Relapse Prevention

1. Relapse Prevention Substance Abuse and Disability in Rehabilitation Counseling 4/5/05

2. Relapse Prevention • “Relapse Prevention (RP) is a cognitive-behavioral approach with the goal of identifying and preventing high-risk situations for relapse.” Witkiewitz & Marlatt (2004, p. 224)

3. Goals of RP • Understand relapse as a process, • Identify and cope effectively with high-risk situations, • Cope with urges and craving, • Implement damage control procedures during a lapse to minimize its negative consequences, • Stay engaged in treatment even after a relapse, and learn how to create a more balanced lifestyle.

4. RP Strategies • Assess clients for psychiatric comorbidities and facilitate treatment for any coexisting disorders. • Help clients anticipate their high risk relapse factors and develop coping skills or strategies to manage them. • Take into account the nuances of each client’s high risk factors. Need to look into why a factor is a risk (e.g., depression – is it interpersonal or physiological?) • Help clients identify and manage relapse warning signs, which are part of the process of relapse. • Impulsive, attitudinal, emotional, cognitive, or behavioral changes?

5. RP Strategies • Help clients identify negative feelings and manage negative emotional states • e.g., feeling identification, anger management, other CBT techniques. • Help clients identify and prepare to handle direct and indirect social pressures to engage in substance use. • Identification of high risk relationships • “Apparently irrelevant decisions”

6. RP Strategies • Help clients improve their interpersonal communications and relationships and develop a recovery support system. • Giving and receiving criticism • Refusing offers of alcohol or drugs or food • Developing close/intimate relationships • Encourage to become involved in self-help groups • Develop an RP Network • Who to include and exclude • How and when to ask for support/help (Rehearsal)

7. RP Strategies • Write a RP Action Plan • How to communicate about and deal with relapse warning signs/high risk situations • How to interrupt a lapse • How to intervene if a relapse occurs • How to explore all the details of lapse and/or relapse

8. RP Strategies • Help clients understand and manage their cravings to use substances as well as “cues” that trigger cravings. • Systematic relaxation, behavioral alternatives, visual imagery, cognitive interventions. • Help clients identify and manage patterns of thinking that increase relapse risk • Have client discuss or write down: • Specific relapse-related thoughts • What is wrong with this type of thinking in terms of potential effect on relapse • New self-statements or thoughts that counteract negative thinking.

9. RP Strategies • Help clients work toward a more balanced lifestyle. • Evaluate patterns of ADLs, sources of stress, stressful life events, daily hassles, uplifts, balance between wants and shoulds, health, exercise, and relaxation patterns, interpersonal activities, and religious beliefs. • Help develop positive habits/substitute indulgences for an addictive behavior.

10. RP Strategies • Combine pharmacologic and psychosocial treatments • Meds such as Naltexone or methadone or reductil may help control some of the cravings allowing for greater improvement with psychosocial interventions. • Prepare clients to interrupt lapse and relapses as early as possible to minimize damage caused by setbacks.

11. RP Technique: Centering • When you begin a group or an individual session or when you want a client to calm down and get in touch with thoughts and feelings, you can use a technique called centering. This is basically a relaxation technique. Instruct the patient to do the following: • Put both feet on the floor, sit up straight and close your eyes. • Breathe in through your nose and out through your mouth. • Breathe in deeply, hold it for a second, then breathe out. • Do this again and feel your lungs fill with air, then empty. • Slow your breathing to a steady rhythm. • See if any thoughts are entering your mind. • Ask yourself if you are feeling any body tensions. • Open your eyes when you are ready. • Speak slowly as you give the instructions. This will help the client calm down.

12. RP Technique: Sentence completion • Sentence completion is a technique used to help clients identify thoughts that they have that may not be true. These thoughts are called mistaken beliefs. Many times when a client is acting in a self-defeating way, it is a result of mistaken beliefs he or she has about the world and himself or herself. When a client is behaving in a way that hurts himself or herself and others, it is because the client believes that this is the only choice he or she has. Sentence completion is a way to help a client identify and correct mistaken beliefs.

13. RP Technique: Sentence completion • Have the client form a sentence stem: A sentence stem is the beginning of a sentence that has meaning for the client. You can form these stems based on topics the client is talking about. Examples are:"I know my recovery is in trouble when . . .""When I think about food, I . . .""Right now, I am feeling . . ." • Have the client write down the sentence stem. • Have the client repeat it out loud and end it differently six to eight times or until he or she cannot think of new endings. • Have the other group members write down the endings. If you are in an individual session, do this yourself. • Have the group members read the endings back to the client as they write them down. Have them use the following form: A(client's name), I heard you say (sentence stem)(first ending)." Repeat the exercise until all the endings have been read. • Look for a common theme in the endings. You may form a new sentence stem from the common theme and repeat the exercise, or stop here if the mistaken belief is identified. • Have the client identify the mistaken belief if he or she can and write it down.

14. Traditional Understanding of RP • Relapse can be considered as both an outcome (individual is ill or well) and a process (a misstep in process of behavior change). • When people begin to change a problematic behavior, an initial setback is probable (lapse) – one outcome is a return to that problematic behavior (relapse) – another outcome is to get back on track toward the direction of positive change (prolapse). • Most individuals who try to change their behavior will suffer lapses that frequently lead to relapses (Polivy & Herman, 2002).

15. Overview of Traditional RP Model (Marlatt & Gordon, 1985) Decreased probability of relapse Effective coping response Increased self-efficacy High-Risk Situation Decreased self-efficacy and positive outcome expectancies for effects of alcohol Abstinence violation effect & perceived positive effects of alcohol Ineffective Coping Response Increased probability of relapse Lapse (initial) use of alcohol)

16. Traditional Understanding of RP • Determinants of Relapse • High Risk Situations! • Negative emotional states • Anger, anxiety, depression, frustration etc. • Interpersonal situations • Argument with a family member • Social pressure • Being around people who are drinking/using • Positive emotional states • Celebrations • Other cues • Seeing an advertisement, walking by a liquor store, “testing willpower”, cravings

17. Active eating/using by other employees Pay day Working a rotating, graveyard or night shift Seasonal work Lack of supervision Working excessive overtime Dealers near the job site Access to marketable goods or petty cash Receiving cash tips Transportation issues Too much free time on the job Working two jobs Too much pressure on the job Job dissatisfaction or boredom Required business meetings, dinners and parties where food and alcohol is expected. Some work-related triggers

18. Traditional Understanding of RP • Coping • Person’s response to stimuli determines whether s/he will experience a lapse. • An individual’s coping behavior in a high-risk situation is a critical determinant of the likely outcome. • People that have coped successfully with high-risk situations are assumed to have a heighten sense of mastery (increased self-efficacy). • People with low self-efficacy perceive themselves as lacking in the motivation or ability to resist using in a high-risk situation.

19. Traditional Understanding of RP • RP has traditionally used a three-step model of behavior change: • Motivation and commitment • Enhancing motivation • Screening to determine prognosis • Methods: behavioral/motivation & predictor variables • Ethical problems…. • Initial Behavior Change • Decision making • Cognitive restructuring • Coping skills • Maintenance • Continued monitoring • Social support • General life-style change

20. Relapse steps and interventions Self-monitoring & behavior assessment Relaxation training stress management & efficacy enhancing imagery Contract to limit extent of use & reminder card (what to do when you have a slip) High Risk situation No coping response Decreased self-efficacy Positive outcome expectancies Initial use of substance Abstinence violation effect Relapse fantasies & descriptions of past relapses Programmed relapse Skill training & relapse rehearsal Education about immediate vs. delayed effects of substances: use of decision matrix Cognitive restructuring (slip=mistake. attribution to situation vs. self)

21. Criticisms of Marlatt’s model • Relapse is complex and largely unpredictable. This static model does not account for the mixture of urges, cues, and automatic thoughts concerning the problematic behaviors that need modification. • Relapse factors are hierarchical. Research does not support the primacy of one factor over another.

22. Re conceptualization of Relapse Prevention Model • “Multiple influences trigger and operate within high-risk situations and influence the global functioning of the system…” Witkiewitz & Marlatt (2004, p. 229)

23. Re conceptualization of Relapse Prevention Model • Determinants of a relapse • Intrapersonal • Self-efficacy • Outcome expectancies • Craving • Motivation • Coping • Emotional states • Interpersonal • Functional social support • Level of support • Quality of support • Structure of social support (non-using support group) • Availability of social support

24. Dynamic, self-organizing process • Interactions between: • Background factors (e.g., family history, years of use, social support, other diagnoses) • Physiological states (e.g., withdrawal) • Cognitive processes (e.g., self-efficacy, cravings, outcome expectancies) • Unlike previous model, there is no presumption that certain factors are more influential than others.

25. Re conceptualization of Relapse Prevention Model • Contextual Factors: High Risk Situations • Relapse Risks: • Distal (stable predispositions that increase vulnerability to lapse) • Proximal (immediate precipitants that increase the likelihood of a lapse) • Relapse Processes: • Tonic (chronic vulnerability for relapse) • Phasic responses (situational, cognitive, affective/physical states, and coping skill utilization)

26. Reconceptualization of Relapse Prevention Model High Risk Situations (Contextual Factors) Tonic Processes Phasic Responses Substance Use Behavior Perceived Effects (reinforcement, abstinence, violation effect) Coping Behavior Distal Risks (family hx, social support Etc.) Cognitive Processes (self-efficacy, outcome expectancies, craving) Affective State Physical withdrawal Witkiewitz & Marlott, 2004, p. 230

27. Future of RP • More research is need to validate the dynamic model. • Brief intervention or booster session • Medications & Meditation as adjunctive treatments?