OCTOBER 2011
Review Article
Management of Lapse and Relapse in
Drug Dependence
RC Jiloha
Director Professor & Head, Department of Psychiatry, G.B. Pant Hospital & MAMC, New Delhi 110002
Almost all cultures have used psycho-active
drugs to facilitate social interaction, to alter
consciousness to heal. Our society’s expanded
chemical manipulation simply represents large
technical capacity, more wealth, leisure, individual
choice and conversely reduction in constraining
social settings, peer and family standards and
personal proscriptions. These conditions assume a
considerable variety in addiction behaviour.
Addiction behaviour like human behaviour in
general is conceived of as an outcome of genetic
and biochemical characteristics, past learning
experiences, motivational states, psycho-social
antecedents and cultural context in which it
unfolds.1
Addiction is therefore, a primary brain disease
which is determined genetically, expressed
biochemically and has psycho-social consequences.
Addiction may be defined as a chronic, often
relapsing brain disease with compulsive drug-
seeking and using the drug despite harmful
consequences. It is a brain disease because the drug
leads to changes in structure and function of the
brain. Initial decision of drug-intake may be
voluntary but repeated drug exposure affects
person’s self-control and ability to make sound
decision.
Regardless of the drug of addiction, relapse
rates following addiction treatment are alarmingly
high. There is an old saying that “Quitting drug and
alcohol use is easy, staying quit is hard part.”
A slip, or a lapse or relapse, are terms that
convey the length of time and severity of the fall
back into the old addictive behaviors. A relapse is
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DELHI PSYCHIATRY JOURNAL Vol. 14 No.
considered a full fall back into the old addictive
behaviors. It may be short-term. It may be as short
as one or two days. Usually though, it implies a
week or two, or months or years. A lapse or a slip
is considered a single episode, one day, and not that
severely re-initiating, not only the addictive
behavior, but all the consequences and all the other
associated behaviors that go with it. Relapse is
considered a full blown return to the addiction. A
lapse or a slip is just a temporary return, picking
back up rather quickly, getting back on the horse
metaphorically and getting back on with life.
Lapse and relapse in addiction
Why do they occur?
1. Low self-efficacy to cope up without drink
or drug use and positive outcome-
expectancy for drug effects are the
immediate precursors to a lapse.
2. After a lapse, the Abstinence Violation
Effect (AVE) occurs that involves loss of
perceived control experienced by the
patient.
3. AVE increases the probability of relapse.
4. AVE prevents patient to stay sober.
Abstinence Violation Effect (AVE)
The abstinence violation effect (AVE) occurs
when an individual, having made a personal
commitment to abstain from using a substance, has
an initial lapse whereby the substance is used at
least once. Some individuals may then proceed to
uncontrolled use. The AVE occurs when the person
attributes the cause of the initial lapse (the first
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violation of abstinence) to internal, stable, and
global factors within (e.g., lack of will power or
the underlying addiction or disease).2
In relapse prevention, the aim is to teach people
how to minimize the size of the relapse (i.e., to
counter the AVE) by directing attention to the more
controllable external or situational factors that
triggered the lapse (e.g., high-risk situations, coping
skills, and outcome expectancies), so that the person
can quickly return to the goal of abstinence and not
“lose control” of the behavior. Specific intervention
strategies include helping the person identify and
cope with high-risk situations, eliminating myths
regarding a drug’s effects, managing lapses, and
addressing misperceptions about the relapse
process. Other more general strategies include
helping the person develop positive addictions and
employing stimulus-control and urge-management
techniques. Researchers continue to evaluate the
AVE and the efficacy of relapse prevention
strategies.
Triggers that lead to relapse
There are some very traditional situations that
are predictable triggers for relapse. They generally
are thought of as both internal and external. Internal
ones would be uncomfortable feelings, such as
depression, anxiety, stressors, a re-remembering of
certain traumas in one’s life. These are all internal
states that bring about, often trigger, a relapse.
External ones, such as the friends and family and
liquor stores and people that are associated with
that often could trigger a relapse.
High-risk situations
There are many high-risk situations when a
patient is recovering. All high risk situations such
as attending parties where alcohol is served should
be avoided 3.
High risk situations for relapse
(There are 8 categories, 5 within the
intrapersonal class and 3 within the interpersonal
class) are described below.
I. Intrapersonal-Environmental Determinants
The first category includes all determinants that
are primarily associated with intrapersonal factors
(within the individual), and/or reactions to non-
personal environmental events. It includes reactions
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to interpersonal events in the relatively distant past
(i.e. in which the interaction with others is no longer
of significant impact).
A. Coping with negative emotional states.
Determinants involve coping with a negative
(unpleasant) emotional state, mood, or feeling.
(1) Coping with frustration and/or anger.
Determinants involve an experience of frustration
(reaction to a blocked goal-directed activity), and/
or anger (hostility, aggression) in terms of the self
or some non-personal environmental event. Includes
all references to guilt, and responses to demands
(“hassles”) from environmental sources or from
within the self that are likely to produce feelings of
anger.
(2) Coping with other negative emotional
states. Determinants involves coping with
emotional states other than frustration/anger that
are unpleasant or aversive including feeling of fear,
anxiety, tension, depression, loneliness, sadness,
boredom, worry, apprehension, grief, loss, and other
similar dysphoric states. It also includes reactions
to evaluation stress (examinations, promotions,
public speaking, etc.), employment and financial
difficulties and personal misfortune or accident.
B. Coping with negative physical-
physiological states. Determinants involve coping
with unpleasant or painful physical or physiological
reactions.
(1) Coping with physical states associated with
prior substance use. Coping with physical states
that are specifically associated with prior use of
drug or substance, such as “withdrawal agony” or
“physical craving” associated with withdrawal.
(2) Coping with other negative physical states.
Coping with pain, illness, injury, fatigue and
specific disorders (e.g. headache) that are not
associated with prior substance use.
C. Enhancement of positive emotional states.
Use of substance to increase feelings of pleasure,
joy, freedom, celebration and so on (e.g. when
traveling or on vacation). Includes use of substance
for primarily positive effects-to “get high” or to
experience the enhancing effects of a drug.
D. Testing personal control. It includes use of
substance to “test” one’s ability to engage in
controlled or moderate use; to “just try it once” to
see what happens; or in cases in which the
individual is testing the effects of treatment or a
OCTOBER 2011
commitment to abstinence (including tests of
“willpower”).
E. Giving in to temptations or urges. Use of
drugs in response to “internal” urges, temptations,
or other promptings includes references to
“craving” or intense subjective desire, in the
absence of interpersonal factors.
(1) In the presence of substance cues. Use
occurs in the presence of cues associated with
substance use (e.g. running across a pack of
cigarettes, passing by a bar, seeing an ad for
cigarettes).
(2) In the absence of substance cues. Here, the
urge or temptation comes “out of the blue” and is
followed by the individual’s attempt to procure the
substance.
II. Interpersonal Determinants
The second category includes determinants that
are primarily associated with interpersonal factors:
reference is made to the presence or influence of
other individuals as part of the precipitating event.
It implies the influence of present or recent
interaction with another person or persons, who
exert some influence on the user (reactions to events
that occurred in the relatively distant past are
classified in Category I). Just being in the presence
of others at the time of the relapse does not justify
an interpersonal classification, unless some mention
is made or implied that these people had some
influence or were somehow involved in the event.4
A. Coping with interpersonal conflict. It
includes coping with a current or relatively recent
conflict associated with any interpersonal
relationship such as marriage, friendship, family
patterns, and employer-employee relations.
(1) Coping with Frustration and/or Anger.
Determinants involves frustration (reaction to
blocked goal-directed activity), and/or anger
(hostility, aggression) stemming from an
interpersonal source. Emphasis is on any situation
in which the person feels frustrated or angry with
someone and includes involvement in arguments,
disagreements, fights, jealousy, discord, hassles,
guilt and so on.
(2) Coping with other interpersonal conflict.
Determinants involve coping with conflicts other
than frustration and anger stemming from an
interpersonal source. Feelings such as anxiety, fear,
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DELHI PSYCHIATRY JOURNAL Vol. 14 No.2
tension, worry, concern, apprehension, etc. which
are associated with interpersonal conflict, are
examples. Evaluation stress in which another person
or group is specifically mentioned would be
included.
B. Social pressure. Determinants involve
responding to the influences of another individual
or group of individuals who exert pressure (either
direct or indirect) on the individual to use the
substance.
(1) Direct social pressure. ‘Here is direct
contact (usually with verbal interaction) with
another person or group who puts pressure on the
user or who supplies the substance to the user (e.g.
being offered a drug by someone, or being urged to
use a drug by someone else). Distinguish from
situations in which the substance is obtained from
someone else at the request of the user (who has
already decided to use).
(2) Indirect social pressure. It includes
responding to the observation of another person or
group that is using the substance or serves as a
model of substance use for the user.
C. Enhancement of positive emotional states.
Use of substance in a primarily interpersonal
situation to increase feelings of pleasure,
celebration, sexual excitement, freedom and the like
include enhancement of positive emotions.
Distinguish from situations in which the other
person(s) is using the substance prior to the
individual’s first use (classify these under Section
II-B, above).
What can be learnt from relapse?
Relapse can be an extraordinarily positive
experience if one analyses after the relapse the
things such as (i) what was going on just prior to
the relapse, (ii) who were the people with just prior
to the relapse, (iii) how were the feelings inside
just before the relapse, (iv) what was the person
thinking just before the relapse, (v) a life event that
could account for the relapse. What the forces were,
(a) if hungry, (b) if tired, or (c) if feeling
uncomfortable that could lead to the relapse. It is
an opportunity that’s full of information to gain
insight. Generally speaking, these insights are only
available right after the relapse happens, so in
general, the sooner the better.5
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Coping with Lapses
What to do when a lapse occurs? Occurrence
of a lapse cannot be viewed as a totally benign
event; nor should it be cause for catastrophe and
giving in to a full-blown relapse.
During a lapse episode (slip) the most
dangerous period is the time immediately following
the event. Since specific coping strategies will vary
from client to client, therapist may wish to help a
particular client to prepare an individualized
reminder card that fits that person unique set of
vulnerabilities and resources.6
The strategies are listed in order of temporal
priority, with the most important immediate steps
listed first. The main points of this information can
be presented to patients in summary form by the
use of a Reminder Card that should be kept handy
in the event that a lapse occurs.
(1) Stop, look, and listen. The first thing to do
when a lapse occurs is to stop the ongoing flow of
events and to look and listen to what is happening.
The lapse is a warning signal indicating that the
patient is in danger.
(2) Carry out Lapse Management Plan. After
a slip, renewed commitments should be turned into
a plan of action to be carried out immediately.
Therapists can help patients identify Emergency
Action Plans, which may include a crisis hotline
telephone number, an alternative activity, or a
trustworthy friend.
(3) Keep Calm. Just because the patient slipped
once does not indicate failure. One slip does not
have to make a total relapse. Look upon the slip as
a single, independent event, something that can be
avoided in the future. A slip is a mistake, an
opportunity for learning, not a sign of total failure.
(4) Renew Commitment. After a lapse, the most
difficult problem to deal with is motivation. The
client may feel like giving up and may need
reminding of the long-range benefits to be gained
from this change. Clients should be encouraged to
reflect optimistically on their past successes in being
able to quit the old habit, instead of focusing
pessimistically on current setbacks.
(5) Review the situation leading up to the lapse.
Look at the slip as a specific unique event. The
following questions may help clarifying the lapse
episode:
(i) What events led up to the slip? (ii) Were
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there any early warning signals that preceded the
lapse? (iii) What was the nature of the high-risk
situation that triggered the slip? Each of these
questions may yield valuable information
concerning sources of stress and high-risk situations
for the patient. The fact that a slip occurred often is
an event that tells that something is going on that
needs attending to.
Dealing with the Abstinence Violation Effect
The cognitive restructuring process designed
to assist clients to cope with a lapse after a period
of abstinence or controlled use includes the
following points:6
(1) Teach patient not to view the cause of the
lapse as a personal failure or as a lack of willpower,
but instead ask him to pay attention to the
environmental and psychological factors in the
high-risk situation, to review what coping skills they
had available but didn’t implement, and to notice
how they felt decreased self-efficacy when they
couldn’t deal with the situation adequately.
(2) Help the patient to deal with the inevitable
feelings of guilt and shame and the cognitive
dissonance that usually accompany a lapse. Guilt
and shame reactions are particularly dangerous
because the emotions they produce are likely to
motivate further substance use as a means of coping
with these unpleasant reactions to the slip.
(3) After the lapse has occurred, react to the
patient with compassion and understanding, and
with the encouragement to learn everything possible
about how to cope with similar situations in the
future by a thorough debriefing of the lapse and its
consequences.
(4) Help patients identify any of the cognitive
distortions they may have succumb to in exposing
themselves to the high-risk situation, limiting their
ability to engage in an effective coping response,
and finally, making the decision to choose to take
that first drink, dose of drugs, or to engage in
criminal activity.
(5) Consult and revise the Decision Matrix or
Decision Balance Sheet to renew motivation by
focusing on the practical advantages for others and
the patient of continuing on the journey of habit
change.
Cognitive Behavioral Model of Relapse
Relapse prevention therapy (RPT) is based on
OCTOBER 2011
a cognitive-behavioral model of the relapse
process.5 This model of relapse addresses several
key questions about relapse both as a process and
as an event:
1. Are there specific situational events that
serve as triggers for relapse?
2. Are the determinants of the first lapse the
same as those that cause a total relapse to occur, if
not, how can they be distinguished from one
another?
3. How does an individual react to and
conceptualize the events preceding and following
a lapse and how do these reactions affect the
person’s subsequent behavior regarding the
probability of full-blown relapse?
4. Is it possible for an individual to covertly
plan a relapse by setting up a situation in which it
is virtually impossible to resist temptation?
5. At which points in the relapse process is it
possible to intervene and alter the course of events
so as to prevent a return to the addictive habit
pattern?
6. Is it possible to prepare individuals during
treatment to anticipate the likelihood of relapse and
to teach them coping behaviors that might reduce
the likelihood of lapses and the probability of
subsequent relapse? In order to investigate these
key questions about relapse, it is helpful to engage
in a microanalysis of the relapse process. This
approach focuses on the immediate precipitating
circumstances of relapse as well as on the chain of
events that may precede and set-up a relapse.
7. Interpersonal, and psychological factors that
precede a relapse and to the individual’s
expectations and attributions in reaction to a lapse.
This analysis is consistent with the view that the
maintenance stage of habit change is a time when
mistakes are expected, but can be overcome with
renewed effort.
Cognitive-Behavioral Model of Relapse Process
The cognitive-behavioral model of relapse
flowchart (above) refers to the immediate
precipitants of relapse that occur once a client is
exposed to a high-risk situation. In RPT, it is
assumed that clients who have successfully avoided
alcohol or drug use for a period of time will begin
to feel a sense of self-efficacy regarding their ability
to maintain abstinence. If a client has not learned
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DELHI PSYCHIATRY JOURNAL Vol. 14 No.2
an effective coping response to avoid a lapse in
response to high-risk situations, or if an effective
coping response is not implemented due to a lack
of motivation or anxiety, then there is an increased
likelihood of a lapse. This increased probability of
relapse is mediated by positive expectancies for the
initial use of drug.
Relapse Management
When a relapse occurs, the incorporation of
relapse management strategies prepare a patient to
implement damage control skills to reduce further
harmful consequences and prevent the situation
from escalating into a full-blown relapse. After a
lapse, patient may experience the abstinence
violation effect (AVE) that involves a loss of
perceived control experienced after the client’s
failure to adhere to his or her self-imposed rules of
conduct regarding alcohol and drug use2. On an
emotional level, the AVE increases the probability
of relapse because once a lapse has occurred, the
shame, guilt, self blame and other negative feelings
motivate further drinking or using drugs. In
addition, the AVE affects the likelihood of relapse
on a cognitive level because a lapse is also followed
by an internal conflict over the inconsistency of
one’s efforts to abstain from alcohol and/or drugs
combined with the reality of just using a substance.
Finally, the AVE also leads the patient to attribute
his “failure” to stay sober to stable internal factors
within his character that demonstrate that they are
flawed or beyond redemption. At the same time that
the cognitive and emotional reactions that
characterize the AVE are operating to disturb and
upset a patient about their lapse, the patient is also
beginning to experience the intoxicating effects of
the substance just used (e.g., enhanced pleasure and/
or reduced pain) further contributing to the
likelihood of continued use which may ultimately
lead to a full-blown relapse 7.
The reinforcing aspects of the initial use of the
substance are based in part on the principles of
operant conditioning. An individual who
experiences a positive consequence (e.g., euphoria)
from drinking or using drugs is more likely to do
so in the future due to the principle of positive
reinforcement. Similarly, if engaging in substance
use behavior results in the reduction of negative
consequences (e.g., pain or negative emotional
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states) the person is also more likely to use in the
future due to the process of negative reinforcement.
Because using alcohol and drugs is so
reinforcing, most patients are unable to make the
ultimate trip to abstinence from drinking and drug
use successfully the first time. Instead of reacting
to a lapse or relapse with a sense of self-blame and
failure, they should be treated as temporary setbacks
that may ultimately have positive outcomes and
become pro-lapses.
Pro-lapses are defined as mistakes that patients
learn from that improve their eventual chances of
success. For some patients, the change process is
slow and laborious and it takes many attempts
before the goal is attained. Others may find that
behavior change is less taxing, perhaps based on
the experiences they have gained in previous quit
attempts or because they have more resources, such
as greater coping capacity, stable employment, or
social support from family and friends. Whether a
patient feels he has succeeded or failed in their
previous attempts, the goal of RPT remains the
same, to help patient prevent relapse, even if he
“slip” and drink or use drugs at some point after
setting out on the trip, through relapse management
strategies, ultimately the journey of habit change
can still be made!
Can medication help to keep a behavioral
addict sober
Medication can be extremely helpful in
recovery depending on the type of addiction. They
help to diminish craving. There is going to be a
punishment such as that, if you do involve yourself
in that destructive behavior, you are going to have
a bad experience, such as through the use of
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OCTOBER 2011
antabuse or something like that. So, therefore, I do
support the appropriate use or the scientific use of
current medications to help one obtain and sustain
new behaviors
References
1. Cronce, Jessica M. Interview with author.
Addictive Behaviors Research Center,
University of Washington, 2000.
2. Curry SJ, Marlatt GA, Gordon JR. Abstinence
violation effect: Validation of an attributional
construct with smoking cessation. J Consult
Clin Psychol 1987; 55 : 145-149.
3. Larimer, Mary E. Palmer, Rebekka S, Marlatt
G. Alan. “Relapse prevention: An overview of
Marlatt’s cognitive-behavioral model.” Alcohol
Res Health 1999; 23 : 151-160.
4. Laws DR. “Relapse prevention—The state of
the art.” J Interpers Violence 1999; 14 : 285-
302.
5. Marlatt GA, Gordon JR. Relapse prevention:
Maintenance strategies in the treatment of
addictive behaviors. New York: Guilford Press
1985.
6. Shiffman, Saul, Hickcox, Mary, Paty, Jean A.
Gnys, Maryann, Kassel, Jon D, Richards,
Thomas J. “The abstinence violation effect
following smoking lapses and temptations.”
Cogn Ther Res 1997; 21(5) : 497-523.
7. Shiffman, Saul, Hickcox, Mary, Paty, Jean A,
Gnys, Maryann, et al. “Progression from a
smoking lapse to relapse: Prediction from
abstinence violation effects, nicotine
dependence, and lapse characteristics.” J
Consult Clini Psychol 2004; 121-136.