Transcript Relapse Prevention and Response in Drug Court

Relapse Prevention and
Response in Drug Court:
Terrence D Walton, MSW, ICADC
Director of Treatment
Pretrial Services Agency for the District of Columbia
© Terrence Walton, January 25, 2011
The following presentation may not be copied in whole or in part without the written
permission of the author or the National Drug Court Institute. Written permission will
generally be given without cost, upon request.
True or False?
Research shows that even
while in treatment, some
addicted people can only stay
clean a couple of days before
relapsing.
The 1st Big Question
Is it “relapse” or
“continued use”?
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
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.
The 2nd Big Question
Is it a “slip” or a
“relapse”?
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
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
Two Secrets
1.
2.
“No use” doesn’t mean you’re in
recovery
“Use” _________________________
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
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
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
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
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.
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
A Big Resource
National Registry of Evidenced-based
Programs and Practices:
www.nrepp.samhsa.gov
“Relapse Prevention
Therapy”
Traffic Signal Approach
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
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
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
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
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.
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
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.
Relapse Prevention and
Response in Drug Court:
BONUS SLIDES
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
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
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.
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
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
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
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
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
Relapse Prevention and
Response in Drug Court:
[email protected]
This project was supported by Grant No. 2009-DD-BX-K003
awarded by the Bureau of Justice Assistance. The Bureau of
Justice Assistance is a component of the Office of Justice
Programs, which also includes the Bureau of Justice
Statistics, the National Institute of Justice, the Office of
Juvenile Justice and Delinquency Prevention, and the Office
for Victims of Crime. Points of view or opinions in this
document are those of the author and do not represent the
official position or policies of the United States Department
of Justice.