Relapse prevention strategies: what they are and how they work

Relapse prevention is a set of skills and planning steps meant to help a person keep going with recovery and handle the moments when substance use becomes tempting or returns. It grew out of cognitive-behavioral therapy and is now part of many treatment programs. This page explains the main ideas, the evidence behind them, and where their limits lie.

What relapse means, and why it is common

In this field, relapse means a return to substance use after a period of stopping or cutting back. According to the National Institute on Drug Abuse (NIDA), relapse is common and does not mean treatment has failed. NIDA says treating a chronic condition involves changing deeply rooted behaviors, and that a return to use is a signal to speak with a doctor about resuming, adjusting or changing treatment.

NIDA also compares relapse across conditions. A chart on its treatment and recovery page, citing a 2000 paper in JAMA, shows rates of roughly 40 to 60 percent for substance use disorders and roughly 50 to 70 percent for hypertension and asthma. It places addiction alongside other long-term conditions and predicts nothing for any one person.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) calls alcohol use disorder a chronic, relapsing condition and says people more often try to quit or cut back over time, have recurrences, learn from them, and continue.

The Marlatt model in outline

Most relapse prevention programs trace back to a model proposed by G. Alan Marlatt and Gordon in 1985. A 1999 review in the journal Alcohol Research & Health by Larimer, Palmer and Marlatt summarizes it. The model treats relapse as a process that unfolds over time rather than a single event.

It separates factors into two groups. Immediate determinants include high-risk situations, a person's coping skills, expectations about what a substance will do, and the abstinence violation effect (explained below). Less obvious factors include overall stress, an unbalanced lifestyle, and urges and cravings. The review notes that the model also applies to people who use drugs other than alcohol.

A central idea is that the situation itself is not the whole story. According to the review, it is the person's response that largely decides whether use begins. Someone who can leave the situation or use a mental strategy such as positive self-talk is less likely to relapse, and each successful coping experience is assumed to raise self-efficacy, meaning confidence in handling that kind of situation.

Triggers and high-risk situations

The review draws on Marlatt's 1996 analysis of what people described before a return to drinking. Negative emotional states such as anger, anxiety, depression, frustration and boredom were linked to the highest rate of relapse. Together with interpersonal conflict, these accounted for more than half of relapse episodes in that analysis. Social pressure contributed to more than 20 percent, and celebrations, cues such as passing a familiar bar, and testing one's own willpower were also named.

These figures come from one study of people treated for alcohol problems, so they describe patterns rather than rules.

Coping plans and day-to-day strategies

The same review describes specific strategies that a therapist and patient work on together. These include identifying personal high-risk situations, building skills for coping with them, strengthening self-efficacy, challenging myths about what a substance does, and planning ahead for lapses. It also lists broader strategies: balancing daily life so stress does not build up, using stimulus control (changing exposure to cues), learning urge-management techniques, and drawing up a "relapse road map" of the steps that lead toward use.

NIDA summarizes the goal of cognitive-behavioral therapy as helping people recognize, avoid and cope with the situations in which they are most likely to use. For more on that approach, see cognitive behavioral therapy.

Lapse versus relapse

The model draws a line between a lapse, the first break from a goal, and a full relapse, a return to uncontrolled use or abandoning the goal. The review states that a lapse raises the risk of relapse but that the move from one to the other is not inevitable.

What often decides it is the abstinence violation effect. People who see a lapse as proof of personal failure tend to feel guilt, and that guilt can lead to more use as a way of escaping the feeling. People who see a lapse as a coping problem that can be worked on are less likely to give up.

Mindfulness-based relapse prevention

Mindfulness-based relapse prevention (MBRP) combines cognitive-behavioral relapse prevention with mindfulness practices, such as noticing cravings and thoughts without acting on them. A systematic review by Grant and colleagues, published in the Journal of Addiction Medicine in 2017, pooled nine randomized trials. It did not find a statistically significant difference between MBRP and comparison treatments on relapse, and it rated the quality of evidence as low or very low, partly because many trials were small. The research does not show that it outperforms other aftercare. A related page covers mindfulness-based approaches.

The 1999 review also summarizes relapse prevention in general: studies tend to support it for reducing how often and how severely relapse occurs, but it was not linked to higher abstinence rates than other valid treatments.

Peer support and when to contact a clinician

Many people add peer support alongside professional care. NIDA describes 12-step programs as not medical treatments but as social and complementary support. See mutual-help groups, described neutrally for a descriptive overview.

NIDA advises that a relapse is a reason to talk with a doctor about resuming or changing treatment. NIAAA suggests asking any program how it handles a return to use. Some medications can also reduce the chance of returning to drinking or other use, and a clinician can explain which, if any, fit a person's situation; see medications used in treatment. Anyone unsure how to handle stopping again after a return to use can read withdrawal and detox in outline and raise the question with a clinician.

Questions to ask a clinician

• How will we identify my own high-risk situations and early warning signs?
• What should be in a written coping plan, and who should have a copy?
• How does this program respond if I lapse or relapse?
• Would medication, a mindfulness-based group or peer support fit alongside therapy?