Reading: Lapses, relapse, and coming back
Planning for high-risk moments, and responding to a slip so that the client comes back sooner, not later.
Reading: Lapses, relapse, and coming back
What you’ll learn
- Help clients identify triggers and build a coping plan.
- Respond to a lapse in a way that keeps the client engaged.
- Help a client reenter the cycle of change quickly.
In maintenance, the client is working to hold on to what they’ve achieved. They learn what triggers the urge to use, build ways to cope, and build a life that supports the change. Lapses are common, especially under stress or grief, and how you respond decides whether the client comes back or hides the next one.
Plan for high-risk situations
Start with an open question: “Tell me about the times you’ve been most likely to drink or use, or to use more than you meant to. They might be with certain people, in certain places, at certain times, or when you’re feeling a certain way.” Then break each situation into its parts.
- Watching a football game with drinking buddies
- External triggerA beer commercial comes on
- Internal trigger“My mouth waters, and I think about how good a beer would taste.”
- Coping strategyGet a cold soft drink from the fridge instead
- Friday night, home alone after a hard week
- External triggerDriving past the liquor store
- Internal trigger“I deserve it after this week.”
- Coping strategyTake a different route; call a friend on the way home
| High-risk situation | External trigger | Internal trigger | Coping strategy |
|---|---|---|---|
| Watching a football game with drinking buddies | A beer commercial comes on | “My mouth waters, and I think about how good a beer would taste.” | Get a cold soft drink from the fridge instead |
| Friday night, home alone after a hard week | Driving past the liquor store | “I deserve it after this week.” | Take a different route; call a friend on the way home |
Ask how they’ve resisted temptation before, and what they could do now to avoid or manage each trigger. Use the confidence ruler to check how confident they feel about each strategy. Affirm their commitment to coping rather than only reflecting; reflecting alone can draw out sustain talk here. If they get stuck, brainstorm together or offer a menu of ideas that have helped others.
Turn the strategies into a written coping plan, as simple as a few lines on a card. Have the client rehearse it, and revisit it as things change.
Build support
Help the client strengthen the things that support recovery: family and friends who back the change, recovery support groups, and new activities and routines that make the old patterns less central. As the change holds, coping takes less effort and confidence grows.
When a lapse happens
Welcome the client back and recognize that they came in. Normalize the lapse without minimizing it, and affirm the progress that still counts. If they miss an appointment, reach out rather than waiting; shame is often what keeps people away.
Then help them keep a lapse from becoming a full relapse:
- Stop, look and listen. Step back and notice what’s happening before reacting.
- Keep calm. Feeling an urge doesn’t mean having to act on it.
- Deal with guilt and shame. Explore them with compassion; they can make further use more likely.
- Review what led up to it: the situation, early warning signs, urges, and the thoughts that justified using.
- Make an immediate plan: who to call (with names and numbers), which meeting to go to, and what to do when cravings hit.
Reentering the cycle
Most clients who return to use don’t go back to precontemplation. They’re more likely to recycle to contemplation, preparation or action. Find out where they are now. If they’re back in contemplation, explore ambivalence and evoke change talk. If they’re in preparation or action, revise the change plan or coping plan together. Treat the lapse as a chance to learn which strategies worked and which didn’t, and ask: “What do you want to do now?”
I blew it. Four months, and I drank at my brother’s funeral.
You’re being really hard on yourself. Losing your brother is huge, and you came in today anyway.
I almost didn’t.
I’m glad you did. Those four months still count. What do you think happened that day?
The counselor acknowledges the grief, affirms the choice to come in, and pushes back gently on all-or-nothing thinking before exploring what happened.
Write a response that reflects the discouragement and draws on past success.
ClientWhy bother? I always end up back at square one.
Show a model answer
“It feels like you’re back at the start. And you’ve learned a lot these past months about what helps. What worked for you before this happened?” It reflects the feeling, offers a different view, and evokes the client’s own experience of success.
Key takeaways
- Map high-risk situations and triggers, and build a written coping plan with the client.
- Welcome clients back after a lapse, and challenge all-or-nothing thinking.
- Most clients recycle to contemplation, preparation or action. Meet them there.
Adapted from SAMHSA, TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment (2019), chapter 7. Public domain. Open TIP 35, coping plans and reentering the cycle