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Each stage of recovery has its own risks of relapse [ 2 ].

Third, the main tools of relapse prevention are cognitive therapy and mind-body relaxation, which change negative thinking and develop healthy coping skills [ 3 ]. Fourth, most relapses can be explained in terms of a few basic rules [ 4 ]. Educating clients in these few rules can help them focus on what is important. I would like to use this opportunity, having been invited to present my perspective on relapse prevention, to provide an overview of the field and document some ideas in addiction medicine that are widely accepted but have not yet worked their way into the literature.

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I have also included a link to a public service video on relapse prevention that contains many of the ideas in this article and that is freely available to individuals and institutions [ 5 ]. The key to relapse prevention is to understand that relapse happens gradually [ 6 ]. It begins weeks and sometime months before an individual picks up a drink or drug. The goal of treatment is to help individuals recognize the early warning signs of relapse and to develop coping skills to prevent relapse early in the process, when the chances of success are greatest.

This has been shown to significantly reduce the risk of relapse [ 7 ]. Gorski has broken relapse into 11 phases [ 6 ]. This level of detail is helpful to clinicians but can sometimes be overwhelming to clients. I have found it helpful to think in terms of three stages of relapse: emotional, mental, and physical [ 4 ]. During emotional relapse, individuals are not thinking about using. They remember their last relapse and they don't want to repeat it. But their emotions and behaviors are setting them up for relapse down the road.

Because clients are not consciously thinking about using during this stage, denial is a big part of emotional relapse. The common denominator of emotional relapse is poor self-care, in which self-care is broadly defined to include emotional, psychological, and physical care. One of the main goals of therapy at this stage is to help clients understand what self-care means and why it is important [ 4 ].

The need for self-care varies from person to person. A simple reminder of poor self-care is the acronym HALT: hungry, angry, lonely, and tired. For some individuals, self-care is as basic as physical self-care, such as sleep, hygiene, and a healthy diet. For most individuals, self-care is about emotional self-care.

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Clients need to make time for themselves, to be kind to themselves, and to give themselves permission to have fun. How are you having fun? Are you putting time aside for yourself or are you getting caught up in life? Another goal of therapy at this stage is to help clients identify their denial.

I find it helpful to encourage clients to compare their current behavior to behavior during past relapses and see if their self-care is worsening or improving. The transition between emotional and mental relapse is not arbitrary, but the natural consequence of prolonged, poor self-care. When individuals exhibit poor self-care and live in emotional relapse long enough, eventually they start to feel uncomfortable in their own skin.

They begin to feel restless, irritable, and discontent. As their tension builds, they start to think about using just to escape. As individuals go deeper into mental relapse, their cognitive resistance to relapse diminishes and their need for escape increases. These are some of the signs of mental relapse [ 1 ]: 1 craving for drugs or alcohol; 2 thinking about people, places, and things associated with past use; 3 minimizing consequences of past use or glamorizing past use; 4 bargaining; 5 lying; 6 thinking of schemes to better control using; 7 looking for relapse opportunities; and 8 planning a relapse.

Helping clients avoid high-risk situations is an important goal of therapy. Clinical experience has shown that individuals have a hard time identifying their high-risk situations and believing that they are high-risk. Sometimes they think that avoiding high-risk situations is a sign of weakness. In bargaining, individuals start to think of scenarios in which it would be acceptable to use.

A common example is when people give themselves permission to use on holidays or on a trip. It is a common experience that airports and all-inclusive resorts are high-risk environments in early recovery. Another form of bargaining is when people start to think that they can relapse periodically, perhaps in a controlled way, for example, once or twice a year. Bargaining also can take the form of switching one addictive substance for another. Occasional, brief thoughts of using are normal in early recovery and are different from mental relapse.

They feel they are doing something wrong and that they have let themselves and their families down. They are sometimes reluctant to even mention thoughts of using because they are so embarrassed by them. Clinical experience has shown that occasional thoughts of using need to be normalized in therapy. They do not mean the individual will relapse or that they are doing a poor job of recovery. Once a person has experienced addiction, it is impossible to erase the memory. But with good coping skills, a person can learn to let go of thoughts of using quickly. Warning signs are when thoughts of using change in character and become more insistent or increase in frequency.

Finally, physical relapse is when an individual starts using again. Clinical experience has shown that when clients focus too strongly on how much they used during a lapse, they do not fully appreciate the consequences of one drink. Once an individual has had one drink or one drug use, it may quickly lead to a relapse of uncontrolled using. But more importantly, it usually will lead to a mental relapse of obsessive or uncontrolled thinking about using, which eventually can lead to physical relapse.

Most physical relapses are relapses of opportunity.

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They occur when the person has a window in which they feel they will not get caught. Part of relapse prevention involves rehearsing these situations and developing healthy exit strategies.

But that is the final and most difficult stage to stop, which is why people relapse. If an individual remains in mental relapse long enough without the necessary coping skills, clinical experience has shown they are more likely to turn to drugs or alcohol just to escape their turmoil. The effectiveness of cognitive therapy in relapse prevention has been confirmed in numerous studies [ 11 ].

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The negative thinking that underlies addictive thinking is usually all-or-nothing thinking, disqualifying the positives, catastrophizing, and negatively self-labeling [ 9 ]. These thoughts can lead to anxiety, resentments, stress, and depression, all of which can lead to relapse. Cognitive therapy and mind-body relaxation help break old habits and retrain neural circuits to create new, healthier ways of thinking [ 12 , 13 ].

Fear is a common negative thinking pattern in addiction [ 14 ]. These are some of the categories of fearful thinking: 1 fear of not measuring up; 2 fear of being judged; 3 fear of feeling like a fraud and being discovered; 4 fear of not knowing how to live in the world without drugs or alcohol; 5 fear of success; and 6 fear of relapse. A basic fear of recovery is that the individual is not capable of recovery. The belief is that recovery requires some special strength or willpower that the individual does not possess.

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Past relapses are taken as proof that the individual does not have what it takes to recover [ 9 ]. Cognitive therapy helps clients see that recovery is based on coping skills and not willpower. One of the important tasks of therapy is to help individuals redefine fun. Clinical experience has shown that when clients are under stress, they tend to glamorize their past use and think about it longingly. They start to think that recovery is hard work and addiction was fun. They begin to disqualify the positives they have gained through recovery. The cognitive challenge is to acknowledge that recovery is sometimes hard work but addiction is even harder.

In the early stages of substance abuse, using is mostly a positive experience for those who are emotionally and genetically predisposed. Later, when using turns into a negative experience, they often continue to expect it to be positive.

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It is common to hear addicts talk about chasing the early highs they had. On the other hand, individuals expect that not using drugs or alcohol will lead to the emotional pain or boredom that they tried to escape. Therefore, on the one hand, individuals expect that using will continue to be fun, and, on the other hand, they expect that not using will be uncomfortable. Cognitive therapy can help address both these misconceptions. How individuals deal with setbacks plays a major role in recovery. A setback can be any behavior that moves an individual closer to physical relapse.

Some examples of setbacks are not setting healthy boundaries, not asking for help, not avoiding high-risk situations, and not practicing self-care. A setback does not have to end in relapse to be worthy of discussion in therapy. Recovering individuals tend to see setbacks as failures because they are unusually hard on themselves [ 9 ]. Setbacks can set up a vicious cycle, in which individuals see setbacks as confirming their negative view of themselves.

They feel that they cannot live life on life's terms. This can lead to more using and a greater sense of failure. Eventually, they stop focusing on the progress they have made and begin to see the road ahead as overwhelming [ 16 ].