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Relapse Prevention and Response in Drug Court: Terrence D Walton, MSW, ICADC Director of Treatment Pretrial Services Agency for the District of Columbia Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. True or False? Research shows that even while in treatment, some addicted people can only stay clean a couple of days before relapsing. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. The 1st Big Question Is it “relapse” or “continued use”? Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Defining Relapse 1. 2. 3. When a person in recovery returns to the self-prescribed, non-medical use of any mood altering chemical (MAC) and the risk of the problems associated with that use The return to use after a period of abstinence that interrupts the addicts ongoing attempts to recover A return to drug use that is precipitated by and/or leads to lessening of commitment to recover Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Defining Recovery In conjunction with a day-by-day commitment to remain abstinent, the ongoing process of overcoming physical and psychological dependence on mood altering chemicals and learning to live in a state of total abstinence, without the need for those substances. In recovery, the individual relies on healthy, constructive activities and experiences for happiness and fulfillment. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. The 2nd Big Question Is it a “slip” or a “relapse”? Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. A Slip Initial episode of alcohol or other drug use after a period of recovery/remission Does not indicate or precipitate a lessening in commitment to change Can end quickly or lead to a relapse of varying degrees Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Slipping Neither a slip, nor relapse is accidentally using Both are willful decisions to use Slip = Set Back Relapse = Collapse Slip = Rapidly restored commitment to change Relapse = Recycling back through change stages Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Two Secrets 1. 2. “No use” doesn’t mean you’re in recovery “Use” _________________________ Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Research 1. 2. 3. Studies show relapse rates of 40% to 60% at one year follow-up Most relapses occur in the first year of recovery, with two thirds occurring in the first 90 days Clients who remain in treatment longer generally have the better outcomes Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Causes Pretreatment Factors Treatment Factors Degree of substance dependence Co-occurring disorders Combat related trauma Type, length and quality of treatment Post Treatment Factors Family/social supports Social/coping Skills Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Impact on the Individual Relapse is a persistent risk in recovery Consequences may include: Return to active use Criminal behavior Physical, social, or emotional collapse Re-commitment to recovery Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Relapse An unfolding process in which the resumption of substance abuse is the last event in a long series of maladaptive responses to internal or external stressors or stimuli Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. WHAT IS RELAPSE PREVENTION? Therapy designed to teach people to engage in recovery-supportive activities and to recognize, anticipate, and manage the relapse warning signs so that they can interrupt the relapse process early and return to the process of recovery. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Relapse Prevention Planning 1. 2. 3. 4. 5. Written, specific, and rehearsed plans Reiterates commitment to and rationale for recovery Outlines and schedules recovery supportive activities Identifies warning signs, cues, and high risk situations (triggers) Details preventive and progressive responses to all triggers Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. A Big Resource National Registry of Evidenced-based Programs and Practices: www.nrepp.samhsa.gov “Relapse Prevention Therapy” Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Traffic Signal Approach Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Green Light Problems– Failing to engage fully in recovery-supportive activities 1. 2. 3. 4. 5. Skipping or coming late to meetings Neglecting spiritual activities and readings Skipping work or cutting class Failing to plan and participate in leisure activities Neglecting physical exercise, adequate sleep, or healthy diet Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Yellow Light Problems– Situations requiring caution, extra support, and/or prompt resolution 1. 2. 3. 4. 5. 6. 7. Negative moods & attitudes (angry, afraid, sad, lonely, hurt, guilty, bored, anxious, embarrassed, frustrated, rebellion, resentful, stubborn) Fleeting cravings, urges, or euphoric recall Holidays, celebrations; vacations, and other “down-time”; Sleeping (using dreams) Dishonesty, greed, or having extra money Feeling depleted, deprived, entitled or exhausted Sobriety milestones Re-entering from institutions Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Red Light Problems– Situations to avoid, persistently resist, and/or requiring urgent external support 1. 2. 3. 4. 5. 6. 7. Offers to use or drink Persistent cravings, urges, or euphoric recall Feeling hopeless, like giving up, or not caring Euphoric recall Sudden, unexpected external triggers (sound, sight, smell, taste, sensation) Trauma reactions A slip Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Relapse Response Planning 1. 2. 3. Written & specific plans Detailing immediate post-use actions Full disclosure 4. 5. Who is to be informed immediately Program to be informed at first opportunity Expected & accepted consequences Plan for re-evaluation and intervention Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Honesty Matters 1. 2. 3. 4. Participant lies about using even after testing positive. Participant readily acknowledges using after testing positive. Participant acknowledges using before testing positive. Participant acknowledges thoughts of using before doing so. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Responses to Relapse 1. 2. 3. 4. 5. 6. Reassess Continued Use Potential and Change Readiness Conduct Functional Analysis of Relapse Determine Whether “Continued Use”, “Slip”, “Relapse” Apply Planned Court-related or SupervisionRelated Responses (e.g. sanction, phase freeze, staffing) Apply Planned Clinical Responses (e.g., enhancing treatment, increase drug/alcohol testing) Re-stabilize and Re-engage (e.g. detoxification, treatment readiness); Re-instill hope Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Program Response Tips “Continued use” or dishonesty usually sanctioned more severely than a readily acknowledged “relapse/slip” 2. Relapse prevention and response planning should be implemented early in the treatment process 3. Prepare to respond to repeated “continuing use” or relapses/slips in some participants, especially early in treatment 1. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Relapse Prevention and Response in Drug Court: BONUS SLIDES Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. 8 Relapse Precipitating Variables 1. 2. 3. 4. Affective variables —e.g. depression, anxiety Behavioral variables —e.g. inadequate coping skills or leisure management skills Cognitive variables —e.g. attitudes and beliefs about recovery/relapse; self efficacy Environmental and relationship variables —e.g. lack of social support, poor role models, social pressures to use Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. 8 Relapse Precipitating Variables 5. 6. 7. 8. Physiological variables —post acute withdrawal, cravings, pain, medication use Psychological/psychiatric variables —level of motivation to change, co-occurring disorder Spiritual variables —excessive guilt or shame, feeling empty, meaninglessness Treatment system variables —clinician’s knowledge and skills; access to needed services; quality and appropriateness of interventions Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. How to help 1. 2. 3. 4. 5. Help clients anticipate their high risk relapse factors and develop strategies to manage them. Help clients identify and manage relapse warning signs. Help clients identify feelings and manage negative emotions. Help clients identify and prepare to handle direct and indirect social pressure to use. Help clients improve their interpersonal communications and relationships and to develop a recovery support system. Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. How to help 6. 7. 8. 9. 10. Assess clients for psychiatric conditions and facilitate treatment. Help clients understand and manage their cravings to use, as well as cues that trigger cravings. Help clients identify and manage patterns of thinking that increase relapse risk. Help clients work toward a more balanced lifestyle. Include pharmacologic interventions Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. How to help 11. 12. 13. Facilitate transition between levels of care Incorporate strategies to improve adherence to treatment Prepare clients to interrupt lapses and relapses as early as possible; Relapse Response Planning Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Green Light Problems– Failing to engage fully in recovery-supportive activities 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Skipping or coming late to meetings Neglecting recovery related readings Isolating from supportive people Neglecting spiritual activities and readings Skipping work or cutting class Failing to plan and participate in leisure activities Neglecting physical exercise Avoiding the doctor, dentist, or therapist Failing to eat well Refusing to confide in trustworthy others Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Yellow Light Problems– Situations requiring caution, extra support, and/or prompt resolution 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Stress; Negative moods or attitude (resentment, rebellion, angry, afraid, sad, lonely, hurt, guilty, bored, anxious, embarrassed, frustrated) Fleeting cravings, urges, or euphoric recall Holidays, vacations, and other moments of celebration Life instability, conflicts, drama, or crisis Experiencing loss, grief, or illness; emotional or physical pain Dishonesty, greed, or having extra money Focusing on someone else’s problems Feeling depleted, deprived, entitled or exhausted Defensiveness, argumentative, or defiant Sobriety milestones Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Red Light Problems– Situations to avoid, persistently resist, and/or requiring urgent external support 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Offers to use or drink Encountering old using associates or areas Persistent cravings Doubting the need to avoid use all together Feeling hopeless, like giving up, or not caring Euphoric recall Obsessive use-related thoughts or negative feelings after having a using dream Unexpected external triggers (sound, sight, smell, taste, sensation) Trauma reactions A slip Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed. Relapse Prevention and Response in Drug Court: [email protected] Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational use allowed.