Relapse is a common component of recovery in the dynamic behavior change process. When working to make a lifestyle change, it is only natural that an individual will encounter obstacles. Ineffective coping with obstacles or triggers, a lack of control, and a high-risk situation can result in relapse. This should not be viewed as a failure but as an opportunity to learn more about recovery and the underlying attitudes and beliefs that may be getting in the way of change. An effective relapse prevention plan is based on an individual assessment of the client’s high-risk situations, triggers, and patterns of maladaptive coping. Using cognitive-behavioral techniques, the client and counselor will develop effective ways of coping with high-risk conditions. This flexible plan emphasizes that the client creates the insight and skills to cope with any situation consistent with their long-term goals.
Identifying Triggers
A trigger and response sheet is valuable for clients in trigger identification. The aim is to become aware of exactly what feelings and thoughts precede a relapse into addictive behavior. Identify the trigger, the thoughts and feelings, the undesired behavior, and the consequence. This will help to make the connection between a seemingly unrelated mood and a relapse, and it can help to bring the client back to the sheet if he is aware of an undesired behavior.
For most, an exploration of triggers starts with the recognition of the irritable, irrational, and depressed mood, which signals the potential for self-defeating behavior. Clients are encouraged to explore the thoughts and circumstances that led to the mood. Frequently, it is easy to link the mood to the behavior when it is already a strong habit. In early recovery, however, the habit may be so ingrained that it has become a trigger in and of itself, sometimes with very little thought or conscious mood involved. This can be the case with persons in early recovery from drug or alcohol problems who suddenly find themselves in a high-risk situation. For example, people, places, and things that are associated with past substance use continue to provide a strong temptation.
Clients are taught early on in recovery that identifying and dealing with internal and external triggers for substance abuse is a critical element in preventing relapse. The experience of an irresistible urge to use or drink is familiar to most chemically dependent persons seeking treatment and to plenty of recovering ones as well. The power of triggers is in their ability to bring on a re-occurrence of the undesired behavior (in this case, substance use) without the person even being fully aware of what has happened. This is because the experience is usually a compulsive one, which leads to use in the same way as it was with the addictive behavior.
Developing Coping Strategies
Third, the client should be encouraged to put his alternative behaviors and decisions into action in real situations, evaluate outcomes, and give himself credit for what has gone wrong. At this point, positive reinforcement from the counselor is invaluable. For example, a client who has gone out looking for a job after deciding to quit one involving drug abuse and has been turned down because the new employer knows no reason why he left the old one may feel he has made a wrong decision and will need support in seeing its wisdom. By contrast, a client who has used avoidance to handle a high-risk situation and has any adverse outcomes from his decision to leave will know he needs improvement and can make it. By regularly using these coping strategies, the client will build self-efficacy and will see confidence in dealing with trigger situations.
Second, if it is decided that the client can and should change his behavior in certain trigger situations, he will need to plan alternative actions and practice them. This is especially important in initial efforts at avoidance since the availability of the abused substance will often be more significant than usual at first (e.g., beer in the refrigerator when quitting a job with a drinking group). In each situation, the client will need to weigh the pros and cons of the alternative behavior, especially if it is a potentially risky situation. At this point, the client will do best to balance the decisions involving no action or leaving the problem and will usually need the counselor’s encouragement to do this. With practice, the client will gain confidence in his ability to control the trigger situation.
First, the client should be encouraged to play the tape through when considering a drinking or drug episode. He should think in specific behavioral terms about what he is likely to do and the consequences. This can be done in imagination with the counselor, with the client stopping the counselor whenever his imagined scenario is unrealistic or likely to worsen a bad situation. The client can then make a cost/benefit analysis of his usual behavior in the triggering situation and change the behavior. This will show whether the behavior is worth the long-term consequences and whether the client believes he can alter it.
If coping with high-risk situations is the essence of relapse prevention, developing effective coping strategies is the cornerstone of the effort. Once the triggers for a particular client’s substance abuse have been identified, the counselor can help the client examine his usual pattern of response and, in doing so, find where it is unproductive. Then, the two can work to find alternative behaviors that the client can carry out. This process involves several steps.
Building a Support Network
Changing behaviors is always easier with support from others. If others in your social network also commit to avoiding high-risk situations, you can help each other maintain change. For example, if friends decide to reduce spending too much time in the bar, they can do things with each other that do not involve bars. They can provide each other with support and alternate activities. If they know that if anyone suggests going back to the bar, that this will be met with resistance, it will be easier for each individual not to go to the bar. In this case, the best support is simply the changes in the behavior of others. This type of support can be challenging to find if communities are heavily involved in substance abuse. In some cases, it may be necessary to find an entirely new group of friends who do not abuse substances to provide the type of support that is needed. Involvement in 12-step groups or other self-help groups can also offer an enormous amount of support and help from others who have been in similar situations. Change maintenance can be complicated without involvement in some groups to provide support.
The third key element in relapse prevention is developing a support network. Once a person has identified personal high-risk situations (triggers) and has worked to develop specific ways to avoid them (coping strategies), they have laid the groundwork for making lasting changes. The final critical task is to establish a new living pattern and commit to continue it. Everyone who has made significant changes in their life has done so with the support of others. Highly self-reliant individuals may find it difficult to ask for help, but this is an important step. It is almost impossible to do something as challenging as changing the way you live life without some support. This is not a sign of weakness but wisdom. What sort of support can help?