Until recently, little focus was placed on relapse prevention programmes, however research has now begun to develop ways in which relapsing can be prevented.
Addiction is known as a relapsing condition, whereby relapsing is not an event, it is a part of the recovery process. Until recently, little focus was placed on relapse prevention programmes, however research has now begun to develop ways in which relapsing can be prevented. Relapse prevention programmes are derived largely from cognitive behavioural therapy (CBT) (triggers, cravings and lapse management components) and they are based on individualised client formulations. This blog post explores what triggers and high-risk situations are in relation to relapse, and critically discuss the therapeutic strategies of eye movement desensitisation and reprocessing (EMDR) and memory focused cognitive therapies (MFCT) to avoid relapsing.
High risk situations are external factors which surface a memory of drugs; these may present as people, places and times. Triggers, on the other hand, are more cognitive, but can also be physical (e.g., negative/positive thoughts, physical sensations). In combination, the two can lead to an increased risk of one using drugs. This has been demonstrated in research where the drug Stroop Effect (DSE) suggests an attention bias to drug-related cues and cue-induced cravings in people who use drugs. A higher DSE score has been shown to be associated with more severe dependence and also with lower retention rates in treatment of people with cocaine-use disorder. This therefore conveys the detrimental impact that high-risk situations and triggers can have on someone in terms of attentional biases and associated behaviours.
Early work relating to relapse prevention highlights that relapsing is the result of a lifestyle imbalance, whereby there is a perceived conflict between what people want, and what people need. From here there are two different ways of coping with this imbalance: urges by cravings or denial and seemingly irrelevant decisions. This may then place someone in a high-risk situation, which is a situation that increases the risk of someone using drugs or alcohol. If no coping response is in place, then self-efficacy is assumed to be low, which may lead to initial indulgence followed by the rule violation effect (characterised by cognitive dissonance and self-attribution), thus increasing the probability of relapsing.
Gorski’s model, on the other hand, holds stress denial as key in avoiding relapses; the model takes a more psychodynamic approach to relapsing, whereby denial leads to internal/external dysfunction thus leaving the individual with few options to manage the stress, and so they relapse. In this sense, people use drugs to reduce the dysfunction they experience and build positive expectations of the drug (e.g., alcohol helps to reduce my anxiety). It is therefore essential that patients are equipped with the right tools and techniques in order to reinstate self-efficacy, challenge perceived ‘positive expectations’ and help gain control over intrusive thoughts, triggers and high-risk situations.
Relapse can be avoided using therapeutic strategies such as EMDR and memory focused cognitive therapies. EMDR therapy was initially developed to treat post-traumatic stress disorder, but over recent years it has been applied to the addictions. The main goal of EMDR is to work with unprocessed (often traumatic) memories linked to the addiction problems and to reprocess these memories with standardised protocols, which include “…bilateral sets of rapid (saccadic) eye movements, auditory signals, or tactile stimulation.” Shapiro argues that the traumatic memories underlie the dysfunction and triggers, thus EMDR may be used as a form of relapse prevention through enabling a ‘reprocess’ of these memories (ibid). Indeed, this paper found that reprocessing the addiction memory using EMDR significantly decreased craving in alcohol dependent participants and fewer participants in the EMDR condition relapsed in comparison to control. Although the sample size in this study was small, thus lacking statistical power, it indicates that more research should be done into EMDR and how to modify such interventions in order to prevent relapse.
In addition to EMDR, promising findings have been shown for MFCT in reducing cravings. MFCT works by targeting fast-flowing thoughts which often produce cravings; for example, drug neutral objects such as an ATM may become conditioned through repeated exposure, and so seeing the ATM may prompt thoughts or feelings related to drug use or cravings (e.g., permission giving thoughts). In this sense, MFCT addresses the implicit autonomous mind through changing what has been remembered, much like editing and resaving a word document. A recent study conducted on people with cocaine-use disorder (CUD) stimulated craving in participants through using a short video and then asked them to generate a past-positive (e.g., pleasurable memory before cocaine use), past-negative (bad memory relating to cocaine use), future-positive (wished for event if they recover from CUD) and future-negative memories (most feared event) and then randomised participants to each condition. What they found was that positive themes were able to reduce craving by 32%, whereas imagery simulating worsened CUD did not. Given no treatments currently are able to reduce stimulant use cravings, MFCT may be key in not only preventing relapse in CUD, but in many other addiction problems, too. Further research should therefore be done to examine how this can be further developed as a treatment option for relapse prevention.
In conclusion, it is vital that great significance is placed on relapse prevention programmes given relapse is very likely to occur in people in recovery. People in recovery should be equipped with the tools and self-efficacy to manage and control cravings, triggers and high-risk situations, as without a coping mechanism in place, the probability for relapse is high. Further research should also be conducted on therapeutic treatments for relapse prevention, where both EMDR and MFCT have been shown to be very promising in reducing cravings for alcohol dependency and CUD.
Source: Written by Anya Aggarwal