This document discusses relapse prevention and provides details about: 1) Relapse theory and the importance of managing relapse as part of recovery for substance abuse disorders. 2) Gorski and Marlatt's models of relapse prevention, which identify phases and warning signs of impending relapse. 3) A list of 37 warning signs organized into 10 phases that can help individuals personalize warning signs most relevant to them.

1. Relapse PreventionRelapse Prevention
VA PrescottVA Prescott
Guy C. Lamunyon MSN, RN, CASGuy C. Lamunyon MSN, RN, CAS
(Certified Addiction Specialist)(Certified Addiction Specialist)
An evidence based practice forAn evidence based practice for
substance abuse treatmentsubstance abuse treatment

2. Relapse PreventionRelapse Prevention
““Insanity:Insanity: doing the same thingdoing the same thing over and over againover and over again
and expectingand expecting different results.” Albert Einsteindifferent results.” Albert Einstein
““The most predictable outcome from rehabilitation isThe most predictable outcome from rehabilitation is
relapse.”relapse.”
““If you don’t understand relapse, you don’t understandIf you don’t understand relapse, you don’t understand
addiction.”addiction.”
Relapse is part of recovery for severely relapse proneRelapse is part of recovery for severely relapse prone
individualsindividuals

3. AwardsAwards
HALL OF FAME – California Association of Alcohol andHALL OF FAME – California Association of Alcohol and
Drug Abuse Counselors (2002)Drug Abuse Counselors (2002)
VA BEST PRACTICE – MHICM PROGRAMVA BEST PRACTICE – MHICM PROGRAM
DEVELOPMENT (2003)DEVELOPMENT (2003)
SECRETARYS AWARD – Advanced Practice Nursing – VASECRETARYS AWARD – Advanced Practice Nursing – VA
Long Beach (2006)Long Beach (2006)
VA BEST PRACTICE – OIF/OEF Outreach – VA HeadVA BEST PRACTICE – OIF/OEF Outreach – VA Head
Nurse Conference Wash DC (2007)Nurse Conference Wash DC (2007)

4. Addiction Medicine SpecialistsAddiction Medicine Specialists
Joseph Zuska – Navy Alcohol Rehabilitation ProgramsJoseph Zuska – Navy Alcohol Rehabilitation Programs
Paul Ohligher – ARS, DOCTOR, ALCOHOLIC, ADDICTPaul Ohligher – ARS, DOCTOR, ALCOHOLIC, ADDICT
chapter in the AA Big Bookchapter in the AA Big Book
Max Schneider – CareManor and Educational VideosMax Schneider – CareManor and Educational Videos
Joseph Pursch – treated Betty Ford - author and columnistJoseph Pursch – treated Betty Ford - author and columnist
Walter Ling – Matrix Institute and researchWalter Ling – Matrix Institute and research

5. PsychiatristsPsychiatrists
Robert Gerner – Mood Disorders ResearchRobert Gerner – Mood Disorders Research
William Wirshing – Schizophrenia/MedicationWilliam Wirshing – Schizophrenia/Medication
DevelopmentDevelopment
Andrew Shaner – Dual Diagnosis ResearchAndrew Shaner – Dual Diagnosis Research
Stephen Marder – Schizophrenia, MIRECC22Stephen Marder – Schizophrenia, MIRECC22

6. Confrontational StylesConfrontational Styles
and Outcomeand Outcome
STYLE OUTCOMESTYLE OUTCOME
HIGHHIGH WORSTWORST
MEDIUMMEDIUM IN BETWEENIN BETWEEN
LOWLOW BESTBEST

7. Project MATCH OutcomeProject MATCH Outcome
Compared Motivational EnhancementCompared Motivational Enhancement
Therapy (MET), Cognitive BehavioralTherapy (MET), Cognitive Behavioral
Therapy (CBT) and 12 Step FacilitationTherapy (CBT) and 12 Step Facilitation
(TSF).(TSF).
Twelve Step Facilitation was slightly but notTwelve Step Facilitation was slightly but not
significantly more effective than MET andsignificantly more effective than MET and
CBTCBT

8. Relapse by AddictionRelapse by Addiction

9. Relapse by diseaseRelapse by disease

10. Gorski/CENAPS Model (1982)Gorski/CENAPS Model (1982)

11. Marlatt Relapse Prevention (1985)Marlatt Relapse Prevention (1985)
Professor of Psychology at theProfessor of Psychology at the
University of WashingtonUniversity of Washington and Director of theand Director of the
Addictive Behaviors Research CenterAddictive Behaviors Research Center

12. Marlatt Mindfulness BasedMarlatt Mindfulness Based
Relapse PreventionRelapse Prevention

13. Marlatt: Harm ReductionMarlatt: Harm Reduction

14. Relapse TheoryRelapse Theory
1. Relapse is part of the management of any1. Relapse is part of the management of any
chronic lifestyle related diseasechronic lifestyle related disease
2. It is unrealistic to expect a zero relapse rate as2. It is unrealistic to expect a zero relapse rate as
an outcome standardan outcome standard
3. It is realistic to3. It is realistic to
A. To reduce the relapse rateA. To reduce the relapse rate
B. Manage relapse episodes more efficientB. Manage relapse episodes more efficient

15. Critical indicators of effectiveCritical indicators of effective
relapse managementrelapse management
1. Frequency. Occurring less often1. Frequency. Occurring less often
2. Duration. Getting shorter2. Duration. Getting shorter
3. Severity. Having fewer consequences3. Severity. Having fewer consequences
4. Getting less expensive to manage4. Getting less expensive to manage

16. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
A Reliable & Valid Predictor of Alcohol
Relapses
Miller, W. R., & Harris, R. J. (2000). A
simple scale of Gorski’s warning signs for
relapse. Journal of Studies on Alcohol, 61,
759-765.

18. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase1: The Return of DenialPhase1: The Return of Denial
1. Concern about Well Being1. Concern about Well Being
2. Denial of the Concern2. Denial of the Concern

19. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase2: Avoidance and DefensivePhase2: Avoidance and Defensive
Behaviour.Behaviour.
3. Believing “I’ll never drink again”3. Believing “I’ll never drink again”
4. Worrying about Others Instead of Self4. Worrying about Others Instead of Self
5. Defensiveness.5. Defensiveness.
6. Compulsive Behaviour.6. Compulsive Behaviour.
7. Impulsive Behaviour.7. Impulsive Behaviour.
8. Tendencies towards Loneliness.8. Tendencies towards Loneliness.

20. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 3: Crisis Building.Phase 3: Crisis Building.
9. Tunnel Vision9. Tunnel Vision
10. Minor Depression10. Minor Depression
11. Loss of Constructive Planning11. Loss of Constructive Planning
12. Plans Begin to Fail12. Plans Begin to Fail

21. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 4: ImmobilizationPhase 4: Immobilization
13. Daydreaming and Wishful Thinking.13. Daydreaming and Wishful Thinking.
14. Feelings that nothing can be solved.14. Feelings that nothing can be solved.
15. Immature wish to be happy.15. Immature wish to be happy.

22. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 5: Confusion andPhase 5: Confusion and
Overreaction.Overreaction.
16. Periods of confusion.16. Periods of confusion.
17. Irritation with friends17. Irritation with friends
18. Easily Angered18. Easily Angered

23. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 6: DepressionPhase 6: Depression
19. Irregular Eating Habits.19. Irregular Eating Habits.
20. Lack of desire to take action20. Lack of desire to take action
21. Irregular sleeping habits21. Irregular sleeping habits ..
22. Loss of daily structure.22. Loss of daily structure.
23. Periods of deep depression.23. Periods of deep depression.

24. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 7: Behavioural Loss of Control.
24. Irregular attendance at AA and
Treatment meetings
25. Development of an “I don’t care”
attitude.
26. Open Rejection of Help.
27. Dissatisfaction with life.
28. Feelings of powerlessness and
helplessness

25. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 8: Recognition of Loss of controlPhase 8: Recognition of Loss of control
29. Self Pity.29. Self Pity.
30. Thoughts of social drinking.30. Thoughts of social drinking.
31. Conscious Lying.31. Conscious Lying.
32. Complete loss of self confidence.32. Complete loss of self confidence.

26. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 9: Option reductionPhase 9: Option reduction
33. Unreasonable Resentment.33. Unreasonable Resentment.
34. Discontinuance of all treatment34. Discontinuance of all treatment
and AAand AA
35. Overwhelming Loneliness,35. Overwhelming Loneliness,
Frustration, Anger and Tension.Frustration, Anger and Tension.

27. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
Phase 10: Acute Relapse Episode.Phase 10: Acute Relapse Episode.
36. Loss of behaviour control.36. Loss of behaviour control.
37. Acute Relapse Episode.37. Acute Relapse Episode.

28. The Phases and 37 WarningThe Phases and 37 Warning
Signs of RelapseSigns of Relapse
37. Acute Relapse Episode.37. Acute Relapse Episode.
A. Degeneration of all life areas.A. Degeneration of all life areas.
B. Alcohol or drug Use.B. Alcohol or drug Use.
C. Emotional Collapse.C. Emotional Collapse.
D. Physical ExhaustionD. Physical Exhaustion
E. Stress Related Illnesses.E. Stress Related Illnesses.
F. Psychiatric Illness.F. Psychiatric Illness.
G. Suicide.G. Suicide.
H.H. Accident Proneness.Accident Proneness.
I.I. Disruption of Social Structure.Disruption of Social Structure.

29. Constructing a PersonalizedConstructing a Personalized
Warning Sign ListWarning Sign List
1. Check three to five warning signs from the list above that1. Check three to five warning signs from the list above that
you find most interesting for you.you find most interesting for you.
2. In your own words, rewrite the summary title of the2. In your own words, rewrite the summary title of the
warning sign that you have checked. The summary titlewarning sign that you have checked. The summary title
is the word or short phrase at the beginning of eachis the word or short phrase at the beginning of each
warning sign.warning sign.
3. Write a brief paragraph that describes in your own words3. Write a brief paragraph that describes in your own words
each of the warning signs that you have selected.each of the warning signs that you have selected.
4. Read your warning signs (as you have written them) to4. Read your warning signs (as you have written them) to
an addictions counsellor, your A.A. sponsor, or a friend,an addictions counsellor, your A.A. sponsor, or a friend,
and ask for feedback. Rewrite the warning signs if theyand ask for feedback. Rewrite the warning signs if they
are unable to understand clearly what you mean.are unable to understand clearly what you mean.

30. Constructing a PersonalizedConstructing a Personalized
Warning Sign ListWarning Sign List
5. Review the list every morning and every5. Review the list every morning and every
evening to remind yourself to look for theevening to remind yourself to look for the
presence of these warning signs.presence of these warning signs.
6. Discuss the list with your friends and family and6. Discuss the list with your friends and family and
ask them to tell you if they see any of theask them to tell you if they see any of the
warning signs appearing in your life.warning signs appearing in your life.
7. If you notice a warning sign, evaluate your need7. If you notice a warning sign, evaluate your need
to get help.to get help.

31. Relapse AssessmentRelapse Assessment
1.1. Begin with a period of solid sobrietyBegin with a period of solid sobriety
2.2. Review progression of relapse warningReview progression of relapse warning
signssigns
3.3. Discuss the thoughts, feelings andDiscuss the thoughts, feelings and
actions leading up to the first useactions leading up to the first use
4.4. Determine relapse dynamicsDetermine relapse dynamics
5.5. Educate client about their unique relapseEducate client about their unique relapse
dynamicsdynamics

32. Development Model ofDevelopment Model of
RecoveryRecovery
1.1. Tasks must be completed in orderTasks must be completed in order
2.2. Recovery task incompletion causesRecovery task incompletion causes
“stuck points” in recovery“stuck points” in recovery
3.3. Stuck points in recovery may causeStuck points in recovery may cause
relapserelapse
4.4. Completing recovery tasks out of orderCompleting recovery tasks out of order
may cause relapsemay cause relapse

33. Development Model ofDevelopment Model of
RecoveryRecovery
Active Addiction:Active Addiction: During this stage substanceDuring this stage substance
abusers are actively using alcohol and otherabusers are actively using alcohol and other
drugs, receiving substantial perceived benefitsdrugs, receiving substantial perceived benefits
from their use, experiencing few perceivedfrom their use, experiencing few perceived
adverse consequences, and as a result see noadverse consequences, and as a result see no
reason to seek treatmentreason to seek treatment
Prochaska/DiClementeProchaska/DiClemente (Precontemplation):(Precontemplation):

34. Development Model ofDevelopment Model of
RecoveryRecovery
Transition:Transition: During this stage patientsDuring this stage patients
recognize that they are experiencingrecognize that they are experiencing
alcohol and drug related problems andalcohol and drug related problems and
need to pursue abstinence as a life styleneed to pursue abstinence as a life style
goal in order to resolve these problems.goal in order to resolve these problems.
Prochaska/DiClemente:Prochaska/DiClemente:
ContemplationContemplation

35. Development Model ofDevelopment Model of
RecoveryRecovery
Stabilization:Stabilization: During this stage patientsDuring this stage patients
recover from acute and post acuterecover from acute and post acute
withdrawal and stabilize their psychosocialwithdrawal and stabilize their psychosocial
life crisis.life crisis.
Prochaska/DiClemente:Prochaska/DiClemente: PreparationPreparation

36. Development Model ofDevelopment Model of
RecoveryRecovery
Early Recovery:Early Recovery: During this stage patientsDuring this stage patients
identify and learn how to replace addictiveidentify and learn how to replace addictive
thoughts, feelings, and behaviors with sobriety-thoughts, feelings, and behaviors with sobriety-
centered thoughts, feelings, and behaviors.centered thoughts, feelings, and behaviors.
THEME: SELF AND SOBRIETYTHEME: SELF AND SOBRIETY
Prochaska/DiClemente: ActionProchaska/DiClemente: Action

37. Development Model ofDevelopment Model of
RecoveryRecovery
Middle Recovery:Middle Recovery: During this stageDuring this stage
patients repair the life style damagedpatients repair the life style damaged
caused by the addiction and develop acaused by the addiction and develop a
balanced and healthy life style.balanced and healthy life style.
THEME: SELF AND SOCIETYTHEME: SELF AND SOCIETY
Prochaska/DiClemente: ActionProchaska/DiClemente: Action

38. Development Model ofDevelopment Model of
RecoveryRecovery
Late Recovery:Late Recovery: During this stage patientsDuring this stage patients
resolve family of origin issues which impairresolve family of origin issues which impair
the quality of recovery and act as long-the quality of recovery and act as long-
term relapse triggers (PTSD here).term relapse triggers (PTSD here).
THEME: SELF AND HISTORYTHEME: SELF AND HISTORY
Prochaska/DiClemente: ActionProchaska/DiClemente: Action

39. Development Model ofDevelopment Model of
RecoveryRecovery
Maintenance:Maintenance: During this stage patientsDuring this stage patients
continue a program of growth andcontinue a program of growth and
development and maintain an activedevelopment and maintain an active
recovery program to assure that they don'trecovery program to assure that they don't
slip back into old addictive patterns.slip back into old addictive patterns.
Prochaska/DiClemente:Prochaska/DiClemente: MaintenanceMaintenance

40. Addicted Self versus Sober SelfAddicted Self versus Sober Self

41. Addicted Self versus Sober SelfAddicted Self versus Sober Self
ADDICTED SELF – mean, angry, lonely,ADDICTED SELF – mean, angry, lonely,
greedy, hates for you to succeed, alwaysgreedy, hates for you to succeed, always
wants the easy way out, is interested inwants the easy way out, is interested in
short-term kicks regardless of the price, isshort-term kicks regardless of the price, is
willing to kill you to get what it wants,willing to kill you to get what it wants,
doesn’t care about anyone or anythingdoesn’t care about anyone or anything
except getting more booze and drugs andexcept getting more booze and drugs and
is angry when you get sober and try tois angry when you get sober and try to
stay that way.stay that way.

42. Addicted Self versus Sober SelfAddicted Self versus Sober Self
SOBER SELF – is intelligent, warm, caring,SOBER SELF – is intelligent, warm, caring,
sober, in touch with higher power, can besober, in touch with higher power, can be
strong at times, feels comfortable withstrong at times, feels comfortable with
your faults and weaknesses, is able to askyour faults and weaknesses, is able to ask
for help, is willing and able to help othersfor help, is willing and able to help others
and gets involved with other peopleand gets involved with other people

43. Addicted Self versus Sober SelfAddicted Self versus Sober Self

44. Addicted Self versus Sober SelfAddicted Self versus Sober Self
““The goal of recovery is to put theThe goal of recovery is to put the
sober self back in charge.”sober self back in charge.”

45. Coping with PAW/PAWSCoping with PAW/PAWS
1.1. Educate clients about PAW symptomsEducate clients about PAW symptoms
2.2. Identify PAW symptoms for clientsIdentify PAW symptoms for clients
3.3. Relate PAW symptoms to drugs ofRelate PAW symptoms to drugs of
abuseabuse
4.4. Avoid stimulants and sedativesAvoid stimulants and sedatives
5.5. Stress reductionStress reduction
6.6. Encourage recoveryEncourage recovery

46. Coping with cravingsCoping with cravings
1.1. Stress ReductionStress Reduction
2.2. ExerciseExercise
3.3. Diversion (reading, television)Diversion (reading, television)
4.4. Sharing with others (peers, professionalSharing with others (peers, professional
staffstaff
5.5. PrayerPrayer
6.6. One Day At A TimeOne Day At A Time

47. DOM Relapse Prevention ProgramDOM Relapse Prevention Program
Criteria:Criteria:
1. Four or more previous treatments1. Four or more previous treatments
oror
2. History of alcohol/drug use in treatment2. History of alcohol/drug use in treatment

48. DOM Relapse Prevention ProgramDOM Relapse Prevention Program
1. More restrictions – must have a safety1. More restrictions – must have a safety
plan to leave the DOMplan to leave the DOM
2. Use of Relapse Prevention Therapy2. Use of Relapse Prevention Therapy

49. DOM Relapse Prevention ProgramDOM Relapse Prevention Program

50. DOM Relapse Prevention ProgramDOM Relapse Prevention Program
ASSIGNMENTS:ASSIGNMENTS:
1.1. Alcohol/Drug HistoryAlcohol/Drug History
2.2. Relapse HistoryRelapse History
3.3. 37 Relapse Warning Signs Exercise37 Relapse Warning Signs Exercise
4.4. Relapse Prevention PlanRelapse Prevention Plan
5.5. Lapse/Relapse Intervention PlanLapse/Relapse Intervention Plan

51. RELAPSE PREVENTIONRELAPSE PREVENTION
PROGRAM OUTCOMEPROGRAM OUTCOME
IRREGULAR DISCHARGES - 2010IRREGULAR DISCHARGES - 2010
MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACK
APR 9 6APR 9 6
MAY 5 5MAY 5 5

52. RELAPSE PREVENTIONRELAPSE PREVENTION
PROGRAM OUTCOMEPROGRAM OUTCOME
IRREGULAR DISCHARGES - 2010IRREGULAR DISCHARGES - 2010
MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACK
JUN 12 0JUN 12 0
JUL 11 2JUL 11 2
AUG 6 1AUG 6 1
SEP 10 1SEP 10 1
OCT 13 1OCT 13 1

53. RELAPSE PREVENTIONRELAPSE PREVENTION
PROGRAM OUTCOMEPROGRAM OUTCOME
IRREGULAR DISCHARGES - 2010IRREGULAR DISCHARGES - 2010
MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACK
NOV 15 9NOV 15 9
DEC 14 8DEC 14 8
IRREGULAR DISCHARGES – 2011IRREGULAR DISCHARGES – 2011
JAN 2011 12 EST 9JAN 2011 12 EST 9
FEB 12 EST 5FEB 12 EST 5
MAR 12 EST 5MAR 12 EST 5

54. SECOND CHANCE PROGRAMSECOND CHANCE PROGRAM
RELAPSE IN TREATMENTRELAPSE IN TREATMENT
N = 10N = 10
Irregular Discharge = 80 percentIrregular Discharge = 80 percent
Regular Discharge = 20 percentRegular Discharge = 20 percent

55. SECOND CHANCE PROGRAMSECOND CHANCE PROGRAM
RELAPSE IN TREATMENTRELAPSE IN TREATMENT
New criteria:New criteria:
1.1. Relapse and ask for help may continueRelapse and ask for help may continue
2.2. Found in relapse by UDS, breath test orFound in relapse by UDS, breath test or
clinical observations are dischargedclinical observations are discharged

56. 12 Step Resistance ? ? ?12 Step Resistance ? ? ?
(When the only tool you have is a hammer, everything(When the only tool you have is a hammer, everything
looks like a nail)looks like a nail)
Suggest SMART RecoverySuggest SMART Recovery
No stepsNo steps
No higher powersNo higher powers
No lifelong commitmentNo lifelong commitment
Uses CBT/RET methodsUses CBT/RET methods
Stop trying to shove square pegs in round holesStop trying to shove square pegs in round holes

57. QUESTIONS ? ? ? ?QUESTIONS ? ? ? ?
Email: guy.lamunyon@va.govEmail: guy.lamunyon@va.gov
Google Profile: Guy LamunyonGoogle Profile: Guy Lamunyon