanisms.

My own story is that I came to a point where I was unable to cope with life and that’s when drinking and drug use – which had never been a problem for me in the past – became my way to escape from life. I was a practicing doctor and psychotherapist giving people advice, yet I couldn’t manage my own life. Learning how to cope with life, no matter what life brings, has not only made me clean and sober, but it’s made me happier and better adjusted than I have ever been in my life, even before the drugs and alcohol were a problem. Coping skills are crucial to recovery, and to relapse prevention.

Some of the recovery programs out there are about learning to cope with life. I don’t like to tout one program over another, but the 12 Step program is an outstanding system for moving people from an extreme negative psychology to a positive psychology, all by teaching them to forgive themselves, and to handle life on life’s terms. The need, obsession, or desire to drink or use falls away. Some other program, such as SMART Recovery, likewise teach coping skills.

I suggest that anyone who drinks or uses (or eats, or gambles, etc.) to cope find some kind of a program of recovery or counselling program specifically designed for learning healthy coping mechanisms.

In the meantime, the U.S. National Institute of Drug Abuse (NIDA) developed the acronym TIPS to remind addicts of how to cope with difficult situations: TIPS: Truth, Information, Priorities, and Support.

Truth means that we need to let others know honestly about the current struggle we are experiencing. This is about having someone safe and who knows us and our situation to talk to.

Priorities means that we see the number-one priority as staying sober. If we put our recovery first, all the other good stuff will follow. If we put other stuff ahead of our recovery and we relapse, we will lose everything again. So. recovery must come first.

Support reminds the addict to turn to others for support when in a difficult situation, before it is too late.

The Big Three Relapse Prevention Tools

When your addict’s brain starts making you believe that drinking or using is a good idea, here are three tools for taking back control. All three techniques are borrowed from the 12 Step program, but all addiction counsellors teach their clients to use them:

1. remember when: when your mind starts telling you that drinking or using is or was fun, think back to all the pain, misery, sickness, loss, and regret that it caused you, how badly you wanted to be able to stop, and how hard it was to stop. Remembering specific situations that were especially painful for you during your drinking or using days is helpful.

• follow the tape through to the end: when our addict’s mind starts to talk us into drinking or using, it tends to just think about “the party.” However, by playing the tape through to the end, we follow through in our mind what happens after the party, the next day, and so on. We imagine the guilt, self-disappointment, shame, sicknees, and renewed obsession to drink or use that will follow “the party.”

• actively avoid high-risk situations: it is much easier to say no at the beginning than it is at the end. We should cut off a high-risk situation as soon as we recognize it developing, rather than allow it to progress to where getting ourselves out of it will be very hard. Many of the people I have seen relapse did so after allowing themselves to go into a situation that they knew very well was high-risk.

What Techniques do Counselors Use for Relapse Prevention?

Counselors have several lines of theory and techniques that they use to help people in recovery harden themselves against relapse. We’ll go through some of their "tricks" now.

The basic underlying principle that counselors use is to help their client become more self-aware.  They have various techniques for doing this, including “urge surfing,” mindfulness, “brain hygiene,” and the “empty chair” exercise.

Urge surfing is where the client is asked to watch themselves after they pass through an urge, and then make a journal entry that breaks down the urge in terms of the sensations and thoughts that occurred through the urge. Doing this makes them aware of the sensations of the urge, which they can use to detach themselves from any future urges.

"Brain hygiene" is a pretty cool concept, where the person develops a mind-body connection and uses the brain's self-learning, plastic qualities to improve the brains’ performance for improved physical, emotional and social well-being. Just like our muscles benefit from exercise, so does our brain. Sitting around with an inactive brain watching TV doesn’t do much for the brain. Getting drunk or high does even less! Regular physical exercise, yoga, massaging, deep breathing, sound sleep, relaxation, socialization, positive thinking, hobbies, sports, listening to music, meditation, reading, and mindfulness are very enhancing activities for the brain and mind.  Good brain hygiene helps us to better tolerate stress, and think our way through adversity, as well as relapse urges.

Mindfulness has been shown in clinical trials to lower the risk of relapse.  Mindfulness is the practice of tuning everything out and focussing on the emotions, thoughts and sensations occurring in the present moment. Mindfulness is also the basis of urge surfing, and a powerful tool for brain hygiene. Mindfulness is a type of meditation in the moment," and you can see our article on the subject for a "how-to guide" (click here).

Counselors also use the "empty chair" technique, a type of role-play where they get you to carry on a dialogue with yourself based on imagined difficult scenarios. People can do this on their own, by imagining difficult relapse situations and playing them through in their mind with some light meditation.

Now, we will go through the three most prevalent techniques that drug and alcohol counselors use for relapse prevention. You will notice that there is nothing magic about what they do, everything they do follows the principles and facts that we have just discussed.

The Daley & Marlatt Counseling Approach

The Daley and Marlatt technique is a comprehensive approach, where counselors help their clients to see relapse as a process, identify high-risk situations, develop  coping strategies, be aware of cues that can set off cravings, develop a balanced lifestyle, and develop a lapse/relapse plan.

They focus on 17 overall strategies:

1. Educating about relapse and relapse prevention.

2. Enhancing awareness of warning signs.

3. Being aware of substance-specific factors that may trigger relapse.

4. Avoiding the presence of the abstinence violation effect (AVE): this is the guilt we feel after a lapse, by keeping it to ourselves and not seeking help with it.

5. Increasing awareness of seemingly irrelevant decisions (SIDS). Most of the time we know a bad decision when we see it, but our addict's brain tries to tell us it's OK.

6. Addressing the fantasy of controlled use.

7. Addressing the resistance to abstinence from all mood-altering drugs.

8. Dealing with “pink cloud” or “honeymoon” recovery feelings. To learn about the "pink cloud" effect click here.

9. Creating a balanced lifestyle.

10. Encouraging the presence of visible reminders of the negative consequences of use.

11. Monitoring alcohol and drug use (urine testing).

12. Addressing gaps that are present socially and recreationally.

13. Teaching how to cope with social pressure to use.

14. Teaching new ways to cope with feelings.

15. Encouraging the letting go of all-or-none thinking.

16. Teaching anger management skills.

17. Encouraging the acceptance of one's identity as being in recovery.

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Gorski's Developmental Model of Recovery (DMR) Model

Gorski's developmental model of recovery (DMR) model is another counselling technique used by addiction counsellors. Like the other techniques, the DMR is linked closely with the 12-step recovery program.

According to the DMR, recovery is broken down into three phases: early, middle, and late recovery, and the counselor endeavors to help the person develop through the stages until he or she is in the stable, late stage of recovery. There are nine principles of relapse-prevention work in the DMR:

1. Self-regulation. Activities of daily living are stabilized.

2. Integration. The relapse risks are examined in terms of self-defeating behaviors, relationship-building, decreased psychological and mental pain, and creation of a relapse history.

3. Understanding. The person has accurate information about what contributes to a relapse in general.

4. Self-knowledge. The person can see the warning signs of relapse.

5. Coping skills. The person learns to avoid high-risk situations, address self-talk, and examine core beliefs that are unreliable.

6. Change. This involves taking a daily inventory of warning signs by having goals for a day and looking at any related problems at the end of the day.

7. Awareness. The person maintains the inventory of change.

8. Significant other support. This support helps with the relapse prevention.

9. Maintenance. Updates of the relapse-prevention plan are done.

Marlatt and Gordon's Relapse-Prevention (RP) Model

The relapse prevention (RP) model is a self-management program that tries to increase the chances of a habit change being maintained, where the "habit" is the healthy lifestyle of recovery. This is probably the most influential model of relapse prevention currently in use by counselors. It a cognitive-behavioral therapy-based program, where the goal is to teach clients how to anticipate and cope with potential relapse by increasing client awareness and choice about behavior, capacity for coping and self-control, and confidence/mastery/self-efficacy.

Relapse is viewed as a two-step process. Step 1 is a lapse, where the person violates the behavioral goal that has been set. In Step 2, the relapse, is the return to full-blast drinking or using at pretreatment levels.

The lapse is a chance for the client to learn from the temporary setback. For example, the client may view himself or herself as a hopeless failure at staying sober after having one joint of marijuana (leading to a relapse of previous higher levels of marijuana use), or the client may view himself or herself as having made a mistake and needing to learn what preceded the marijuana use in order to prevent a relapse. The focus of RP is to assist people in viewing lapses as mistakes they can learn from rather than a behavior for which they are to be judged or punished.

According to the RP model of addiction counseling, relapse is a decision-making process: What occurs before and after the initial lapse is critical, and there are many opportunities that may increase or decrease the risk of relapse. A successful recovery from an addictive behavior is based on a high motivation to change and a high degree of self-efficacy.

Counselors help clients learn seven specific target behaviors:

1.Recognizing and avoiding situations that are high risk for them.

2. Skills to cope in high-risk situations.

3. Relaxation and stress management skills.

4. Examination of positive outcome expectancies: realistic outcomes of addictive behavior (sometimes described in self-help groups as “follow the drink or drug through to its inevitable outcome”).

5. Immediate and delayed effects of the addictive activity.

6. Action to take if a relapse occurs.

7. Control over behavior through programmed relapse

Final Word

So, you can see a lot of common principles shining through. Anybody can use self-awareness to incorporate these principles into his or her own recovery to strengthen their relapse prevention plan.

I must say that for me, overcoming the obsession, cravings, and thoughts of using or drinking was a big part of what locked in my own relapse prevention. For reasons that have to do with brain plasticity, there is a meditation technique that is backed by science and experience as a highly effective way of overcoming the misery of cravings, obsessive thoughts about drinking or using. It's a technique known as "remember when" meditation. Click here to see a how-to guide and to learn why this undoes the changes that addictive behavior made to our brains.

Thanks for reading! The next article will be a follow-up piece about what to do when coming back from a relapse, and how to help someone after they relapse. We would appreciate your comments, wisdom, and experiences, and please subscribe for free to receive upcoming articles.