Relapse and Recycling : What is the Point? 25th Anniversary Presentation Presented by: Carlo C. DiClemente, Ph.D.

Conflicts and Acknowledgements

• I have no conflicts of interest in this area

• Studies reported in this talk were funded by a variety of NIH Institutes. NIAAA funded Project Match, the Relapse Replication and Extension and the Combine Studies

• The work reported here has been collaborative and I acknowledge the contribution of my colleagues and graduate students in Houston and Maryland

Overview

• Reality of Relapse• Models of Relapse• Measuring Relapse• Understanding Recovery• Role of Recycling• Relapse, Recycling, and Recovery• Replacing the Term “Relapse”• Is Relapse and Recycling Necessary for Recovery

Hunt, Barnett, & Branch, 1971

Mean Percent Days Abstinent as a Function of Time (Outpatient)

0

10

20

30

40

50

60

70

80

90

100

-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15CBT MET TSF

PMRG, 1997

Only 24% completely abstinent for 12 months

Mean Drinks per Drinking Day as a Function of Time (Outpatient)

0

2

4

6

8

10

12

14

-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15

CBT MET TSF

PMRG, 1997

Proportion Avoiding a Heavy Drinking (5 Drinks) Day as a Function of Time Outpatient)

0

0.2

0.4

0.6

0.8

1

1.2

0 50 100 150 200 250 300 350 400

DaysCBT MET TSF

PMRG, 1997a; 1997b

Drinking and Problem Status by Treatment Condition (Outpatient)

0%

20%

40%

60%

80%

100%

cbt met tsf cbt met tsf cbt met tsf cbt met tsfAbstinent Light DrinkingHeavy Drinking w/minimum consequence Heavy Drinking w/severe consequence

Cisler & Zweben, 1999

3-month periods of follow-upBaseline

Drinking and Problem Status by Treatment Condition (Aftercare)

0%

20%

40%

60%

80%

100%

cbt met tsf cbt met tsf cbt met tsf cbt met tsfAbstinent No Problems Heavy or Problem Heavy and Problem

Cisler & Zweben 1999

3-month periods of follow-upBaseline

Relapse rates

• The Combine Study (Anton et al., 2006)oEOT PDA - 56% CBI to 80% naltrexoneoOne-year FU PDA – 64-67%oFU one or more heavy drinking (>5) days 80%oFU Good Clinical Outcome 38-50%

• Relapse Replication Study RREP (Connors et al, 1996)oPDA 41% baseline to 75-80% EOT (16 weeks)oAbstinent – 6 months – 23% 12 MONTHS – 28%

Drinking Outcomes Past Year (Dawson et al. 2005)

0 10 20 30

Abstain

LR Drink

HR Asymp

HR Partial

HR Dep

18%

18%

12%

28%

25%

N = 4,422

Relapse is Not an Alcohol or Substance Use Problem

• Relapse is probable with any health behavior change• Often at same rates as addictive behaviors• A problem of instigating and sustaining behavior

change• A problem of adequately completing the critical tasks of

the stages of change

This Photo by Unknown Author is licensed under CC BY-SA

What do we Know

• Reality is it is difficult to sustain substantial change over time for AUD and other health behaviors• Outcomes of change attempts are varied and difficult to

categorize• Outcomes vary by timeframe and are not stable• Sustained Abstinence most stable

Dawson et al., 2007

Models of Relapse How do we understand the difficult to sustain change?

Models of Relapse: Medical Model

• Recurrence due to some pathogen or brain neuroadaptation that makes change difficult if not impossible without some pharmacological intervention• AA à Chronic relapsing disease

Models of Relapse: Cognitive Behavioral Model

• Focus originally on Maintenance - how to continue change and what interfered• Focused shifted to relapse and

how to prevent failure• Remediating cognitive

distortions & coping skills• Marlatt & Gordon (1985)– Cues,

coping, cognitions, & lifestyle balance

“ I already messed up… I might as well keep drinking.

”

This Photo by Unknown Author is licensed under CC BY-NC-ND

Relapse Replication Study Conclusions

• “Exposure to high risk situations does not in itself trigger relapse. In fact, relapse, trigger and precipitant may be misleading constructs.”

• “Exposure to adversity was virtually universal in our sample… It was client’s coping skills for dealing with the environment and not mere exposure to risk and stress that determined whether relapse would occur.”

• “All must face adversity. The key is how one responds and copes when it comes”.

Connor et al, 1996

Relapse Precipitants

• Cravings, Urges, Temptations• Social Cues & Situations• Pleasure & Positive

Reinforcement• Testing Control• Significant Others• Stress, Negative Affect• LIFE

Models of Relapse: Learning Model

• Successive Approximation Learning• Social Learning Perspective• Transtheoretical Model à

oAdequately completing Stages of Change Tasks

Bandura 1977; DiClemente, 2008

What is a relapse?Defining when someone has Relapsed has been an elusive undertaking

Defining Relapse for AUD

• “Relapse” is NOT…

oA categorical outcome: Success vs. Failure

oDefinable by number of drinks (Maisto et al., 2016)

oThe opposite of recovery

oMaybe necessary for but not really a part of Recovery

Defining AUD Relapse (Maisto et al., 2016)

• Numbers of drinks or consequences did not predict relapse well

• Need a better way than counting drinks or consequences

• Drinking during treatment predicted drinking after treatment: oThis is not relapseo It is a failure to instigate or make a change

Who Decides?

• Biochemistry (positive urinalysis; biochemical marker)• Consequences• Arbitrary number of drinks or drinking QF

oPercent Days AbstinentoDrinks per Drinking DayoPercent Heavy Drinking Days

• Provider• Drinker – When Individuals give up on efforts to

make the change

Defining Relapse for AUD

• A multidimensional process (RREP studies, Addiction Supplement, 1996)

• Influenced by:o Individual, contextual, and social factors and Interactions among

these factors

• A Learning Process for Achieving Successfully Sustained Change and Recovery

• Defined best by the client as abandonment of the current attempt to change

DiClemente & Crisafulli, 2016

“Relapse” is…

Error free learning – Errors are Valuable

• Experimental investigations indicate that errorfullearning followed by corrective feedback is beneficial to learning (Metcalfe, 2017)

“If at first you don’t succeed, try, try, try again.” ~ William Edward Hickson

Not just harder but smarter!

Failure (Firestein, 2016)

• The Lifeblood of Scientific Inquiry• There are “Good” Failures• If the Goal is Success• A continuum of failure• Types of failure

oMistakesoLife LessonsoUnexpected LearningoOpportunities for Future Discovery

The Road to RecoveryHow Process of Change Tasks and Mechanisms Understand and Predict Substance Use Disorder Outcomes

THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY

ADDICTION

RECOVERYSustainedChange

Dependence

PROCESSES, CONTEXT AND MARKERS OF CHANGE

Dependence

PC C PA A M

PC C PA A M

DiClemente 2018

Stage of Change Labels and Tasks

STAGE• Precontemplation

o Not interested• Contemplation

o Considering• Preparation

o Preparing• Action

o Initial change• Maintenance

o Sustained change

TASK• Interested, concerned and willing to

consider• Risk-reward analysis and decision

making• Commitment and creating a plan

that is effective/acceptable• Implementing plan and revising as

needed• Consolidating change into lifestyle

DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. .(Second Edition) NY: Guilford Press; 2018. DiClemente. J Addictions Nursing. 2005;16:5. DiClemente et al, Relapse Prevention, 2019

Theoretical and Practical Considerations Related to Movement Through the Stages of Change

Motivation

Precontemplation Contemplation Preparation Action Maintenance

PersonalConcerns

What would help or hinder completion of the tasks of each of the stages and deplete the self-control strength needed to engage in the processes of change needed to complete the tasks?

Decision Making Self-efficacy

Relapse

EnvironmentalPressure

Decisional Balance

CognitiveExperiential Processes

Behavioral Processes

Recycling

Regression, Relapse & Recycling through the Stages

• Regression represents movement backward through the stages• Slips and Lapses are brief returns to the prior behavior

that represent problems in the action plan• Relapse is a reoccurrence or significant re-engagement

in the problematic behavior after a period of change and abandoning the change effort• After a relapse, individuals Recycle back into pre-action

stages (precontemplation, contemplation, or preparation).

DiClemente, 2018; DiClemente et al., 2019

Relapse and Recycling

• Movement through the stages is not inexorably linear: consists of stasis, progression and regression, relapse and recycling • Relapse is not a stage of change• Recycling through the process is a reality for many

struggling with AUD• There is a difference between recycling and just a redo:

must use a learning perspective

DiClemente, 2018

Change ≠ Linear Process: Relapse & Recycling

Relapse: An “Unfolding Process”

• To understand person in context need a complex, multidimensional model (Witkeiwicz & Marlatt, 2007)

• Need a dynamic not static system perspective• Need to understand macro and micro processes (stage

tasks, mechanisms, context)• Need complex, nonlinear analytic techniques

oTransition AnalysesoDynamical system modelingoChaos Theory

Witkiewitz & Marlatt, ,2007; Brandon et al., 2007

PrecontemplationIncrease awareness of need to change

ContemplationMotivate and increase confidence

in ability to change

ActionReaffirm commitment

and follow-up

Termination

Stages of Change Model

RelapseAssist in Coping

MaintenanceEncourage activeproblem-solving

PreparationNegotiate a plan

Task Completion & Movement Between Stages

PC CON PREP ACT MAIN

INTERESTCONCERN

RISK/REWARDDECISION

COMMMITMENTPLANNINGPRIORITIZING

IMPLEMENTTHE PLANREVISE

LIFESTYLEINTEGRATIONAVOIDRELAPSE

If we use a learning perspective, we need to learn how to accomplish each task well enough to support sustained change

Can’t they get it right the first time?

• Alcohol Use disorders involve critical addiction mechanisms: neuroadaptation, impaired self-regulation and importance/salience in the life of the individual• Learning how to manage and overcome these mechanisms and

accomplish stage tasks takes time, energy and focus• Many ways recovery can become compromised• IT’S A COMPLICATED PROCESS• RECOVERY IS A MARATHON NOT A SPRINT

DiClemente, 2018

Examining Failure – Promoting Success

• Black Box Thinking (Matthew Syed, 2015)

• Examining failures and mistakes to figure out how to learn from them

• Airline Industry Black BoxoExamine the data – but looking for the right dataoReconstruct the event – entire not just moment oSimulate the event to ensure you understand what went

wrong – thinking, feeling, and behavior

What Do We Know About the Recovery Process and What Predicts Successful Change?

Recovery and Change

• SAMHSA’s working definition of recovery from mental health & substance use disorders:

“A process of change through which individuals improve their health and wellness, live a self-directed life, and

strive to reach their full potential” (SAMHSA, 2012).

What Predicts Success: Multiple Studies

• Coping Skills• Self-Efficacy• Commitment• Decision making• Planning• Reduction in Temptation/Craving• Adequate Completion of Stage Tasks

DiClemente, et al., 2019

Temptation, Confidence & Relative Levels

• Both Temptation and Self-Efficacy predicted Match Drinking Outcomes (PDA & DDD)

• Temptation minus Confidence:oLevel of temptation to drink Measure across multiple relapse

situations of the relative to the level of self-efficacy across the same situations.

oPredicted post treatment PDA and DDD in MATCHoEOT T-C predicted time to first drink and number of drinks in

first day (significant but small effect size)

DiClemente et al., Project Match Causal Chain Monograph, 1996; Shaw & DiClemente, 2017 Witkiewitz, 2013

MATCH EOT Process Profiles Predict Outcomes

• Client status during 1-year follow-up period:oAbstinent - 100% PDA N=110oModerate drinking (no binge) N=285oHeavier drinking N=278

• No differences between these groups by treatment

• Client Profile on URICA Stage of Change Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential and Behavioral Processes of Change

-0.8-0.6-0.4-0.2

00.20.40.60.8

Pre Con Act Main Conf Temp Exp Beh

PDA = percent days abstinent

Carbonari, JP & DiClemente, CC. J Consult and Clin Psych. 2000; 68:810.

TTM Variables

Stan

dar

d S

core

s Abstinent Moderate Heavier

TTM Profile: Outpatient PDA Post-treatment

Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

-0.8-0.6-0.4-0.2

00.20.40.60.8

Pre Con Act Main Conf Temp Exp Beh

TTM variables

Stan

dar

d s

core

s Abstinent Moderate Heavier

TTM Profile: Aftercare PDA Post-treatment

Keys to Successful Recovery

• Most addicted individuals will recycle through multiple quit attempts and multiple interventions

• They need to accomplish each of the stage tasks well enough to support sustained change and enter into recovery

• However successful recovery occurs for a large number of addicted individuals over time (42 million former smokers)

DiClemente, 2007

How Can We Promote Recovery

• Reducing Temptation by oDeveloping Positively Reinforcing ActivitiesoBuilding a repertoire of alternativesoActivating Behavioral Processes of Change

• Emphasizing choicesoPersonal resilience & Self-EfficacyoApparently Irrelevant DecisionsoStage Tasks

• Building social capital• Support and build affect regulation not just ECF

A Role for Harm Reduction?

• How can we make relapse less risky and fatal?• Are harm reduction and abstinence incompatible• How to make harm reduction serve recovery?• How can we create messages that recognizes the reality

of relapse and recovery and the value of harm reduction• The process is the same for harm reduction behaviors as

for recovery behaviors.• People are in different stages of change for a

whole host of recovery behaviors

Cyclical Model for Successfully Sustained Change

• Keys to successful recyclingoPersistent effortsoRepeated attemptsoLearning from the pastoRecovering from neuroadaptationoFind support for impaired self-regulation (scaffolding)oBegin building a new life without the addictive behavioroNever Give Upo “Stick and Stay”

Let’s retire the term “Relapse”

• It is stigmatizing blaming, and contributes to a fatalistic/failure identity• Recycling on the Road to Recovery

oA setback in sustaining change, a mistake that can be corrected, an opportunity to learn

oLong-term multidimensional perspectiveoGetting Well and Getting Better

Yes

• Is relapse and recycling necessary for AUD Recovery?• Reoccurrence happens often with all chronic conditions

(why they are “chronic”)• Focusing on how individuals can benefit from the

experience of a failure to sustain change can change the perspective of research and clinical practice in health and addictive behaviors

Thank YouQuestions?

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