Relapse Prevention in Alcoholism Treatment


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Relapse Prevention - Part 1

Relapse Prevention Exercise

Alcoholism Treatment Relapse Prevention - Part 2


There is some bad news and some good news about relapse from alcohol addiction. The bad news is that many clients have problems with relapse in early sobriety. About two thirds of clients coming out of alcohol addiction programs relapse within 3 months of leaving treatment (Hunt, Barnett, & Branch, 1971). The good news is that most people who go through treatment ultimately achieve a stable recovery (Frances, Bucky, & Alexopolos, 1984). Relapse does not have to happen to you, and even if it does, you can do something about it. Relapse prevention is a daily program that can help prevent relapse. It also can stop a lapse from becoming a disaster. This exercise has been developed using a combination of the models. This uses the disease concept model in combination with motivational enhancement, cognitive behavioral therapy, skills training and 12-step facilitation.



Relapse is a process that begins long before you use drugs or alcohol. There are symptoms that precede the first use of chemicals. This exercise teaches you how to identify and control these symptoms before they lead to actual drug or alcohol use. If you allow these symptoms to go on without acting on them, then serious problems will result.


All relapse begins with warning signs that will signal for you that you are in trouble. If you do not recognize these signs, you will decompensate and finally use chemicals. All of the signs are a reaction to stress, and they are a reemergence of the disease. They are a means by which your body and mind are telling you that you are in trouble. You might not have all of these symptoms, but you will have some of them long before you actually use chemicals. You must determine which symptoms are the most characteristic of you, and you must come up with coping skills for dealing with each symptom.

Interpersonal factors

Practice each of these ten things at least a five times in group, with your counselor, you sponsor/mentor/coach. You need to get used to thinking and moving in a certain way when faced with craving. If these behaviors are not practiced in stills training sessions they are unlikely to be used when you get into trouble. Just knowing what do is not enough; you need to practice the thoughts and motor movements to get good at the skill.

Think about the first time you learned how to ride a bike. Your teacher probably taught you all of the things you had to do to ride, but it was only after you practiced ridding, repeatedly, that you began to trust yourself to ride a bike safely.

Make a list of five things in your life that you had to practice. Maybe it was basketball, baseball, soccer, or starting a conversation with someone you did not know.

At first, you were terrible, making mostly mistakes, but after practicing thousands of times, you got better. Maybe you had to learn how to shoot a basket from the free throw line. The first times you tried, you missed most every shot. As you got better, and particularly after you were coached, you got better. After thousands of shots, you got so you could make the shot most of the time. Then there came the big game and the score was tied and you had to shoot the final basket. If you made the shot your team won if you missed, you lost. Now you need to go on automatic, athletes call this getting in the zone, where all of the fans and other players disappear and it is only you and that simple shot you have practiced so many times. If you miss the shot or relapse it is not the end of the world it just means you need more practice until the skill becomes automatic.

Higher levels of self-efficacy predict improved addiction treatment outcomes (Greenfield, Hufford, Vagge, Muenz, Costello & Weiss, (2000); Burling, Reilly, Molten, & Ziff, (1989).


When you recognize you are in trouble, you need to take action. Make a list of the coping skills you can use when you experience a high-risk situation that is common for you. It might be interpersonal conflict, anger, boredom, certain music or parts of town, seeing old friends, social pressure, negative emotions or a celebration. This will happen. You will have high-risk situations in recovery. Your task is to take affirmative action. Remember, craving is a danger signal. You are in trouble. Make a list of what you are going to do. Are you going to call your sponsor, go to a meeting, call your counselor, call someone in AA/NA, tell someone, exercise, read the “Big Book” (Alcoholics Anonymous, 2002), pray, become involved in an activity you enjoy, turn it over, or go into treatment? List five telephone numbers of people you can call if you are in trouble. Remember what AA says, “What we cannot do alone, we can do together.”

Plan 1.

Plan 2.

Plan 3.

Plan 4.

Plan 5.

Positive Outcome Expectations

This means the positive things we think will happen if we drink or use. These are dangerous thoughts and if not corrected may lead to relapse. Write down 5 positive thoughts about what the addiction can do for you. Things like, one drink will not hurt, I deserve to relax with a few drinks, I would only have one drink, I have had a hard day, I need to relax at the casino, nobody will know, I am going to show them, I am going to get even, I am going to make them sorry, I am under too much stress, I need a break etc.

Now write down 10 accurate thoughts that will keep you clean and sober, like I cannot drink one drink I am an alcoholic, If I start gambling I would never stop, I would use drugs again I would go right back into that addiction misery again, I can go home and talk to my wife, I can go for a walk, I can meditate, I can go to a 12-step meeting, I can call my sponsor or spiritual leader and go out for a cup of coffee, I can read some AA/NA/GA material. I can cope with this feeling. If I just wait for 15 minutes, the craving will pass. If I move away from the high-risk situation, I would feel better soon.

Write down these 10 alternative behaviors and carry them with you. Remember that you have to practice these skills until they become automatic. Practice saying and doing these things with your group, counselor, sponsor, mentor, coach, spouse, friend or 12-step member. Practice, practice, practice, until you feel comfortable with the new skill.

You need to check warning signs daily in your personal inventory. You also need to have other people check you daily. You will not always pick up the symptoms in yourself. You might be denying the problem again. Your spouse, your sponsor, and/or a fellow 12-step member can warn you when they believe that you might be in trouble. Listen to these people. If they tell you that, they sense a problem, and then take action. You might need professional help in working the problem through. Do not hesitate to call and ask for help. Anything is better than relapsing. If you overreact to a warning sign, you are not going to be in trouble. If you under react, you might be headed for real problems. Addiction is a deadly disease. Your life is at stake.


Motivation is the conscious or unconscious stimulus leading to the energy that gives you the power to act. Either you can act in an adaptive or a maladaptive way both can be positive or negative reinforcers. You can have motivation to stay clean and sober and you can have motivation to return to your addiction.

Prochaska and DiClemente (1984) proposed a model for motivation that goes through five stages or readiness for change. Precontemplation, contemplation, preparation, action and maintenance. Each stage characterizes a different level of motivational readiness for change.

Negative Emotions

Many people relapse when feeling negative feelings that they cannot cope with. Most feel angry or frustrated, but some feel anxious, bored, lonely, or depressed. Almost any negative feeling can lead to relapse if you do not learn how to cope with the feeling. Feelings motivate you to take action. You must act to solve any problem.

Circle any of the following feelings that seem to lead you to use chemicals.




















20.Left out































A Plan to Deal with Negative Emotions

These are just a few of the feeling words. Add more if you need to do so. Develop coping skills for dealing with each feeling that makes you vulnerable to relapse. Exactly what are you going to do when you have this feeling? Detail your specific plan of action. Some options are talking to your sponsor, calling a friend in the program, going to a meeting, calling your counselor, reading some recovery material, turning it over to your Higher Power, and getting some exercise. For each feeling, develop a specific plan of action.

Feeling ___________________________________

Plan 1. _________________________________________________________________

Plan 2. _________________________________________________________________

Plan 3. _________________________________________________________________

Feeling ____________________________________

Plan 1. ________________________________________________________________

Plan 2. ________________________________________________________________

Plan 3. ________________________________________________________________

Feeling ___________________________________

Plan 1. ____________________________________________________________

Plan 2. ____________________________________________________________

Plan 3. ____________________________________________________________

Continue to fill out these feeling forms until you have all of the feelings that give you trouble and you have coping skills for dealing with each feeling.

Social Pressure

Social pressure can be direct (where someone directly encourages you to use chemicals) or indirect (a social situation where people are using). Both of these situations can trigger intense craving, and this can lead to relapse. More than 60% of alcoholics relapse in bars.

Certain friends are more likely to encourage you to use chemicals. These people do not want to hurt you. They want you to relax and have a good time. They want their old friend back. They do not understand the nature of your disease. Perhaps they are chemically dependent themselves and are in denial.

High-Risk Friends

Make a list of the friends who might encourage you to use drugs or alcohol.

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

4. __________________________________________________________

5. __________________________________________________________

What are you going to do when they offer you drugs? What are you going to say? In group, set up a situation where the whole group encourages you to use chemicals. Look carefully at how you feel when the group members are encouraging you. Look at what you say. Have them help you to develop appropriate ways of saying no. The skills of saying no are the following:

High-Risk Social Situations

Certain social situations will trigger craving. These are the situations where you have used chemicals in the past. Certain bars or restaurants, a particular part of town, certain music, athletic events, parties, weddings, and family events—all of these situations can trigger intense cravings. Make a list of five social situations where you will be vulnerable to relapse.

1. ________________________________________________________________

2. ________________________________________________________________



In early sobriety, you will need to avoid these situations and friends. To put yourself in a high-risk situation is asking for trouble. If you have to attend a function, where there will be people using chemicals, and then take someone with you who is in the program. Take someone with you who will support you in your sobriety. Make sure that you have a way to get home. You do not have to stay and torture yourself. You can leave if you feel uncomfortable. Avoid all situations where your sobriety feels shaky.


Interpersonal Conflict

Many addicts relapse when in a conflict with some other person. They have a problem with someone and have no idea of how to cope with conflict so they might revert to old behavior and use the addiction to deal with the uncomfortable feelings. The stress of the problem builds and leads to using. This conflict usually happens with someone who they are closely involved with—wife, husband, child, parent, sibling, friend, boss, and so on.

You can have a serious problem with anyone—even a stranger—so you must have a plan for dealing with interpersonal conflict. You will develop specific skills in treatment that will help you to communicate even when you are under stress.

You need to learn and practice the following interpersonal skills repeatedly.

1.Tell the truth all of the time.

2.Share how you feel.

3.Ask for what you want.

4.Find some truth in what the other person is saying.

5.Be willing to compromise.

If you can stay in the conflict and work it out, that is great. If you cannot, then you have to leave the situation and take care of yourself. You might have to go for a walk, a run, or a drive. You might need to cool down. You must stop the conflict. You cannot continue to try to deal with a situation that you believe is too much for you. Do not feel bad about this. Interpersonal relationships are the hardest challenge we face. Carry a card with you that list the telephone numbers of people who you can contact. You might want to call your sponsor, minister, or counselor or a fellow AA/NA/GA member, friend, family member, doctor, or anyone else who may support you.

In an interpersonal conflict, you will fear abandonment. You need to get accurate and reassure yourself that people can disagree with you and still care about you. Remember that your Higher Power cares about you. A Higher Power created you and loves you. Remember the other people in your life who love you. This is one of the main reasons for talking with someone else. When the other person listens to you, that person gives you the feeling that you are accepted and loved.

If you still feel afraid or angry, then get with someone you trust and stay with that person until you feel safe. Do not struggle out there all by yourself. Any member of your 12-step group will understand how you are feeling. We all have had these problems. We all have felt lost, helpless, hopeless, and angry.

Make an emergency card that lists all of the people who you can call if you are having difficulty. Write down their phone numbers and carry this card with you at all times. Show this card to your counselor. Practice asking someone for help in treatment once each day. Write down the situation and show it to your counselor. Get into the habit of asking for help. When you get out of treatment, call someone every day just to stay in touch and keep the lines of communication open. Get used to it. Do not wait to ask for help at the last minute. This makes asking more difficult.

Positive Feelings

Some people relapse when they are feeling positive emotions. Think of all the times you used drugs and alcohol to celebrate. That has gotten to be such a habit that when something good happens, you will immediately think about using. You need to be ready when you feel like a winner. This may be at a wedding, birth, promotion, or any event where you feel good. How are you going to celebrate without drugs and alcohol? Make a celebration plan. You might have to take someone with you to a celebration, particularly in early recovery.

Positive feelings also can work when you are by yourself. A beautiful spring day can be enough to get you thinking about drinking or using. You need an action plan for when these thoughts pass through your mind. You must immediately get accurate and get real. In recovery, we are committed to reality. Do not sit there and recall how wonderful you will feel if you get high. Tell yourself the truth. Think about all of the pain that addiction has caused you. If you toy with positive feelings, then you ultimately will use chemicals.

Circle the positive feelings that may make you vulnerable to relapse.



















































A Plan to Cope with Positive Feelings

These are the feelings that may make you vulnerable to relapse. You must be careful when you are feeling good because pleasure triggers the same part of the brain that triggers addiction. Make an action plan for dealing with each positive emotion that makes you vulnerable to using chemicals.

Feeling _____________________________________

Plan 1._______________________________________________________

Plan 2.______________________________________________________ 

Plan 3._______________________________________________________

Feeling ________________________________________

Plan 1. _____________________________________________________

Plan 2. _____________________________________________________

Plan 3. _____________________________________________________

Feeling ________________________________________

Plan 1. _____________________________________________________

Plan 2. _____________________________________________________

Plan 3. ______________________________________________________

Continue this planning until you develop a plan for each of the positive feelings that make you vulnerable. Practice what you are going to do when you experience positive feelings.

Test Control

Some people relapse to test whether they can use the addiction again. They fool themselves into thinking that they might be able to use normally. This time they will use only a little. This time they will be able to stay in control of themselves. People who fool themselves this way are in for big trouble. From the first use, most people are in full-blown relapse within 30 days.

Testing personal control begins with inaccurate thinking. It takes you back to Step One. You need to think accurately. You are powerless over mood-altering chemicals. If you use, then you will lose. It is as simple as that. You are physiologically, psychologically, and socially addicted. The cells in your body will not suddenly change no matter how long you are clean and sober. You are chemically dependent in your cells. This never will change.

How to See Trough the first use

You need to look at how the illness part of yourself will try to convince you that you are not chemically dependent. The illness will flash on the screen of your consciousness all the good things that the addiction did for you. Make a list of these things. In the first column, marked “Early Use,” write down some of the good things that you were getting out of using chemicals. Why were you using? What good came out of it? Did it make you feel social, smart, pretty, intelligent, brave, popular, desirable, relaxed, or sexy? Did it help you to sleep? Did it make you feel confident? Did it help you to forget your problems? Make a long list. These are the good things that you were getting when you first started using. This is why you were using.

Early Use ____________________________________________Late Use











Now go back and place in the second column, marked “Late Use,” how you were doing in that area once you became addicted. How were you doing in that same area right before you came into treatment? Did you still feel social, or did you feel alone? Did you still feel intelligent, or did you feel stupid? You will find that a great change has taken place. The very things that you were using for in early use, you get the opposite of in late use. If you were drinking for sleep, then you cannot sleep. If you were using to be more popular, then you are more isolated, insecure and alone. If you were using to feel brave, then you are feeling more afraid. This is a major characteristic of addiction. The good things you got at first you get the opposite of in addiction. You can never go back to early use because your brain has permanently changed in chemistry, structure and genetics.

Take a long look at both of these lists and think about how the illness is going to try to work inside of your thinking. The addicted part of yourself will present to you all of the good things you got in early use. This is how the disease will encourage you to use. You must see through the first use to the consequences that are dead ahead.

Look at that second list. You must see the misery that is coming if you use chemicals. For most people who relapse, there are only a few days of controlled use before loss of control sets in. There usually is only a few hours or days before all of the bad stuff begins to click back into place. Relapse is terrible. It is the most intense misery that you can imagine.

Lapse and relapse

A lapse is the use of any addictive substance or behavior. A relapse is continuing to use the behavior until the full biological, psychological, and social disease is present. All of the complex biological, psychological, and social components of the disease become evident very quickly.

The Lapse Plan

You must have a plan in case you lapse. It is foolish to think that you never will have a problem again. You must plan what you are going to do if you have a problem. Hunt et al. (1971), in a study of recovering addicts, found that 33% of clients lapsed within 2 weeks of leaving treatment, and 60% lapsed within 3 months. At the end of 8 months, 63% had used. At the end of 12 months, 67% had used.

The worst thing you can do when you have a lapse is to think that you have completely failed in recovery. This is inaccurate thinking. You are not a total failure. You have not lost everything. A lapse is a great learning opportunity. You have made a mistake, and you can learn from it. You let some part of your program go, and you are paying for it. You need to examine exactly what happened and get back into recovery.

A lapse is an emergency. It is a matter of life or death. You must take immediate action to prevent the lapse from becoming a full relapse. You must call someone in the program, preferably your sponsor, and tell that person what happened. You need to examine why you had a problem. You cannot use the addiction and the tools of recovery at the same time. Something went wrong. You did not use your new skills. You must make a plan of action to recover from your lapse. You cannot do this by yourself. You are in denial. You do not know the whole truth. If you did, you would not have relapsed.

Call your sponsor or a professional counselor and have that person develop a new treatment plan for you. You may need to attend more meetings. You may need to see a counselor. You may need outpatient treatment. You may need inpatient treatment. You have to get honest with yourself. You need to develop a plan and follow it. You need someone else to agree to keep an eye on you for a while. Do not try to do this alone. What we cannot do alone, we can do together.



All behavior occurs in a certain sequence. First, there is the trigger. This is the external event that starts the behavioral sequence. After the trigger, there comes thinking. Much of this thinking is very fast, and you will not consciously pick it up unless you stop and think about it. The thoughts trigger feeling, which gives you energy and direction for action. Next comes the behavior or the action initiated by the trigger. Lastly, there always is a consequence for any action.

Diagrammed, the behavior chain looks like this:


Let us go through a behavioral sequence and see how it works. On the way home from work, Bob, a recovering alcoholic, passes the local bar. (This is the trigger.) He thinks, “I have had a hard day. I need a couple of beers to unwind.” (The trigger initiates thinking.) Bob craves a beer. (The thinking initiates feeling.) Bob turns into the bar and begins drinking. (The feeling initiates behavior.) Bob relapses. (The behavior has a consequence.)

Let us work through another example. It is 11 p.m. and Bob is not asleep (trigger). He thinks, “I would never get to sleep tonight unless I have a few drinks” (thinking). He feels an increase in his anxiety about not sleeping (feeling). He gets up and consumes a few drinks (behavior). He gets drunk and wakes up hung over and unable to work the next morning (consequence).

How to Cope With Triggers

At every point along the behavior chain, you can work on preventing relapse. First, you need to carefully examine your triggers. What environmental events lead you to using chemicals? We went over some of these when we examined high-risk situations. Determine what people, places, or things make you vulnerable to relapse. Stay away from these triggers as much as possible. If a trigger occurs, then use your new coping skills.

Do not let the trigger initiate old behavior. Stop and think. Do not let your thinking get out of control. Challenge your thinking and get accurate about what is real. Let us look at some common inaccurate thoughts.

1.It is not going to hurt.

2.No one is going to know.

3.I need to relax.

4.I am just going to have a couple.

5.I have had a hard day.

6.My friends want me to drink.

7.I never had a problem with pot.

8.It is the only way I can sleep.

9.I can do anything I want to.

10.I am lonely.

All of these inaccurate thoughts can be used to fuel the craving that leads to relapse. You must stop and challenge your thinking until you are thinking accurately. You must replace inaccurate thoughts with accurate ones. You are chemically dependent. If you drink or use drugs, then you will die. That is the truth. Think through the first drink. Get honest with yourself.

How to Cope With Craving

If you think inaccurately, then you will begin craving. This is the powerful feeling that drives compulsive drug use. Craving is like an ocean wave; it will build and then wash over you. Craving does not last long if you move away from your drug of choice. If you move closer to the drug, then the craving will increase until you are compelled to use. Immediately on feeling a desire to use, think this thought:

“Drinking/Drug use/Gambling is no longer an option for me.”

Now drinking and using drugs no longer is an option. What are your options? You are in trouble. You are craving. What are you going to do to prevent relapse? You must move away from your drug of choice. Perhaps you need to call your sponsor, go to a meeting, turn it over, call the AA/NA/GA hot line, call the treatment center, call your counselor, go for a walk, run, or visit someone. You must do something else other than thinking about chemicals. Do not sit there and ponder using. You will lose that debate. This illness is called the great debater. If you leave it unchecked, it will seduce you into using chemicals.

Remember that the illness must lie to work. You must uncover the lie as quickly as possible and get back to the truth. You must take the appropriate action necessary to maintain your sobriety.


If you work a daily program of recovery, then your chances of success increase greatly. You need to evaluate your recovery daily and keep a log. This is your daily inventory.

1.Assess all relapse warning signs.

a.What symptoms did I see in myself today?

b.What am I going to do about them?

2.Assess love of self.

a.What did I do to love myself today?

b.What am I going to do tomorrow?

3.Assess love of others.

a.What did I do to love others today?

b.What am I going to do tomorrow?

4.Assess love of God.

a.What did I do to love God today?

b.What am I going to do tomorrow?

5.Assess sleep pattern.

a.How am I sleeping?

6.Assess exercise.

a.Am I getting enough exercise?

7.Assess nutrition.

a.Am I eating right?

8.Review total recovery program.

a.How am I doing in recovery?

b.What is the next step in my recovery program?

9.Read the 24 Hours a Day book (Walker, 1992).

10.Make conscious contact with God.

a.Pray and meditate for a few minutes.

b.Relax completely.

Social Support System

Every client needs to build a social support system. Positive social support is highly predictive of long-term abstinence rates across many addictive behaviors. You need to write down specifically who is going to be your advocate at home, work, community and school. This person needs to talk to your counselor and understand exactly what being an advocate means. This person will have different tasks depending upon whether or not they are a school teacher, parent, spouse, pastor, sponsor, mentor, coach, community leader, school counselor, doctor, nurse, counselor, etc. You need to make a list of all of these people and decide who is going to do what. Someone needs to run up to three urine drug screens every week for the first six months and up to one drug screen a week for the next five years. This person is best the continuing care cast manager. The client calls in every morning to see if this is one of their drug testing days or not. If so, the client goes to the clinic and gives a urine sample.

1. Case manager ___________________phone ____________________

The continuing care case manager makes sure everyone on the team is working together to keep the client clean and sober. This person keeps a record of all therapy meetings, 12-step groups and drug screens. They have a contract with the client that outlines exactly what is expected of the client and what the consequences are if the client does not follow through with the recovery program.

2. Parent or spouse ___________________phone _________________

The parent or spouse will be the person who knows what behavior is adaptive and maladaptive. What friends are to be avoided? If an adolescent develops the behavioral contract and is responsible for rewards and consequences.

3. The teacher _______________________phone __________________

or employer  _________________________phone __________________

knows about what behavior is to be expected and what is not to be tolerated. Members of the team often call each other to check up on the facts and make sure everyone is on the same team.

4.The sponsor/mentor/coach ________________phone ____________

 Is the person who guides the client through recovery. They have are in a 12-step program themselves and take the client to meetings and meet regularly to discuss the recovery process.

5. The physician ___________________phone __________________

Orders the medication and does history and physical examinations to maintain good health.

6. The spiritual guide ______________phone ___________________

Helps the patent discuss and grow in his or her spiritual journey. The client shares their spiritual journey and maybe keeps a spiritual prayer journal.

Fill out this inventory every day following treatment, and keep a journal about how you are doing. You will be amazed as you read back over your journal from time to time. You will be surprised at how much you have grown.

Make a list of 10 reasons why you want to stay clean and sober.

1. _______________________________________________

2. _______________________________________________

3. ________________________________________________

4. _______________________________________________

5. _______________________________________________

6. _______________________________________________

7. _______________________________________________

8. _______________________________________________

9. _______________________________________________

10. ______________________________________________

Never forget these reasons. Read this list over and over to yourself. Carry a copy with you and memorize them. If you are struggling in sobriety, then take it out and read it to yourself. You are important. No one has to live a life of misery. You can recover and live a clean and sober life.

Find a treatment facility near you

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