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REVIEW ARTICLE

Relapse prevention
Jayakrishnan Menon, Arun Kandasamy
Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India

ABSTRACT

Addiction and related disorders are chronic lapsing and relapsing disorders where the combination of long term
pharmacological and psychosocial managements are the mainstay approaches of management. Among the psychosocial
interventions, the Relapse Prevention (RP), cognitive‑behavioural approach, is a strategy for reducing the likelihood and
severity of relapse following the cessation or reduction of problematic behaviours. Here the assessment and management
of both the intrapersonal and interpersonal determinants of relapse are undertaken. This article discusses the concepts of
relapse prevention, relapse determinants and the specific interventional strategies.

Key words: Relapse Prevention, Relapse determinants, High‑risk situations, psychosocial interventions, Alcohol dependence
syndrome

INTRODUCTION The initial transgression of problem behaviour after a quit

attempt is defined as a “lapse,” which could eventually
Addiction is conceptualised as a chronic relapsing brain lead to continued transgressions to a level that is similar
disorder. Miller and Hester reviewed more than 500 to before quitting and is defined as a “relapse”. Another
alcoholism outcome studies and reported that more than possible outcome of a lapse is that the client may manage
75% of subjects relapsed within 1 year of treatment1. to abstain and thus continue to go forward in the path
A study published by Hunt and colleagues demonstrated of positive change, “prolapse”4. Many researchers define
that nicotine, heroin, and alcohol produced highly relapse as a process rather than as a discrete event and thus
similar rates of relapse over a one‑year period, in the attempt to characterize the factors contributing to relapse3.
range of 80‑95%2. A significant proportion (40–80%) of
patients receiving treatment for alcohol use disorders Relapse prevention (RP) is a cognitive– behavioural approach
have at least one drink, a “lapse,” within the first year with the goal of identifying and addressing high‑risk
of after treatment, whereas around 20% of patients situations for relapse and assisting individuals in maintaining
return to pre‑treatment levels of alcohol use3. Relapse desired behavioural changes. RP has two specific aims:
prevention (RP) is a strategy for reducing the likelihood (a) Preventing an initial lapse and maintaining abstinence
and severity of relapse following the cessation or or harm reduction treatment goals
reduction of problematic behaviours4. (b) Providing lapse management if a lapse occurs such that
further relapses can be prevented4.
Address for correspondence: Arun Kandasamy,
Associate Professor of Psychiatry, National Institute of Mental Relapse prevention initially evolved as a calculated response
Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, to the longer‑term treatment failures of other therapies. The
India.
E-mail: [email protected]
This is an open access article distributed under the terms of the Creative
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Quick Response Code others to remix, tweak, and build upon the work non‑commercially, as long as the
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www.indianjpsychiatry.org For reprints contact: [email protected]

DOI:
How to cite this article: Menon J, Kandasamy A. Relapse
10.4103/psychiatry.IndianJPsychiatry_36_18
prevention. Indian J Psychiatry 2018;60:473-8.

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Menon and Kandasamy: Relapse prevention

assumption of RP is that it is problematic to expect that the outcomes and does not consider larger long term adverse
effects of a treatment that is designed to moderate or eliminate consequences when they lapse. This can be worked on
an undesirable behaviour will endure beyond the termination by creating a decisional matrix where the pros and cons
of that treatment. Further, there are reasons to presume a of continuing the behaviour versus abstaining are written
problem will re‑emerge on returning to the old environment down within both shorter and longer time frames and the
that elicited and maintained the problem behaviour; for therapist helps the client to identify unrealistic outcome
instance, forgetting the skills, techniques, and information expectancies5.
taught during therapy; and decreased motivation5.
Marlatt, based on clinical data, describes categories of
Cognitive Behavioural model of relapse relapse determinants which help in developing a detailed
A high‑risk situation is defined as a circumstance in taxonomy of high‑risk situations. These components
which an individual’s attempt to refrain from a particular include both interpersonal influences by other individuals
behaviour is threatened. They often arise without warning. or social networks, and intrapersonal factors in which the
While analysing high‑risk situations the client is asked person’s response is physical or psychological.
to generate a list of situations that are low‑risk, and to
determine what aspects of those situations differentiate RELAPSE DETERMINANTS
them from the high‑risk situations. High‑risk situations are
determined by an analysis of previous lapses and by reports These can be classified as intrapersonal or interpersonal.
of situations in which the client feels or felt “tempted.” Intrapersonal Determinants
Appropriate responses are those behaviours that lead to Self‑Efficacy
avoidance of high‑risk situations, or behaviours that foster Self‑efficacy is defined as the degree to which an individual
adaptive responses. Seemingly irrelevant decisions (SIDs) feels confident and capable of performing certain behaviour
are those behaviours that are early in the path of decisions in a specific situational context5. The RP model proposes
that place the client in a high‑risk situation. For example, that at the cessation of a habit, a client feels self‑efficacious
if the client understands that using alcohol in the day time with regard to the unwanted behaviour and that this
triggers a binge, agreeing for a meeting in the afternoon in perception of self‑efficacy stems from learned and practiced
a restaurant that serves alcohol would be a SID5. skills3. In a prospective study among both men and women
being treated for alcohol dependence using the Situational
A number of less obvious factors also influence the relapse Confidence Questionnaire, higher self‑efficacy scores
process. These covert antecedents include lifestyle factors, were correlated to a longer interval for relapse to alcohol
such as overall stress level, one’s temperament and use8. The relationship between self‑efficacy and relapse is
personality, as well as cognitive factors. These may serve possibly bidirectional, meaning that individuals who are
to set up a relapse, for example, using rationalization, more successful report greater self‑efficacy and individuals
denial, or a desire for immediate gratification. Lifestyle who have lapsed report lower self‑efficacy4. Chronic
factors have been proposed as the covert antecedents stressors may also overlap between self‑efficacy and
most strongly related to the risk of relapse. It involves the other areas of intrapersonal determinants, like emotional
degree of balance in the person’s life between perceived states, by presenting more adaptational strain on the
external demands and internally fulfilling or enjoyable treatment‑seeking client4.
activities. Urges and cravings precipitated by psychological
or environmental stimuli are also important6. Outcome Expectancies
Outcome expectancies can be defined as an individual’s
An important part of RP is the notion of Abstinence anticipation or belief of the effects of a behaviour on
violation effect (AVE), which refers to an individual’s future experience3. The expected drug effects do not
response to a relapse where often the client blames himself/ necessarily correspond with the actual effects experienced
herself, with a subsequent loss of perceived control4. It after consumption. Based on operant conditioning, the
occurs when the client perceives no intermediary step motivation to use in a particular situation is based on
between a lapse and relapse i.e. since they have violated the the expected positive or negative reinforcement value of
rule of abstinence, “they may get most out” of the lapse5. a specific outcome in that situation5. Both negative and
During RP, these factors need to be worked on. People who positive expectancies are related to relapse, with negative
attribute the lapse to their own personal failure are likely expectancies being protective against relapse and positive
to experience guilt and negative emotions that can, in turn, expectancies being a risk factor for relapse4. Those who
lead to increased drinking as a further attempt to avoid or drink the most tend to have higher expectations regarding
escape the feelings of guilt or failure7. the positive effects of alcohol9. In high‑risk situations,
the person expects alcohol to help him or her cope with
Another factor that may occur is the Problem of Immediate negative emotions or conflict (i.e. when drinking serves
Gratification where the client settles for shorter positive as “self‑medication”). Expectancies are the result of both

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Menon and Kandasamy: Relapse prevention

direct and indirect (e.g. perception of the drug from peers on an urge. “Staying in the moment” and being mindful of
and media) experiences3. urges are helpful coping strategies4.

Emotional states Craving

According to this affective model of drug motivation, Craving has been described as a cognitive experience
excessive substance use is motivated by affective regulation, focused on the desire to use a substance and is often
both positive and negative4. Later researchers such as related to the expectancies for the desired effect of the
Baker proposed the negative reinforcement model of drug, whereas urge has been defined as the behavioural
drug addiction and posit that the escape and avoidance of intention to use a substance7. Craving can be aroused either
negative affect is the major motive for addictive drug use10. by interoceptive or exteroceptive cues, environmental
Studies with alcohol‑dependent patients have shown that situations associated with prior heavy drinking, or with
on‑going depression increases the risk of relapse during the psychological and physical effects of prior withdrawal
and after treatment, and sudden increases in negative affect experiences15. While craving may initiate drinking, relapse
have been shown to immediately precede nicotine relapse11. is facilitated through the complementary phenomenon of
In one study, alcoholic beverage presentation and negative loss of control, a behavioural state characterized by the
affect imagery led to increased subjective reporting of relative inability to respond to either internal or external
desire to drink and predicted time to relapse after inpatient cues which regulate alcohol consumption16.
discharge12. Negative mood states associated with relapse
include anger, loneliness, boredom, fatigue7. Critical for craving and relapse is the process of associative
learning, whereby environmental stimuli repeatedly paired
Coping with drug consumption acquire incentive‑motivational
One of the most critical predictors of relapse is the value, evoking expectation of drug availability and memories
individual’s ability to utilize effective coping strategies of past drug euphoria15.
in dealing with high‑risk situations. Coping is defined as
the thoughts and behaviours used to manage the internal Substance users seem to use drugs or relapse more readily
and external demands of situations that are appraised in environments associated with prior drug use. The
as stressful. A person who can execute effective coping cue‑reactivity paradigm, which monitors their reactions
strategies (e.g. a behavioural strategy, such as leaving the to various drug‑related stimuli, has been used to explore
situation, or a cognitive strategy, such as positive self‑talk) this relationship. Drug‑related stimuli elicit craving, but cue
is less likely to relapse compared with a person lacking reactivity is not a consistent predictor of relapse17.
those skills. Moreover, people who have coped successfully
with high‑risk situations are assumed to experience a Motivation
heightened sense of self‑efficacy4. Oxford English Dictionary defines motivation as “the
conscious or unconscious stimulus for action towards a
There are various classifications of coping described. desired goal provided by psychological or social factors;
Shiffman and colleagues describe stress coping where that which gives purpose or direction to behaviour.
substance use is viewed as a coping response to life stress Motivation may relate to the relapse process in two distinct
that can function to reduce negative affect or increase ways, the motivation for positive behaviour change and the
positive affect. They assume a distinction between stress motivation to engage in the problematic behaviour. This
coping skills, which are responses intended to deal with illustrates the issue of ambivalence experienced by many
general life stress, and temptation coping skills, which patients attempting to change an addictive behaviour.
are coping responses specific to situations in which there Motivational Interviewing provides a means of facilitating
are temptations for substance which could contribute to the change process7.
relapse13.
Interpersonal determinants
Approach coping may involve attempts to accept, confront, Positive social support is highly predictive of long‑term
or reframe as a means of coping, whereas avoidance abstinence rates across several addictive behaviours. Among
coping may include distraction from cues or engaging in social variables, the degree of social support available from
other activities. Approach oriented participants may see the most supportive person in the network may be the best
themselves as more responsible for their actions, including predictor of reducing drinking, and the number of supportive
lapse, while avoidance‑based coping may focus more on relationships also strongly predicts abstinence. Further, the
their environment than on their own actions14. more non‑drinking friends a person with an AUD has, the
better outcomes tend to be. Negative social support in the
Coping may also be experienced as inaction. Inaction has form of interpersonal conflict and social pressure to use
typically been interpreted as the acceptance of substance substances has been related to an increased risk for relapse.
cues which can be described as “letting go” and not acting Social pressure may be experienced directly, such as peers

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Menon and Kandasamy: Relapse prevention

trying to convince a person to use, or indirectly through Client is taught that overcoming the problem behaviour is
modelling (e.g. a friend ordering a drink at dinner) and/or not about will power rather it has to do with skills acquisition.
cue exposure. Another technique is that the road to abstinence is broken
down to smaller achievable targets so that client can easily
While many families can find addiction difficult to deal master the task enhancing self‑efficacy. Also, therapists can
with, negative family behaviours such as withdrawing from provide positive feedback of achievements that the client
a family member with a substance use disorder or avoiding has been able to make in other facets of life6.
dealing with the substance use is actually associated with
more drinking. In addition to familial, marital, friend, Eliminating myths and placebo
and co‑worker relations, research also suggests that The myths related to substance use can be elicited by
community‑based support services, such as recovery exploring the outcome expectancies as well as the cultural
communities, enhance outcomes for those struggling with background of the client. Following this a decisional
cessation once treatment has been completed4. matrix can be drawn where pros and cons of continuing or
abstaining from substance are elicited and clients’ beliefs
Interpersonal relationships and support systems are highly may be questioned6.
influenced by intrapersonal processes such as emotion,
coping, and expectancies18. Lapse management
Lapse management includes drawing a contract with
Dynamic model the client to limit use, to contact the therapist as soon
Earlier models posited that various factors related to as possible, and to evaluate the situation for factors that
relapse progressed in a linear step wise manner. A revised triggered the lapse6.
model proposes that determinants described above are
multidimensional and dynamic. Seemingly insignificant Cognitive restructuring
changes in one risk factor may kindle a downward spiral Cognitive restructuring can be used to tackle cognitive
resulting in relapse. Multiple factors act at the same time errors such as the abstinence violation effect. Clients are
act in varying degrees to ultimately lead onto relapse taught to reframe their perception of lapses, to view them
not as failures but as key learning opportunities resulting
Relapse factors can be viewed as distal risk from an interaction between various relapse determinants,
factors (vulnerability in the form of temperament, both of which can be modified in the future.
personality, family loading, environment including social
and economic background) and proximal factors being the Some of the other common cognitive errors noted are
various determinants of relapse acting and these factors statements like relapse can’t happen to me”; “I’ll never use
interacting among themselves in a complex manner to lead alcohol or drugs again”; “I can control my use of alcohol
onto relapse. Hence, the dynamic model posits a non‑linear or other drugs”; “a few drinks, pills, won’t hurt”; “recovery
progression to relapse19. isn’t happening fast enough”; “I need alcohol or other drugs
to have fun”; and “my problem is cured.” These cognitions
Specific Intervention strategies in Relapse Prevention are listed, their validity questioned, and clients have to
Identifying and coping with high‑risk situations frame alternate thoughts to replace them as in CBT7.
Along with the client, the therapist needs to explore past
circumstances and triggers of relapse. The cues may be Balanced lifestyle and Positive addiction
both internal and external. Also, the client is asked to keep Global self‑management strategy involves encouraging
a current record where s/he can self‑monitor thoughts, clients to pursue again those previously satisfying,
emotions or behaviours prior to a binge. Once this is done, nondrinking recreational activities. In addition, relaxation
two strategies may be employed. One is to help clients training, time management, and having a daily schedule can
identify warning signs such as on‑going stress, seemingly be used to help clients achieve greater lifestyle balance.
irrelevant decisions and significant positive outcome
expectancies with the substance so that they can avoid the Helping clients develop positive addictions or substitute
high‑risk situation. The second is assessing coping skills of indulgences (e.g. jogging, meditation, relaxation, exercise,
the client and imparting general skills such as relaxation, hobbies, or creative tasks) also help to balance their
meditation or positive self‑talk or dealing with the situation lifestyle6.
using drink refusal skills in social contexts when under peer
pressure through assertive communication6. Stimulus control techniques
These techniques encourage the client to remove all items
Enhancing Self‑efficacy directly associated with substance use from his or her
In RP client and therapist are equal partners and the client is home, office. To remove all paraphernalia associated with
encouraged to actively contribute solutions for the problem. drug use such as needles, mirror, pipes, glasses, bottles.

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Menon and Kandasamy: Relapse prevention

More subtle items may include the favourite chair or the across treatment modalities (individual vs. group) and
music the client listened to while using alcohol. In these settings (inpatient vs. outpatient) 22.
cases, a temporary change in seating or listening habits may
be helpful. Similarly, certain social events may have become In a study by McCrady evaluating the effectiveness of
associated with excessive drinking; client may need to psychological interventions for alcohol use disorder such as
decline these invitations6. Brief Interventions and Relapse Prevention was classified as
efficacious23.
Urge management techniques
Urge surfing was developed by Marlatt. Using a wave In a 2013 Cochrane review which also discussed regarding
metaphor, urge surfing is an imagery technique to help relapse prevention in smokers the authors concluded that
clients gain control over impulses to use drugs or alcohol. there is insufficient evidence to support the use of any
In this technique, the client is first taught to label internal specific behavioural intervention to help smokers who
sensations and cognitive preoccupations as an urge, and to have successfully quit for a short time to avoid relapse. The
foster an attitude of detachment from that urge. The focus verdict is strongest for interventions focused on identifying
is on identifying and accepting the urge, not acting on the and resolving tempting situations, as most studies were
urge or attempting to fight it4. concerned with these24.

One of the most notable developments in the last decade Critique

has been the emergence and increasing application of Following the initial introduction of the RP model in the
Mindfulness‑Based Relapse Prevention (MBRP) for addictive 1980s, its widespread application largely outpaced efforts
behaviours. MBRP stresses non‑judgmental attention to to systematically validate the model and test its underlying
thoughts or urges20. assumptions. The Relapse Replication and Extension
Project (RREP) was a multisite study to replicate and extend
Relapse road maps Marlatt’s taxonomy of relapse precipitants. In addition
Cognitive‑behavioural analyses of high‑risk situations that to replicating Marlatt’s original taxonomic system, three
emphasize the different choices available to clients for independent research teams utilized prospective designs to
avoiding or coping with these situations as well as their identify additional predictors of relapse and developed and
consequences. Such a “mapping out” of the likely outcomes evaluated two alternative systems for assessing high‑risk
associated with different choices along the way can be relapse situations. These conclusions are: (1) reliability of
helpful in identifying SIDs5. Marlatt’s taxonomic system was variable both within and
across the three research sites; (2) Marlatt’s taxonomic
Outcome Studies for Relapse Prevention system showed little predictive validity in analyses that
In a meta‑analysis by Carroll, more than 24 RCT’s have used pre‑treatment relapse data to predict post‑treatment
been evaluated for the effectiveness of RP on substance use relapse, (3) an alternative taxonomy provided little more
outcomes. Review of this body of literature suggests that, predictive validity than the original taxonomy even though
across substances of abuse but most strongly for smoking it measured more dimensions of relapse25.
cessation, there is evidence for the effectiveness of relapse
prevention compared with no treatment controls. However, The dynamic model of relapse takes many of the RREP
evidence regarding its superiority relative to other active criticisms into account. Ecological momentary assessment,
treatments has been less consistent. Outcomes in which either via electronic device or interactive voice response
relapse prevention may hold particular promise include methodology, could provide the data necessary to fully test
reducing severity of relapses, enhanced durability of effects, the dynamic model of relapse19.
and particularly for patients at higher levels of impairment
along dimensions such as psychopathology or dependence Relapse Prevention in other areas
severity21. Principles of relapse prevention have been used in the
treatment of sex offenders. In a 2003 meta‑analysis relapse
In a subsequent meta‑analysis by Irwin, twenty‑six prevention treatment revealed moderate mean reductions
published and unpublished studies representing a sample in recidivism and certain elements of the relapse prevention
of 9,504 participants were included. Results indicated model (i.e. training significant others in the programme
that RP was generally effective, particularly for alcohol model and identifying the offense chain) yielded stronger
problems. Additionally, outcome was moderated by effects than others (i.e. provision of booster/aftercare
several variables. Specifically, RP was most effective sessions and developing coping skills) 26.
when applied to alcohol or polysubstance use disorders,
combined with the adjunctive use of medication, and when RP has also been used in eating disorders in combination
evaluated immediately following treatment. Moderation with other interventions such as CBT and problem‑solving
analyses suggested that RP was consistently efficacious skills4.

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Menon and Kandasamy: Relapse prevention

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