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Relapse prevention (RP) is a cognitive-behavioral approach to relapse with the goal of identifying and preventing high-risk situations such as unhealthy substance use, obsessive-compulsive behavior, sexual offending, obesity, and depression. [1] It is an important component in the treatment process for alcohol use disorder, or alcohol dependence. [2] [3] This model founding is attributed to Terence Gorski's 1986 book Staying Sober.
Relapse is seen as both an outcome and a transgression in the process of behavior change. An initial setback or lapse may translate into either a return to the previous problematic behavior, known as relapse, [4] or the individual turning again towards positive change, called prolapse. [1] A relapse often occurs in the following stages: emotional relapse, mental relapse, and finally, physical relapse. Each stage is characterized by feelings, thoughts, and actions that ultimately lead to the individual's returning to their old behavior. [5]
Relapse is thought to be multi-determined, especially by self-efficacy, outcome expectancies, craving, motivation, coping, emotional states, and interpersonal factors. In particular, high self-efficacy, negative outcome expectancies, potent availability of coping skills following treatment, positive affect, and functional social support are expected to predict positive outcome. Craving has not historically been shown to serve as a strong predictor of relapse. [1]
Relapse prevention techniques can include having booster sessions with a therapist, being vigilant for and trying to prevent or avoid high risk situations, and being ready to re-apply previously used therapies if a disturbance does occur. [6]
Carroll et al. conducted a review of 24 other trials and concluded that RP was more effective than no treatment and was equally effective as other active treatments such as supportive psychotherapy and interpersonal therapy in improving substance use outcomes. Irvin and colleagues also conducted a meta-analysis of RP techniques in the treatment of alcohol, tobacco, cocaine, and polysubstance use, and upon reviewing 26 studies, concluded that RP was successful in reducing substance use and improving psychosocial adjustment. RP seemed to be most effective for individuals with alcohol problems, suggesting that certain characteristics of alcohol use are amenable to the RP. [1] Miller et al. (1996) found the GORSKI/CENAPS relapse warning signs to be a good predictor of the occurrence of relapse on the AWARE scale (r = .42, p < .001).
Some theorists, including Katie Witkiewitz and G. Alan Marlatt, borrowing ideas from systems theory, conceptualize relapse as a multidimensional, complex system. Such a nonlinear dynamical system is believed to be able to best predict the data witnessed, which commonly includes cases where small changes introduced into the equation seem to have large effects. The model also introduces concepts of self-organization, feedback loops, timing/context effects, and the interplay between tonic and phasic processes. [1]
Rami Jumnoodoo and Patrick Coyne, in London UK, have been working with National Health Service users and carers over the past ten years to transfer RP theory into the field of adult mental health. The uniqueness of the model is the sustainment of change by developing service users and carers as 'experts' – following RP as an educational process and graduating as Relapse Prevention Practitioners. The work has won many national awards, been presented at many conferences, and has resulted in many publications. [7]
Terence Gorski MA has developed the CENAPS (Center for Applied Science) [8] model for relapse prevention including Relapse Prevention Counseling (Gorski, Counseling For Relapse Prevention, 1983) and a system for certification of Relapse Prevention Specialists (CRPS).
Relapse prevention is a specific intervention modality in the treatment of substance use disorder that focuses on developing skills and cognitive-behavioral techniques to help patients and their clinicians identify and manage situations that increase the risk of relapse. [9] These situations can include both internal experiences, such as automatic thoughts related to substance use, and external cues, like people or places that are associated with substance use. In the relapse prevention model, patients and clinicians work together to develop strategies that target these high-risk situations, using both cognitive and behavioral techniques. By increasing coping skills and confidence, patients learn to handle challenging situations without turning to alcohol. [10] or drugs, thus increasing their self-efficacy. [11]
For the prevention of relapse in major depressive disorder, several approaches and intervention programs have been proposed. Mindfulness-based cognitive therapy is commonly used and was found to be effective in preventing relapse, especially in patients with more pronounced residual symptoms. [12] Another approach often used in patients who wish to taper down antidepressant medication is preventive cognitive therapy, an 8-week psychological intervention program delivered in individual or group sessions that focuses on changing dysfunctional attitudes, enhancing memories of positive experiences and helping patients to develop personal relapse prevention strategies. [13] Preventive cognitive therapy has been found to be equally effective in preventing a return of depressive symptoms as antidepressant medication use alone in the long-term treatment of major depressive disorder. In combination with pharmaceuticals, it was found to be even more effective than antidepressant use alone. [14] [15]
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.
Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused.Citation needed
Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.
Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longer-lasting symptoms. The concept was used by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s.
Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.
Treatment-resistant depression (TRD) is a term used in psychiatry to describe people with major depressive disorder (MDD) who do not respond adequately to a course of appropriate antidepressant medication within a certain time. Definitions of treatment-resistant depression vary, and they do not include a resistance to psychotherapy. Inadequate response has most commonly been defined as less than 50% reduction in depressive symptoms following treatment with at least one antidepressant medication, although definitions vary widely. Some other factors that may contribute to inadequate treatment are: a history of repeated or severe adverse childhood experiences, early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, cognitive impairment, low income and other socio-economic variables, and concurrent medical conditions, including comorbid psychiatric disorders. Cases of treatment-resistant depression may also be referred to by which medications people with treatment-resistant depression are resistant to. In treatment-resistant depression adding further treatments such as psychotherapy, lithium, or aripiprazole is weakly supported as of 2019.
Motivational therapy is a combination of humanistic treatment and enhanced cognitive-behavioral strategies, designed to treat substance use disorders. It is similar to motivational interviewing and motivational enhancement therapy.
The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.
Mindfulness-based cognitive therapy (MBCT) is an approach to psychotherapy that uses cognitive behavioral therapy (CBT) methods in conjunction with mindfulness meditative practices and similar psychological strategies. The origins to its conception and creation can be traced back to the traditional approaches from East Asian formative and functional medicine, philosophy and spirituality, birthed from the basic underlying tenets from classical Taoist, Buddhist and Traditional Chinese medical texts, doctrine and teachings.
Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the patient to the anxiety source or its context. Doing so is thought to help them overcome their anxiety or distress. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and specific phobias.
Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).
Management of depression is the treatment of depression that may involve a number of different therapies: medications, behavior therapy, psychotherapy, and medical devices.
Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.
About 1 in 7 Americans suffer from active addiction to a particular substance. Addiction can cause physical, psychological, and emotional harm to those who are affected by it. The American Society of Addiction Medicine defines addiction as "a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences." In the world of psychology and medicine, there are two models that are commonly used in understanding the psychology behind addiction itself. One model is referred to as the disease model of addiction. The disease model suggests that addiction is a diagnosable disease similar to cancer or diabetes. This model attributes addiction to a chemical imbalance in an individual's brain that could be caused by genetics or environmental factors. The second model is the choice model of addiction, which holds that addiction is a result of voluntary actions rather than some dysfunction of the brain. Through this model, addiction is viewed as a choice and is studied through components of the brain such as reward, stress, and memory. Substance addictions relate to drugs, alcohol, and smoking. Process addictions relate to non-substance-related behaviors such as gambling, spending money, sexual activity, gaming, spending time on the internet, and eating.
Euphoric recall is a cognitive bias that describes the tendency of people to remember past experiences in a positive light, while overlooking negative experiences associated with some event(s). Euphoric recall has primarily been cited as a factor in substance dependence. Individuals may become obsessed with recreating the remembered pleasures of the past, where positive expectancy of outcomes results in the belief that substance use can provide immediate relief.
Guided self-change (GSC) treatment has been accepted by American Psychological Association Division 12, Society of Clinical Psychology, as an empirically supported treatment.
Mary E. Larimer is an American psychologist and academic. Larimer is a professor of psychiatry and Behavioral sciences, Professor or Psychology, and the Director of the Center for the Study of Health & Risk Behaviors at University of Washington (UW). Additionally, she serves as a psychologist at the Psychiatry Clinic at UW Medical Center-Roosevelt.
Katie Witkiewitz is an American psychologist, Distinguished Professor of Psychology at the University of New Mexico in Albuquerque, New Mexico, and Director of the Center on Alcoholism, Substance Abuse, & Addictions, and the Addictive Behaviors and Quantitative (ABQ) Research Lab.
Claudi Bockting is a Dutch clinical psychologist and Professor of Clinical Psychology in Psychiatry at the University of Amsterdams Faculty of Medicine, Amsterdam University Medical Centers. Her research program focuses on identifying etiological factors of common mental health disorders such as depression, anxiety disorders and substance abuse, and developing evidence-based psychotherapeutic interventions.