After reading, Treating Alcohol and Drug Problems in Psychotherapy Practice: Doing What Works, describe relapse dynamics in your own words. What can you, as the counselor, do to impart relapse prevention strategies to your clients?

"Relapse”, as the term is traditionally used in the addiction treatment field, refers to returning to substance use after a period of abstinence. More recently, however, relapse has come to be seen as a complex phenomenon involving much more than the act of using mood-altering chemicals again. Relapse is now seen as a process or dynamic that is set in motion by certain forces and as involving both overt and subtle shifts in patients' attitudes, behaviors, and choices that move them progressively closer to the point of using again. Thus, individuals can be in a backsliding or relapse mode, caught up in the process of heading for relapse, before they actually use alcohol and drugs again. In reviewing relapse experiences, many patients can identify specific clues or warning signs that preceded their return to alcohol and drug use. Typically,they were either totally unaware of these warning signs or paid little attention to them whileheading for relapse. Thus, a significant aspect of relapse prevention strategies is helping patientsto become aware of the earliest signs that they are in a relapse mode and learn how totake appropriate action to short-circuit this process before it culminates in a return to alcohol anddrug use. Although relapse can occur at any point after initial abstinence has been established,most relapses occur within the first 3-6 months. A wide range of variables contribute to therelapse process and in most instances the actual causes of relapse are determined by a multitudeof factors. Rarely does one factor alone precipitate relapse to alcohol and drug use.Several categories of relapse precipitants have been defined by previous investigators (Marlatt& Gordon, 1985), some of which were mentioned in the preceding chapter. These include: (a)both positive and negative mood and affect states; (b) environmental cues or triggers associatedwith prior substance use; (c) inadequate coping and problem solving skills; (d) sexual triggers;(e) unrealistic expectations and other "mind traps” or cognitive distortions; (f) lingeringwithdrawal including post-drug anhedonia and dysphoria; and, (g) conscious and unconscious motivationsto use mood-altering substances again including shame, guilt, and residues of earlier traumaand abuse. Patients in early stages of the relapse process usually exhibit a variety of changes in thought, emotion, attitude, and behavior. At this point, the clinician can intervene to help short-circuit the relapse process before it leads to resumption of substance use. However, this depends on the ability of the clinician to recognize the warning signs coupled with the patient's ability to receive feedback and make the necessary preemptive changes. Sometimes the warning signs are subtle and, therefore, very difficult to recognize as such. Adding to the difficulty is the factthatdifferent patients show different warning signs. Also, since behavior is at timesunconsciously motivated, the client may actually be unaware of warning signs that are apparent to otherpeople. The relapse process has been described as a progressive chain reaction or set ofbehaviors, attitudes, and events set in motion most often by negative feelings and/or stressors. Thischainreaction can take many different forms, but may look something like this (Washton,1989): The Relapse Chain or Progression There is a buildup or onset of stress caused by negative events (e.g., relationship conflict, financial pressures, etc.) The stress activates overly negative thoughts, moods, and feelings that lead the person to feel overwhelmed or emotionally numb Either overreaction or emotional numbing causes failure to take action, leading to continuation and eventual escalation of the problem The person gradually withdraws from his/her established recovery support system and daily routines There is a resurfacing or exacerbation of denial as evidenced by increasingly skeptical and cynical attitudes toward treatment, self-help, and other commitments Feelings of futility about one's ability to manage life comfortably without using alcohol or drugs coupled with an increasing belief that relapse is inevitable, begin to overshadow whatever progress the person has been achieved up to this point Signs of impaired judgment and impulsiveness become evident as the individual makes poor decisions that result in even greater stress As the person's life becomes increasingly unmanageable, feelings of frustration, despair, and self-pity set in and trigger obsessive thoughts about using again Irresistible urges and cravings lead to drug-seeking and drug-using behavior. The relapse chain is complete. Education is an important relapse prevention tool. Patients need to be educated about certain attitudes, thinking, and behavior patterns that are characteristic of addiction and often contribute to relapse. The primary purpose of doing this is to help them anticipate the "traps” most commonly faced by people trying to maintain abstinence and learn how to deal with these traps in order to avoid returning to alcohol and drug use. You should provide patients with education about relapse as soon as possible after initial abstinence has been reasonably well established. Even if they are not strongly motivated to maintain abstinence and do not acknowledge the true severity of their addiction, education on relapse can still be helpful. Educational interventions tend to be nonthreatening ways to counteract denial and motivate patients to change. You can provide these interventions systematically in topic-oriented sessions or spontaneously in individual therapy sessions as specific issues emerge. You can also give patients a list of suggested readings or specific homework assignments in RP workbooks designed specifically for this purpose (Daley, 2000; Washton, 1990a, 1990b, 1990c; Zackon et al., 1993). It is important, however, to not make relapse education a purely intellectual or didactic experience. Information about relapse should be made as personally relevant as possible by helping patients apply this information pointedly to their current life problems, circumstances, and experiences. One of the most important RP strategies is to help patients identify and becomeincreasingly aware of variables most likely to initiate or herald an impending relapse. Throughdiscussions during individual therapy sessions as well as homework (workbook) assignments, you canhelp patients define the specific conditions that are most are most strongly associated with theirprior use and/or most likely to set the stage for resumption of their alcohol and drug use.Relapse precipitants and warning signs have been divided into several categories (Daley & Lis,1995; Marlatt & Gordon, 1985; Rawson et al., 1993; Washton, 1988),including: High-risk situations: certain times of the day or night; people, places, and things previously associated with substance use; idle unstructured time, access to cash, parties, bars, anniversaries, celebrations Behavioral warning signs: interpersonal conflict; failure to cope adequately with life problems and stressors; engaging in other addictive and compulsive behaviors; impulsive decision making and poor judgment; returning to secondary drug use Affective warning signs: negative moods; emotional lability; anger, frustration, hopelessness, and irritability; identity and role confusion; positive moods and excitement; desire to celebrate; sexual arousal Cognitive warning signs: euphoric recall and selective forgetting; repetitive drug using dreams; relapse justification; rationalizations to let up on disciplines and reduce or discontinue recovery-supportive activities Physiological warning signs: unremitting PAWS; resurfacing of intense cravings and urges; physical illness; chronic pain One way to help your patients anticipate and deal with relapse triggers and warning signs is by asking them to describe in detail a likely relapse scenario. This technique can help to make the possibility or threat of relapse more real for patients and encourage them to become more mindful of forces that may propel them toward using again. Their description of a relapse scenario should include exactly what type of situation might put them into a relapse mode, where and with whom, what thoughts and feelings might be evoked, and what options might be available for avoiding alcohol and drug use. If there have been previous relapses, help the patient conduct a detailed retrospective analysis ("microanalysis”) of early warning signs and other precipitants that led up to the relapses. Previous periods of abstinence ending in relapse provide valuable information about how relapses happened and more importantly how to prevent them from happening again.. Another intervention is to ask patients routinely at each visit if they have been any close calls since the last session and if they have experienced any cravings, fantasies, or dreams about using. If patients report any of these, it is important to discuss in detail specifically what events, circumstances, and feelings may have led up to these occurrences. Careful detailed inquiry can help to focus needed attention not only on environmental, but also psychological and interpersonal issues. Conflict in intimate and work relationships and significant personal losses are common relapse precipitants. Helping patients to be mindful of their increased relapse potential around certain holidays, birthdays, anniversaries, and celebrations of various kinds and learn how to manage whatever feelings are elicited by these events, are essential components of the ongoing therapeutic work. 3. Relapse Prevention Strategies 3.3. Dealing with the "Pink Cloud" and Feelings of Being "Cured" The initial positive effects of stopping alcohol and drug use can be striking- at least for a while until the stress and problems of everyday life reappear full force and burst the patient's bubble or "pink cloud” and end the "honeymoon” phase of early recovery. Although some patients do not experience this effect, and feel distinctly worse not better after stopping alcohol and drug use, many if not most will show some evidence of being on the "pink cloud”. Related to the "pink cloud” phenomenon are illusions of being "cured” of the addiction or that it no longer exists (and maybe did not exist in the first place) after several weeks or months of abstinence, especially if remaining abstinent has not been very difficult and devoid of crises, The danger of being in this state is that fosters a sense of overconfidence and a belief that the problem is solved and not likely to return. Having given up alcohol and drugs, the true source of all their problems, so it seems, patients often feel that they can now go on happily with their lives by simply remaining determined to not use again. Patients in this frame of mind are extraordinarily prone to overreacting to almost any negative event that threatens to throw them off of their cloud, no matter how large or small that problem may be. Accordingly, they are at high risk for relapsing in response to feeling disappointed and resentful when problems arise. Patients on a pink cloud pose a dilemma for the treating clinician. On the one hand, it is important to applaud the patients' progress and compliment them for making positive changes. On the other hand, it is equally important to not foster unrealistic hopes and expectations that could set patients up for being blind-sided by serious setbacks. The best approach is to complement patients for making progress and also call their attention to the importance of remaining vigilant about dangers that may lie ahead. Reminding patients of their vulnerability to relapse and describing scenarios that others have experienced as a result of not being sufficiently aware and proactive, can be both instructive and motivating. 3. Relapse Prevention Strategies 3.4. Creating a Balanced and Satisfying Lifestyle Achieving a balanced satisfying lifestyle is an essential part of reducing the potential for relapse. Often, using alcohol and drugs has occupied a significant part of the person's time and caused them to give up other healthy pursuits to the point where stopping the use leaves a large void that can be filled too easily by using again. Many individuals have become so accustomed to instantly modifying their mood and mental state with psychoactive substances that the idea of having to plan, expend effort, and engage in physical activity for enjoyment and stress relief may feel daunting at first. Also, some patients are severe "workaholics” whose daily lifestyles are severely out of balance. Often, using alcohol an drugs is the only for of gratification they have allowed themselves on a regular basis. Thus, once stable abstinence has been achieved it is essential to encourage and guide the development of new leisure and recreational activities that serve intrinsically to reinforce a recovering lifestyle devoid of alcohol and drug use. The primary goal is to learn how to have fun and enjoy the rewards and reap the rewards and pleasures of life without relying on alcohol and drugs. Pleasurable activities should be integrated along with work and family responsibilities on a regular basis. The particular types of activities should be based on the patient's needs, interests, and preferences and ideally should include activities that can be pursued alone as well as those that involve the participation of others. For individuals who previously were in the process of establishing a balanced lifestyle, discontinuing regular exercise, self-help meeting attendance, or other self-care activities without thought or discussion should be a warning signal for the therapist. Other warning signs include neglect of stress management techniques such as avoiding or being watchful when one is hungry, angry, lonely or tired. The therapeutic framework offers the advantage of a structure to notice shifts in routine activities and discuss their implications. How did you decide to cut back your exercise regimen? How did you drift into thinking you could manage on less sleep for extended periods of time? This allows the patient to increase awareness and make appropriate behavioral corrections. It is always easier to interrupt relapse drift in the early stages than when the factors have accumulated. Relapse prevention strategies have become a standard feature of addiction treatment programs and group therapy approaches to treating addictions over the past two decades and they can be integrated quite easily into individual treatment sessions in office-based practice. RP strategies emanate from the premise that the factors that help to initiate abstinence from addictive behaviors are different from those needed to maintain abstinence. These techniques are based primarily on a cognitive-behavioral and skills acquisition approach involving education, therapeutic confrontation, affect management, and coping skills development. Although slips and relapses should never be condoned or encouraged, clinicians should not only help patients face the reality that relapse is an ever-present danger, but also respond therapeutically if and when patients return to using alcohol and drugs again. Preventing slips from escalating into full-blown relapses is one of the primary goals of RP strategies. Helping patients to maintain abstinence and prevent relapse involves, among other things, teaching them how to recognize relapse warning signs and how to cope effectively with high-risk situations and other potential relapse precipitants. Therapists must be mindful of the potential for experiencing negative countertransference reactions to patients who relapse repeatedly While therapists must never downplay the potential dangers of relapses or ignore them, it is essential to show empathy, concern, and a positive problem-solving attitude that reframes relapses as avoidable mistakes, not tragic failures. A genuine belief that patients can learn from these mistakes and move forward in their recovery, should be conveyed to patients routinely. After abstinence has been firmly maintained for several at least months and the potential for relapse is markedly reduced, patients may benefit from more insight-oriented psychotherapy that focuses on a wider range of psychological issues in greater depth.