Relapse Prevention

Note: I downloaded this document several years ago from healinghopes.org. The website is now a depression website, and no longer offers this document. If someone recognizes this as a copyrighted document please email me so that I can give the author credit.

Overall Goal: To increase awareness and choice concerning behavior, develop coping skills and self-control capacities, and develop greater sense of confidence, mastery or self-efficacy.

An important part of the healing process involves identifying behavior and situations which have been healthy as well as unhealthy. Then one will be able to use his/her strengths and begin changing patterns that are no longer effective.

Relapse may be defined as a violation of a self-imposed rule or set of rules governing the rate or pattern of a selected target behavior, while lapse is a single instance of violation of the rule. Relapse may involve self-abusive behavior such as cutting on yourself, head-banging, drug and alcohol abuse, food, victimizing someone else.

It is important to focus on relapse prevention and incremental progress toward self-efficacy of personal effectiveness. Ask your therapist, friend, significant other to assist in encouraging you to continue lifestyle changes to make a better balance of work, rest and recreation. Some of the lifestyle changes needed are related to relationships while other changes address leisure and social life.

All survivors will and do experience inappropriate and unwanted thoughts, fantasies and urges. Most relapses occur because the survivor forgets or chooses not to use effective coping strategies. Negative emotional states (e.g., anger, anxiety, or depression) can set the stage for obsession (i.e., a lapse) and distorted thinking. Interpersonal conflict with a spouse, family member, friend, or employer is another factor contributing to relapse. Negative emotional state, interpersonal conflict and social pressure are triggers for relapse in high risk situations. In recovery and especially early in its early stages, it is essential to avoid high risk situations.

Each survivor must set his/her own limits. It is important to talk with other survivors, your therapist, your spouse or significant others about the decisions you are making with respect to boundaries and reducing risk.

Survivors go through periods of "apparently irrelevant decisions." During periods of negative emotional states or interpersonal conflict, you may discover (usually after the fact) recent choices and behaviors were actually moving you into high risk situations. For example, the individual who has engaged in compulsive extra-marital affairs may find that he/she is frequenting single's bars ("meat markets") "just because I like great music." It is probably impossible to avoid apparently irrelevant decisions. However, active participation in either group therapy work or with your therapist, in which you maintain your honesty and openness, may enable you to recognize a slip and avoid the sequence that leads to relapse.

Another predictable phenomenon in relapse is the desire to test your limits and control. To put yourself to the test is to invite temptation and lapse. Keep in mind that anytime you feel the need to prove your self-control you are in danger of a lapse or relapse.

Alan Marlatt and colleagues have identified one sequence by which negative emotions and interpersonal conflicts trigger relapse. Some of the terms used within this information require definitions.

Self-efficacy: healing is based on hope (expectation of success) and personal empowerment. During the healing process, the survivor is able to make some intimacy-enhancing decisions, and select some healthy coping responses. Self-efficacy refers to the anticipation that your efforts in working a recovery program will promote health and other positive benefits. You will increase your self-efficacy or personal power as you see yourself making positive changes and decisions.

Adaptive coping responses: Adaptive coping includes general strategies, such as going to meetings, sharing your struggles and specific coping techniques. Some coping techniques are relaxation, assertion, communication, and tolerance for conflict.

Lapse: In Marlatt's model, preoccupations or fantasies occur just before acting out. Some, such as strong sexual urges or physiological arousal, unhealthy fantasies, urges and obsessions nearly always signal relapse.

Abstinence Violation Effect: in the cycle of acting out, there is a point where perfectionism, absolutism (all or nothing thinking) and catastrophizing converge. These distortions undermine Relapse Prevention by overwhelming the survivor with shame, hopelessness, helplessness and self depreciation, not self-efficacy. Self depreciation is defined as belittling your value.

By treating the lapse as a failure rather than an opportunity to continue coping, the expectation for failure generalizes quickly. The survivor thinks "since I blew it anyway, I might as well feel good." Thus, the abstinence violation effect (AVE) produces a fully developed relapse. Frequently, the resulting acting out episode produces such guilt and shame that the survivor sets even more rigid and perfectionistic standards for recovery than before. The rigid and perfectionistic approach contributes to higher risk for relapse. One of the antidotes for the AVE is to insure that you have a balanced lifestyle.

The Balanced Lifestyle

Long term Relapse Prevention involves a lifelong process of balancing work, talk, recreation and rest. Similarly, there is a need to balance self and family interests. The goal of Relapse Prevention is to continue personal growth and relationship healing. Work, talk, rest and recreation are the basic steps in the process of healing. Similarly, there is a need to balance self and family interests. Work includes inside and outside the home. It has been found that many survivors are workaholics. Over-responsibility is actually irresponsibility. People who bury themselves in work attempt to suppress anxiety, anger or depression and may turn to easily accessible, quick-fix behaviors such as bingeing, drinking, substance abuse, overeating, self-mutilation, or compulsive sexual behavior. On the other hand, self-efficacy comes from watching yourself work productively. Under achievement undermines faith in yourself.

Talk is another aspect of the balanced life. Honest communication is important in the Relapse Prevention process. While conflict resolution is a valuable function of communication, "non-problem solving talk" is essential in the desired lifestyle balance. Talk can take the form of conversation, phone calls, letter writing, prayer and meditation. One of the goals for relapse prevention should be making several friends and maintaining contact. Don't expect to talk your problems away; you will still have issues to confront on your own.

Rest is an often neglected aspect of life. Poor nutrition, physical ailments and exhaustion are antecedents of relapse. Exercise and a balanced diet are important ingredients in Relapse Prevention. Remember balance is the essence; eating and exercising can become other compulsions.

The last domain of the healthy, balanced lifestyle is recreation. It is important to place an emphasis on the value of activities which are not only enjoyable but also therapeutic, such as art, music, dance/movement, crafts, etc.

The following are examples to review and hopefully help anyone who wished to print out the Relapse Prevention Worksheet included in this information.

Automatic Thoughts

Negative self-attributions or core beliefs that justify and/or fuel relapse behaviors. These thoughts are distorted for the here and now world, though may have been true in the past.

  1. I am a bad person
  2. I am worthless
  3. I have no control
  4. I will be abandoned
  5. I will be rejected
  6. I can not take care of myself
  7. I am responsible for the abuse
  8. I will not get better
  9. I can not handle my responsibilities
  10. I am a victim
  11. I will always be a victim
  12. I am damaged goods
  13. I am a bad (mother, father, son, daughter, etc.)
  14. I do not fit in - no one will like me
  15. I exist only to serve other people
  16. I have to take care of everyone
  17. I am not important
  18. I am evil
  19. I need (alcohol, drugs, food, sex, etc.) to be happy
  20. I need to (cut, use restrict, binge, purge, etc.) to feel alive
  21. I need others to take care of me - I can not take care of myself
  22. I am a little girl/boy - helpless and vulnerable
  23. I am not safe
  24. I can not be sexual
  25. I am going to die
  26. I can run away from people and feelings
  27. I am obligated to initiate sex
  28. I am not allowed to say 'no'
  29. I am bad if I have sexual feelings
  30. I deserve pain and punishment
  31. I am being punished
  32. I am a failure
  33. I never get what I want
  34. I am like my (mom, dad, perpetrator) if I get angry
  35. I am bad/unacceptable if I am overweight
  36. If I do not get what I want right now I am not O.K.
  37. I will not be accepted if I ask for what I want
  38. I am obligated to meet my partner's sexual needs
  39. I am incomplete without my partner
  40. If I am sick they will leave me alone
  41. If I can just (cut, drink, act out, purge, etc.) one more time everything will be O.K.
  42. I am more in control of negative things than I am of positive things
  43. If I feel better, then I know bad things will happen. I can control by making bad things happen.
  44. I will leave them before they leave me
  45. I do not deserve to feel better
  46. I must get hurt on a regular basis in order to feel normal.
Common Relapse Behaviors 1.) Suicidality - Ideation - Attempt 2.) Self Mutilation 3.) Risk Taking 4.) Unmanaged Dissociation -Switching -Flashbacks 5.) Isolation 6.) Eating Disorder Behaviors -Bingeing -Purging -Restricting -Compulsive Overeating -Compulsive Exercise -Laxative Abuse 7.) Sexual Acting Out -Compulsive Masturbation -Unprotected/Stranger Sex -Affairs -Perpetrating Others -Obsessive Thinking of Sexual Behavior -Objectifying Men, Women, or Children 8.) Sexual Dysfunction 9.) Compulsive Spending/Gambling 10.) Breaking Safety Contracts 11.) Nondisclosure to Therapist 12.) Lying to Therapist 13.) Skipping Therapy Appointments 14.) Violent Acting Out Toward Others 15.) Chemical Dependency 16.) Homicidality 17.) Not seeking medical attention 18.) Codependency 19.) Over-dependency 20.) Lack of Boundaries 21.) Overworking 22.) Absenteeism and Tardiness to Work 23.) Overmedication 24.) Under medication/non-compliance 25.) Oversleeping 26.) Deliberate Not Knowing 27.) Panic Attack 28.) Obsessive Thinking 29.) Verbal Self Abuse 30.) Not Asking For What You Want Adaptive Coping Responses (ACR's) 1.) Grounding skills 2.) Mindfulness Practice 3.) Safe Place 4.) Challenge Cognitive Distortions 5.) Anger Work 6.) Healthy Exercise 7.) Support Group 8.) Therapy Group 9.) Individual Therapy 10.) Seeing a Nutritionist 11.) Safety Contract 12.) Journaling 13.) Dialoging 14.) Setting Boundaries 15.) Art Work 16.) Limit Hours at Work 17.) Set Aside time For ___________ 18.) 12-step Meetings 19.) Get a Sponsor 20.) Commit to Hard Work of Recovery 21.) Pacing Skills 22.) Containment Skills 23.) Create and review a Relapse Prevention Plan with Your Therapist 24.) Affirmations 25.) Make Dates with Significant Other 26.) Assertive Communication 27.) Deep Breathing 28.) Make Lists/Schedules 29.) List Needs/Wants 30.) Spend Time with a Pet 31.) Urge Card 32.) Call Friend/Therapist 33.) Count to 10 Negative Consequences The possible or actual unwanted results of relapse behaviors 1.) Death 2.) Permanent Injury or Disability 3.) Vegetative State 4.) Hospitalization 5.) No Progress in Therapy 6.) Treatment Ends 7.) Pushes People Away 8.) Divorce 9.) Marital Discord 10.) Loss of Professional License 11.) Lose Job 12.) Increased Guilt/Shame 13.) Decreased Self Esteem 14.) Increased Anxiety/Tension 15.) Relationship Ends 16.) Increased Flashbacks 17.) Boundaries Don't Get Expressed 18.) Emotions Don't Get Expressed 19.) Sexually Transmitted Disease 20.) Lose Custody of Children 21.) Unwanted/Unplanned Pregnancy 22.) Infection 23.) Others Get Injured or Killed 24.) Go To Jail 25.) Legal Problems 26.) Bankruptcy/Financial Problems 27.) Never Learn To Get Needs Met 28.) Unnecessary Resentment 29.) Inability to Make Decisions 30.) Re-enactment/Re-victimization 31.) Gain/Lose Weight 32.) Malnutrition 33.) Increased Physical Illness REINFORCERS The "pay off" or benefit received from the relapse behavior. A reinforcer is not dependent on the intent of the individual (ex. Suicide has the reinforcer of getting other's attention. Most people do not attempt suicide in order to get attention.) 1.) Perceived Control 2.) Increased Safety (real or perceived) 3.) Tolerate Feelings (usually thought of an "escape") -anger, fear, sadness, rage, terror 4.) Feel cared for 5.) Attention from others 6.) Increased Self Esteem 7.) Sense of Accomplishment 8.) Expresses anger, fear, sadness, rage, terror 9.) Pleasure 10.) Orgasm 11.) Sexual Arousal 12.) Feel open to sex 13.) Feel alive or real 14.) Avoid Rejection or Abandonment 15.) Sets Boundaries 16.) Avoid thinking of suicide 17.) Avoid difficult material (memories) 18.) Parts get to express themselves 19.) Needs get met 20.) Asserts Self 21.) Feel Physically Strong 22.) Fills an emptiness 23.) Distracts from uncomfortable feelings 24.) Sense of relief Triggers External events that do not cause but contribute to the occurrence of relapse behaviors 1.) Someone initiates sex 2.) Someone gets angry 3.) Flashbacks 4.) Violent Movies 5.) Bars 6.) Contact with parents/family of origin 7.) Contact with addicts 8.) Contact with perpetrators 9.) Pornographic Material 10.) Children 11.) Social Situations 12.) Certain Odors 13.) Perceived or Real Rejection 14.) Someone provokes my anger 15.) Family Gatherings 16.) Certain Holidays 17.) Ads for Alcohol 18.) Men with certain characteristics 19.) Women with certain characteristics 20.) Arguments 21.) Trauma Talk 22.) Having a memory 23.) Sexual Contact 24.) Becoming Physically ill 25.) Going to the doctor 26.) Loss of function 27.) Not asking for what you want/need 28.) Bingeing 29.) Looking at self in the mirror 30.) Looking at or touching your body 31.) Masturbating 32.) Wanting Something 33.) Sex 34.) Positive nurturing behavior by other 35.) Things are going well Refer to the examples listed above for completing this worksheet: Relapse Prevention Worksheet Triggers Automatic Thoughts Emotions Relapse Bx Reinforcers ACR's Challenges Negative Consequences Relapse Prevention Daily Worksheet 1.) Lapse: In this section, describe in detail the exact nature of the lapse, urge which you experienced. What was the fantasy or behavior which was exhibited? 2.) Situation: In this section, describe the situation in which the lapse occurred. Details are important. Describe who you were with, what was the activity or subject of discussion. What had occurred just prior to the lapse? Remember, this section is to be descriptive. Avoid interpretations. You may want to ask for help from your peers, therapist or whoever may have been present to obtain reality checks and to assist in memory. 3.) Interpersonal Trigger: Describe the context and the content of the interpersonal situation described in the previous section. What was the interaction about? (Family? Power? Sex?) What was the nature of the interaction? (Supportive? Conflictual? Intimate?) 4.) Emotional Triggers: What feelings were brought up by the interaction? 5.) Non-Addictive Coping Strategy: What did you do to avoid acting out in a full blown relapse? What could you have done to prevent the lapse from occurring?