INSIGHT: Alcohol and Other Drug Training and Education Unit

Induction Module 6 Relapse Prevention and Management

© 2013

Published by InSight: Alcohol and Other Drug Education and Training Unit, Metro North Mental Health - Alcohol and Drug Service, Brisbane Queensland June 2013 This module is available in pdf format and may be downloaded from www.insightqld.wordpress.com © Copyright Queensland Government 2013 This publication is copyright. No part may be reproduced except in accordance with the provisions of the Copyright Act 1968

Metro North Mental Health – Alcohol and Drug Service Phone 07 3837 5655 Email insight.qld.gov.au Website www.insightqld.wordpress.com

2

Contents

Welcome to induction learning material……………………………………………..

3

About InSight …………………………………………………………………………..

3

How to use module materials………………..……………………………...............

4

Relapse prevention and management………………………………………………

5

Aim………………………………………………………………………………….

5

Objectives…………………..……………………………………………………..

5

Introduction……………………………………………………………………………..

6

Lapse and relapse........................................................………………………..

6

Relapse prevention……………………………………………………………………

7

Model of Relapse Prevention……………………………………………………..

7

Key principles………………………………………………………………..........

8

Relapse prevention strategies…………………………………….....………………

8

High risk situations……………………………………………………………....……

9

How to assess high risk situations…………………………………………….....

10

Managing high risk situations…………………………………………………..…

10

Strategies to manage high risk situations…………………………………….....

11

Strategies for managing cravings and urges………………………………….........

11

Urge surfing……….……………………………………………………………….

12

The four Ds……………………………………......................……………………

12

Positive self talk………………………………………....…………………………

12

Drink/drug refusal skills...………………………………………………………….

13

Relaxation/deep breathing..………………………………………………………

13

Alternative behaviours……………………………………………………........….

13

Identifying and challenging thoughts.....................…………………………………

13

Seemingly irrelevant decisions…………………………………………………..

14

Abstinence violation effect (AVE)....……………………………………………..

15

Positive outcome expectancies...............………………………………………..

15

Cognitive distortions...……………………………………………………………..

16

Negative self talk...............………………………………………………………..

17

Global Coping Skills......…………………………………………........................…..

17

Problem solving.........................………………………………………………….

17

Assertiveness skills’ training...........................................................................

19

1

Goal setting.................…………………………………………………………….

19

SMART goals..................................................................................................

20

Relaxation skills..............................................................................................

20

Building supports............................................................................................

20

Healthy behaviours........................................................................................

21

Relapse prevention planning...............................................................................

22

Tips for developing a relapse prevention plan................................................

21

Relapse Management..........................................................................................

22

Relapse management plan............................................................................

23

Special considerations in dual diagnosis............................................................

24

Conclusion...........................................................................................................

25

Course completion certificate...............................................................................

26

Assessment questions.........................................................................................

27

References and further reading...........................................................................

29

Module evaluation................................................................................................

31

2

Welcome to Alcohol and Other Drugs Sector Induction Material

Learning Material This series of modules is designed to service health staff interested in addressing alcohol and other drug (AOD) issues with their clientele.

The introductory material seeks to provide

information to new workers in the alcohol and drug sector. The modules are based on best practice, and contain the most recent information available.

About InSight InSight is a clinical support service that provides AOD clinical education and training, and clinical education services. Insight sits within the ADS which has a mission to minimise alcohol and other drug related harm and improve the health and well being of the Queensland people we serve.

Contact InSight InSight can be contacted by phone or email if you have any queries or comments regarding this module, or for general information regarding training opportunities. Our details are: Web: insightqld.wordpress.com Phone: (07) 3837 5655 Email: [email protected]

3

How to use Module Materials •

The module contains a study guide (PDF) that can be downloaded. Please be aware this is copyrighted material. If a colleague requests this module, direct them to the web page for their personal module download.

• There are suggested readings and references for further study which are located at the end of this module. • There is no recommended text for this module. • The module is designed as a 2 - 4 hour short course. •

A short multiple choice assessment can be submitted to InSight to enable us to forward your completion certificate.

• You may contact InSight regarding this module at any time.

4

Relapse Prevention and Management

Aim The aim of the Relapse Prevention and Management module is to provide health workers with the knowledge to assist their clients prevent and manage the potential of relapse to drug and alcohol use.

Objectives The objectives for this module are to: •

Differentiate between relapse prevention and relapse management.

•

Outline specific interventions to manage a lapse or relapse.

•

Outline common cognitive distortions that may lead to high risk situations.

•

Outline the steps in problem solving and goal setting with clients.

•

Explain the role of communication skills in managing high-risk situations effectively.

•

Recognise the benefits of relaxation and explain its role in relapse prevention.

5

Relapse Prevention and Management: An Introduction

Studies have shown that people who receive treatment for problematic drug and alcohol use are likely to return or ‘relapse’ to problematic use. In fact, many will have multiple episodes of abstinence and relapse (Marlatt & Donovan, 2005). In the substance use field, some form of relapse is considered the norm rather than the exception, though it is important to recognise that this is common with any kind of behaviour change. When people are trying to change their behaviour, whether it be reducing reliance on an addictive substance, recovering from depression, or even trying to subscribe to a new form of exercise, relapse to prior levels of functioning is high (Allsop, 1990). The focus of relapse prevention is on delaying or precluding problematic AOD use.

In

relapse management, the focus is on managing the relapse to enhance the clients return to previous AOD goals.

Lapse and Relapse The terms lapse and relapse are often used interchangeably when in fact they are distinctly different. A lapse is viewed as a ‘slip’ whereby a client has used once or maybe several times after having achieved their AOD goals. The quantity of drug or alcohol use involved in a lapse can be variable; however it is distinct from relapse as a lapse occurs over a brief period of time with a return to AOD goals.

For example, if a client who had stopped smoking several

months earlier were to smoke a cigarette after a meal one evening, and then resume their goal of quitting the next day, this behavior would be described as a lapse. For a client whose goal was to only drink 2 standard drinks per drinking session were to consume half a bottle of spirits at a party on the weekend, they would also be considered to have had a lapse at the party.

If a client experienced an initial lapse, but instead of returning to their original AOD goal, continued using at their previous levels of AOD use, their behavior would be described as a relapse. Relapse is said to occur when a client no longer maintains their AOD goal and returns to pre-treatment levels of use.

6

Relapse Prevention

Model of Relapse Prevention Relapse prevention and management is based on the compensatory model of addiction. In this model, clients are not held responsible for the development of their substance using behaviours; however, they are seen as being responsible and capable of changing their situation. There are some assumptions that underlie relapse prevention. The first is that clients can exercise control over their life and make and sustain their choices, though they may need to acquire skills in order to do this. Another underlying premise is that it is normal for clients to feel that from time to time, they may want to use drugs to cope with factors in their life. Through developing new skills they can learn more optimal ways to manage these normal, yet potential destructive feelings and thoughts. One of the most frequently used models of relapse prevention was originally developed by Marlatt (1985) from clinical work with problem drinkers. While this model was developed over 25 years ago, it coined key concepts which have continued to be used in the relapse prevention field today. This model is illustrated in Figure 1 below.

Figure 1. Cognitive Behavioural Model of Relapse (Marlatt & Gordon, 1985).

7

Marlatt’s model centres on an individuals ability to effectively cope in response to high risk situations. It suggests that people with effective coping responses feel confident that they can manage high risk situations (i.e., increased self efficacy), thereby reducing the probability of experiencing a lapse.

Conversely, people with ineffective coping responses will experience decreased self-efficacy for coping with a high risk situation. This decreased self-efficacy, together with the expectation that use of a drug or alcohol will have a positive effect on the situation (i.e. positive outcome expectancy), can result in an initial lapse. This lapse in turn, can result in the individual experiencing feelings of guilt or failure, or having the misconception that any return to drug or alcohol use equates to absolute failure (i.e. an abstinence violation effect described later on page 16). The abstinence violation effect, coupled with positive outcome expectancies, can increase the likelihood of a relapse occurring.

Key Principles There are a number of key principles that guide the relapse prevention approach (Addy & Ritter, 2000; Daley & Marlatt, 1997) which include: •

the need for the client to develop coping skills to manage high risk situations

•

to make lifestyle changes to decrease the need for alcohol, drugs or tobacco

•

to undertake healthy activities

•

to prepare for interrupting lapses so that they do not lead to relapse

•

to prepare for managing relapse so that potential harms may be minimised.

Essentially, relapse prevention and management techniques are best used in combination with other important common factors in successful therapy. These factors include a solid therapeutic alliance, agreed goals for therapy, and building motivation for change.

Relapse Prevention Strategies One of the core strategies used in relapse prevention is to help client’s distinguish between a lapse and a relapse. The distinction between lapse and relapse remains one of the most critical aspects of the relapse prevention approach. Before commencing specific interventions with your client, it is important to teach the client the relapse prevention model. It may be 8

useful to use the metaphor of change as a journey that includes both easy and difficult experiences. Larimer and colleagues (1999) use the metaphor of a highway with road signs (e.g. warning signs such as slippery road ahead) to indicate high risk situations that may be ahead.

Road signs provide guidance on the road, just as there are indicators in the client’s life that high risk situations may be imminent. As long as the client is willing to learn how to pay attention to these signs in their own lives, they prevent many accidents. It is also the case that not all road accidents can be prevented, even with safe driving, but the driver can carry emergency supplies and prepare for what to do in the case of an accident. Using this metaphor, learning to anticipate and plan for high risk situations is equivalent to having a good road map, a well-equipped tool box, a full tank of petrol, and a spare tyre for the journey.

Figure 2. Car analogy.

It is important to assist the client to understand relapse as both a process and an event. This involves learning to understand and identify the early warning signs and triggers such as high risk situations, cravings, and urges to use, as well as identifying and challenging negative thoughts. Once these are identified, cognitive and behavioural approaches such as specific interventions and global self-management strategies can be implemented. These factors in relapse are outlined below.

9

High-Risk Situations Relapse prevention relies on the initial assessment of potentially high risk situations that are associated with relapse. A high-risk situation is any situation which poses a threat to the individuals’ sense of control and increases the risk of potential lapse and/or relapse (Larimer, Palmer, & Marlatt, 1999).

High-risk situations involve people, places, events, feelings,

thoughts, and behaviours. The health worker can assist the client to identify their own high risk situations, as these will vary from person to person. High risk situations can be managed by developing appropriate cognitive and behavioural coping responses.

Some commonly identified high-risk situations for people include: •

Negative emotional states, such as anxiety, depression, boredom, anger, frustration, guilt and shame.

•

Positive emotional states, such as to enhance their pleasure state.

•

Inadequate skills to deal with interpersonal conflict.

•

Inadequate skills to deal with social pressure.

•

Physical or psychological triggers for drug or alcohol use.

•

Desire to test personal control over alcohol or drug use.

•

Frequent exposure to high-risk situations.

•

Underestimating the risk of the situation.

•

Special occasions and celebrations.

How to assess High Risk Situations As a health worker, the following questions can help the client to identify high risks: •

What were the triggers for relapse or near misses in the past?

•

What does the client identify as their high-risk situations?

Managing High Risk Situations High risk situations that are known to the client can be readily identified and strategies developed for them to cope effectively in these situations. Often clients will find themselves in high risk situations that they were not expecting or did not think posed a threat. Strategies also need to be developed to cope when faced with an unknown risk situation.

In the early stages of recovery, clients should avoid people and places that have led to relapse in the past. When managing unknown risk or “coping with the unavoidable”, it is

10

important to rehearse strategies with the client in advance so that these can be relied on and utilised at the time of risk.

Strategies to Manage High Risk Situations Craving or urge to use substances can be preceded by psychological and environmental triggers. This in turn can erode the client’s goals, and increase their vulnerability in high risk situations, and lead the client to a lapse. While the terms “cravings” and “urges” are used interchangeably, they can be associated with distinct meanings. Larimer, Palmer and Marlatt (1999) originally defined an urge as a sudden impulse to engage in an act of substance use, whereas a craving can be defined as the subjective desire to experience the effects or consequences of substance use.

The health worker can provide information on effective coping strategies which will assist the management of the client’s cravings and urges to use. To manage high risk situations, clients will need to utilise the strategies that best suit their individual style and circumstances. Some useful strategies include: •

Early in the change process: Use avoidance strategies (such as walking away from the situation, avoiding certain people and places associated with use);

•

Later in the change process: Use active coping strategies (such as drink/drug refusal skills, positive self- talk); or

•

Using a combination of coping strategies.

•

Identifying high-risk situations and planning effective coping behaviours.

•

Taking steps to deal with negative emotional states.

Strategies for Managing Cravings and Urges

Cravings can be triggered by: people, places, things, feelings, situations or anything else that has been associated with using in the past.

The following are important points to relay to clients about their craving: •

Cravings are not life threatening and they will pass.

•

People with a heavier history of use will experience stronger urges.

11

•

Each experience of craving rarely lasts more than a few minutes.

•

Cravings will only lose their power if they are NOT strengthened by using. Each time a person doesn’t use, the craving will lose its power. As such, not using is the best way to ensure the experience or craving will fade out. Using occasionally will only serve to keep cravings alive. Cravings are like a stray cat – if you keep feeding them, they will keep coming back.

•

Cravings are most intense in the early parts of quitting/cutting down.

•

Craving management does get easier with time.

•

Craving intensity does vary.

There are a number of other strategies that can also be useful for clients to use to overcome a craving or urge to use. With practice the client can become better skilled at using these, which will also build their distress tolerance and self efficacy.

Urge Surfing Urge surfing is a technique where clients are taught how to experience the urge/craving for what it is: A brief, non-lethal sensation with a relatively predictable course that can be successfully managed.

Urge surfing is a technique that encourages the client to view urges or cravings as “waves in the ocean”, and to treat this as a transient experience that initially increases in intensity, and then fades and passes away in a short time.

The Four Ds Another strategy the client can use is known as the four Ds. These simple actions are used as a means to distract the client when they experience cravings to use: Delay – the client is encouraged to delay the decision to use. Cravings come in waves and will pass. Distract – the client engages in an activity such as reading, going for a walk, practice relaxation techniques, and the craving or urge to use will pass. Deep Breathing – the client is encouraged to practice deep breathing exercises when they have a craving or urge to use. Drink a glass of water - the client has a glass of water.

12

Positive Self Talk Another useful strategy to manage craving is to use positive self talk. While the client is actively experiencing a craving, they can use constructive positive self talk to not only remind themselves about the short-term nature of cravings but to also manage it. For example, “this feeling will pass”, “I can cope with this” and “I don’t have to act on this because it will go away on its own. It is important to “decatastrophise” the experience of cravings, and at the same time, acknowledge that it is an uncomfortable/unpleasant experience that will pass.

Drink/Drug Refusal Skills Clients will often face situations where they experience social pressure to use alcohol or other drugs. Drink/drug refusal skills training teaches clients how to refuse offers of a substance confidently. The health worker needs to acknowledge that saying “No” convincingly and confidently can be difficult, and that it is a skill that can be learned during a session. With practice, drink drug refusal skills will become easier to use. To refuse an offer to use a substance effectively, the client needs to: •

Use appropriate body language, such as direct eye contact and maintain an open posture.

•

Use a non threatening tone of voice.

•

Use direct statements to refuse the offer, such as “No thanks”

•

Request that the person stop asking if they persist. (Jarvis, Tebbutt, Mattick and Shand, 2005).

Relaxation/Deep Breathing If cravings develop in response to stressful situations, relaxation techniques and deep breathing exercises can be useful to manage cravings. It is very difficult for a person to feel relaxed and stressed simultaneously. Consequently, relaxation methods often displace feelings of stress. Relaxation can be achieved using many different techniques such as meditation, listening to music, using imagery and deep breathing.

Alternative Behaviours The health worker can encourage a client to engage in alternative behaviours that are not associated with using (e.g. taking a bath, exercising, meditating, visiting with non-using friends, drinking soft drinks instead of alcohol). These behaviours should be tuned to the client’s individual style and tastes.

13

Identifying and Challenging Thoughts

Marlatt and Gordon (1985) identified a number of common thought patterns and beliefs associated with relapse to substance use.

These patterns include seemingly irrelevant

decisions, abstinence violation effect, positive outcome expectancies, cognitive distortions (unhelpful patterns of thinking). Effectively, when a client becomes aware of the thought patterns that may jeopardise their treatment goals, they can then challenge their thinking and actions to maintain their goals.

Seemingly Irrelevant Decisions Many daily decisions and choices seem to have nothing to do with using in that the connection is not obvious. However, these decisions may subtley move a client closer to a situation that may promote a lapse. It is often through these seemingly irrelevant decisions 1 (SIDS), which may be conscious or subconscious, that a client gradually enters high-risk situations that lead to using.

A common example of a seemingly irrelevant decision leading to a lapse is when a client takes a route home from work that just happens to go past the pub or their dealer’s house. As the client approaches this high-risk situation of the pub or dealer’s house, they decide to go in and say ‘Hi” to an old friend. On entering the premises, they find themselves in a high risk situation that subsequently leads to a lapse.

Had the client taken a moment to be aware that their seemingly irrelevant decision may have unwittingly placed them in a high risk situation, they may have chosen to take a different route home.

Although it is difficult to recognise the potential consequences of the choices we make, it is worth advising our clients that a small decision (or a series of small decisions) can gradually lead them closer to entering a high risk situation. The best way to combat this is to encourage clients to think about the relevance of each choice they make, no matter how seemingly irrelevant it is, so that they can anticipate any potential risks.

1

Marlatt and Gordon (1985) identify Lee Beach as having coined the term Apparently Irrelevant Decisions (AIDS), but due to negative connotations with this acronym the term Seemingly Irrelevant Decisions (SIDS) has formed

14

Seemingly irrelevant decisions need to be identified and addressed with the client. To identify Seemingly Irrelevant Decisions: •

Ask the client to think about their last relapse and to describe the situation/events that preceded the lapse.

•

With the client, determine what seemingly irrelevant decisions led up to the lapse.

•

In the future, encourage the client to choose the lowest risk option when faced with a decision, and encourage them to take time when making decisions.

•

Remind the client that through increased awareness of seemingly irrelevant decisions, they will be better able to avoid high-risk situations and future lapses.

Abstinence Violation Effect (AVE) The abstinence violation effect (AVE) is a thought distortion whereby the client views any form of slip, lapse or return to drug or alcohol use as a complete failure on their part. Marlatt (2005), proposed that AVE consists of two components of maladaptive thinking (i) positive outcome expectancies and (ii) cognitive distortions described below. These two thinking styles tend to result in feelings of shame, guilt and negative affect following any return to AOD use, even if it had only been on a single occasion (e.g. one drink or one smoke). It was proposed that these feelings of failure often justify a return to prior levels of use, through thoughts such as: “I’ve already failed, so might as well keep going”. Research has shown that the AVE is not a clear predictor of relapse for alcohol or smoking. Nonetheless, assessing AVE with a client and challenging any erroneous assumptions of failure should be a core part of treatment (Witkiewitz & Marlatt, 2007).

Positive Outcome Expectancies The anticipated positive effects that a client expects to experience from using a drug is known as positive outcome expectancies. The expected effects do not necessarily correspond to the actual effect that will be experienced after using though. Positive outcome expectancies, e.g. “A drink will help me to relax” may become particularly salient in high risk situations when the client expects their substance use will help them cope in challenging circumstances. In these situations, the client focuses on their immediate gratification, and discounts any negative consequences that may be associated with their use, e.g. “I will lapse if I drink”.

15

Positive outcome expectancies are associated with poorer treatment outcomes, whereas negative outcome expectancies, e.g. “I will have a hangover if I drink” are more protective against relapse. By challenging positive outcome expectancies early on, clients can remind themselves of their initial resolution to keep their treatment goals. It also allows them to revisit the negative aspects of their substance use. (Marlatt & Donovan, 2005; Witkiewitz & Marlatt, 2007).

Cognitive Distortions There are a number of cognitive distortions that are important to be aware of when exploring your clients thinking patterns. These are listed below: •

Black and White Thinking This pattern of thinking is characterised by the interpretation that things are either all good or all bad – with no shades of grey in between. For example, “one lapse means a total failure”.

•

Jumping to Negative Conclusions The person automatically draws a negative conclusion with very little evidence. For example, “everyone’s going to hate me because I have used”.

•

Catastrophising People with this pattern of unhelpful thinking tend to give too much meaning to situations. They convince themselves that if something goes wrong, the result will be unbearable and intolerable. For example, “this craving is terrible, I’m going to die”.

•

Personalising People who ‘personalise’ information, tend to blame themselves (rather than the situation or environment) for anything unpleasant that happens. For example, “Sally looked angry at work today – I must have done something to upset her”.

•

Should/Oughts People with this pattern of thinking use ‘ought’ and ‘must’ when they think about situations. Using “should” leads to inflexibility in situations and may result in feelings of anger, frustration and guilt. For example, “giving up should be simple and I ought to have mastered it by now”.

16

•

Labelling Using labels to describe oneself or others leads to unhelpful feelings such as shame and guilt . For example, “I’m just a junkie”.

•

Overgeneralisation When a person overgeneralises, they assume that because something happened once, it will always happen. For example, “once a junkie, always a junkie”.

During therapy a health worker will employ specific skills to assist the client to challenge these cognitive distortions. In this way more constructive ways of thinking can be explored.

Negative Self-Talk Negative self talk can perpetuate destructive patterns in the client’s life. The health worker can explore whether the client is conscious of this self-talk or if their thinking is set on autopilot. Examples of unwanted self-talk include: “No-one cares about me, so I may as well get high”, or “Why should I attend counselling/meetings…it’s a waste of time and doesn’t work”.

Through careful questioning to discuss and challenge a clients’ negative self talk, the health worker can assist the client to develop alternative and more realistic ways of thinking.

Global Coping Skills There are a number of global skills that clients can learn to assist in relapse prevention. These additional skills can also be used during relapse management to assist the client return to their treatment goals should a lapse occur.

Problem Solving Effective problem solving skills enhance a client’s ability to manage day-to-day tasks and formulate long-term strategies for maintaining treatment goals. Effective problem solving skills involve the client being able to recognise a problem and develop the best possible solution to that problem. The following steps in problem solving skills can be introduced to the client during a session:

17

Steps in Problem Solving Take a deep breath. Step back. Think! •

Identify the problem

•

Make it SPECIFIC

•

Brainstorm alternatives

•

Evaluate each alternative

•

Choose an option

•

Check that it is possible, practical, and legal.

When implementing problem solving strategies with a client, have them practice using the skills with you to increase their self efficacy. A good way to introduce problem solving is by using a simple example, and something they can relate to. A good example is asking them to imagine that their neighbour has a dog that barks all night and is really annoying. Figure 4 below shows an example of how to solve a problem using the steps described above. 1. Problem identification: Barking dog 2. Make it specific: Prompt the client to narrow down the problem. “Well actually the dog does not bark ALL night, but does between 9pm-10pm when the neighbour gets home and it is excited. This means that I can’t sleep as this is when I am trying to go to bed.” 3. Brainstorm alternatives: Prompt the client to generate options a. Talk to the neighbour b. Call the police c.

Move house

d. Call the council e. Buy a dog that barks back! 4. Evaluate: This can be done formally or informally (talk through or write a list) a. This is a good option but I’m scared to do this b. I don’t like this option as I don’t think it is needed yet c.

Too extreme

d. This might be a good idea if talking with the neighbour does not work e. It would be fun in the short term, but I don’t think that will work! 5. Choose an option: a. “I think “a” is best but I need to learn some assertiveness skills”. At this point the clinician can practice identifying what the client wants to say and practice assertiveness skills in session.

6. Check that it is practical, legal etc: Yes it is – the clinician should ensure that the client feels ready and has practiced the skills of assertiveness before they leave the session.

Figure 3. Example of problem solving

18

Assertiveness Skills’ Training Assertiveness skills’ training is useful for clients who have difficulty articulating their needs and emotions. This inability to express themselves assertively can lead to frustration, anger and distress, which in turn can lead to substance use. By learning to communicate assertively, the client can then express themselves effectively in a manner that respects their rights as well as the rights of others. In this way, using basic assertion skills can be an effective relapse prevention strategy. Assertiveness skills’ training involves teaching clients to expresses their needs, wants, beliefs, opinions or feelings clearly by: •

Developing non-verbal assertive behaviours such as using an open posture and staying calm.

•

Using assertive verbal behaviour such ‘I’ statement s. For example : o

“I need to be away by 5 o’clock”

o

“I haven’t thought about that before, I’d like time to think about your idea”.

o

“I feel nervous”

o

“I feel angry”

o

“I feel guilty”

Keeping an assertive statement specific, simple and brief, will clarify exactly what is being communicated.

Goal Setting Goals provide the client with concrete signposts to guide their treatment and measure their progress over time. Working towards a major goal can be daunting for clients, particularly if they have experienced a sense of failure during previous attempts to change behaviour. If the goals are broken down into smaller more manageable targets, the client will develop a sense of mastery and accomplishment as each target is achieved. This experience will enhance their self efficacy and motivation to continue (Jarvis, Tebbutt, Mattick, & Shand, 2005).

Many authors have discussed the essential aspects of, and how to go about goal setting. One framework commonly used globally is the SMART acronym, outlined below.

19

SMART Goals The SMART framework suggests that short term goals should be:

Small (e.g. drink two glasses of water each morning) Measurable (e.g. measure the two glasses and ask the client to record this each day) Achievable (e.g. ask the client, is this achievable? Problem solve any barriers) Realistic (e.g. ask the client, is this realistic? Problem solve any barriers) Time limited (e.g. start with a one week timeframe, extend to a month and so on. At the completion of each timeframe takes some time to reflect and congratulate the client on their success).

These goals also need to be flexible to allow adjustment for new information.

Relaxation Skills As mentioned earlier, when a person is feeling relaxed, they cannot feel stress at the same time. For this reason, relaxation is an essential skill for stress reduction.

Tense people tend to breathe at a faster rate than their normal respiratory rate. Practicing deep abdominal breathing can assist in slowing one’s breathing rate down and induces relaxation. Other techniques such as meditation, guided relaxation, imagery and deep muscle relaxation are all very effective means to achieve relaxation.

Effective relaxation takes practice. Encouraging clients to practice relaxation techniques when they are not under stress or to incorporate them as part of their daily routine can be very productive. Clients who have successfully honed their relaxation skills will generally feel more relaxed and be well equipped to utilise them further during stressful times.

Building Supports Positive relationships with family and friends can provide general support and goal direction for the client. Health workers need to be aware of the interpersonal relationships of their clients, in terms of identifying positive supports versus problematic relationships. Sometimes, the primary supports identified by the client may actually be unsupportive and another source of conflict.

In conjunction with client, the health worker can determine: •

Whether certain relationships involve access to alcohol or drug use.

20

•

Whether high risk situations can arise from interactions with family or friends, e.g. conflict, anniversary dates and special occasions.

•

Which relationships are supportive and provide positive experiences that will be more likely to support the client to adhere to their treatment goals.

•

Whether engaging the partner or significant other in the therapy process (where appropriate) will assist in the provision of support.

Healthy Behaviours Often clients who present with problematic substance use no longer participate in recreational activities they once enjoyed. The health worker can assist in identifying those activities and encourage the client to re-engage in them as an alternative to substance use. This will assist the client in re-establishing a lifestyle balance to promote greater mental, emotional, physical, and spiritual well-being. The following steps can be used to support the client: •

Listing the activities/interests the client stopped as a result of their AOD use

•

List the things the client may like to start

•

Explore barriers to engaging in these activities

•

Identifying stressors and managing these effectively.

•

Outline the importance of stress management and engaging in positive behaviours such as relaxation/meditation, exercise, nutrition.

•

Support the client to make lifestyle changes.

Relapse Prevention Planning Once the client has identified and begun to develop strategies to manage their cravings or urges to use, an action plan can be developed. The action plan outlines exactly which strategies to use in particular high risk situations. This plan can help prepare a client to manage their cravings or urges to use when faced with a high risk situation and will ultimately decrease the likelihood of a lapse occurring.

Tips for Developing a Relapse Prevention Plan •

Write down all the high-risk situations for substance use the client identified during the session on a craving plan template (like that shown in figure 4 below).

21

•

Ask the client to circle the situations they feel they can simply avoid or reduce their exposure (e.g. not having speed in the house or not buying it, thereby reducing the likelihood of experiencing a craving).

•

Of the remaining triggers that cannot be avoided, go through the coping strategies (e.g. urge surfing, relaxation, nominating a support person to call) and jointly decide on those that the client can put in place when they are experiencing cravings and urges to use.

•

If the client has not tried any of the coping skills before, encourage them to practice the technique in the session with you. This will make it easier for them to use the skill at a later date.

•

Assist the client to generate ideas: “What things will I do to help me stay off drugs/alcohol?”

•

Record the final plan on the following table “My craving plan” for them to take home.

•

Ask the client to refer to the plan throughout the week when a craving develops and act on all the strategies generated during the session. Some may work better than others, and once a strategy is found to be helpful, it may be used repeatedly.

High Risk Situations (circle those you can avoid)

My Coping Plan: (What will help me stay off drugs/alcohol?)

Figure 4. Example of a craving plan template.

22

Relapse Management

Once relapse prevention skills have been developed, the focus changes to relapse management. Strategies used here aim to effectively manage or reduce the impact of a lapse should it occur, and to prevent a relapse.

Even after extensive preparation to prevent lapses, many clients will still experience a lapse. There are many reasons why a client may lapse, most common of which are: •

They don’t know how to manage the situation. This may be due to inadequate use of coping skills or other skills that were not identified at the time.

•

They don’t know how to use their coping strategies effectively.

•

They don’t recognise the situation as high risk until it is too late.

•

They use only avoidance strategies.

•

They choose to lapse.

Relapse management or coping with lapses can be discussed with the client as a means to cope in an emergency. In the same way as we have the emergency telephone number “000”, a fire extinguisher or a first aid kit, it can be very useful for a client to have a “lapse emergency kit” available if needed. It is important to emphasise that just because the client has a plan for coping with a lapses, this does not mean they are going to lapse (in the same way as having a fire extinguisher and alarms in our house does not necessarily mean we are going to have a fire!). Adequate preparation ensures that in the event of a lapse, the client has the best chance of returning to their goals. A number of steps are involved in preparing clients to manage a lapse. These are some of the things that need to be to discuss with the client: 1) Lapses are common: Most people lapse and in fact, it normally takes five or six attempts before people successfully maintain change. 2) Lapses are learning opportunities: Clients are encouraged to reframe a lapse as any other kind of learning situation, an opportunity to learn from the situation. 3) Create a plan: The most important thing to remember is to have a plan both to prevent a lapse and manage should one occur.

23

4) Encourage coping: It is also important to distinguish between “planning to lapse” and “planning to prevent/cope with a lapse”. While lapses are common, this does not mean that you are encouraging a client to think it is ok to plan for a lapse. Rather, this approach is designed to help minimise a client’s unhelpful feelings after a lapse (usually of guilt or shame) and encourage learning to promote long-term behaviour change.

Relapse/Lapse Management Plan

Relapse/lapse management strategies that focus on stopping the progression of a relapse/lapse may include: •

Contracting with the client to limit the extent of use.

•

Contacting the therapist as soon as possible after the lapse.

•

Evaluating the situation and identifying the triggers that preceded the lapse.

•

Reframing a relapse as a hiccup, a learning opportunity, or a temporary setback.

•

Using problem solving strategies previously learnt.

•

Using positive self-talk to prevent a lapse becoming a relapse (preventing Abstinence Violation Effect).

•

Utilising a previously negotiated support network; friends, family, doctor and 24-Hour Alcohol and Drug Information Service (ADIS).

•

Providing simple written instructions, for example a lapse coping card to refer to in the event of a lapse (see Figure 5 overleaf).

24

REASONS FOR STAYING SOBER

SOME WAYS TO COPE:

• • • •

Actions I can take to cope when I notice a warning signal or find myself in a high-risk situation where I might use:

(Choose at least one, even when you don’t feel like it)

EMERGENCY CONTACT NUMBERS

REMEMBER THE FOUR “D’s”

• 24-Hour Alcohol and Drug Information Service (ADIS): 1800 177 833

• Distract: distract yourself in the short-term

• Lifeline: 13 11 14 • Friend: • Other:

• Deep breathe: direct focus to your breathing • Drink water: take a moment to stop what you are doing and have a glass or water or cordial • Do something else: Write your own best example here ………………………………………………. (e.g. it may be take a walk, phone a friend)

Figure 5. Example of a coping card. This card is best adapted to your client. The card can be printed and folded so your client can keep this in their wallet at all times.

25

Special Considerations for Dual Diagnosis

Dual Diagnosis within the AOD sector refers to the co-occurrence of substance use and mental health problems. Within this context, Dual Diagnosis is also commonly referred to as ‘co-morbidity’, a general term that means having more than one diagnosed disorder at a time. People with a dual diagnosis are the core business of mental health and AOD services in Australia. Often these clients have multiple and complex needs that require a high level of responsiveness throughout all phases of their treatment, based on their individual needs.

Health workers are presented with significant treatment issues when clients present with a comorbid mental health and substance use problem. Clients often experience an increased severity of illness, have poorer treatment outcomes and higher service use compared to people experiencing a single disorder. Clients with a dual diagnosis also experience higher rates of physical problems, homelessness, financial difficulties, involvement in criminal behaviour and subsequent incarceration, admissions to acute mental health units, self harm, and suicide. As a result, they also experience higher rates of relapse than clients without a mental health issue.

Clients with a dual diagnosis are at a greater risk of relapse to AOD use when symptoms of their mental health disorder recur. Clients with severe mental illness tend to have pervasive cognitive and social dysfunctions, which can impact on their ability to learn new skills effectively and lead to isolation and victimization (Drake, Wallach & McGovern, 2005). In addition, these clients usually need long term mental health treatment and often need assistance to find and maintain housing and employment.

Given the extra consideration needed when working with a dual diagnosis client, a nonjudgmental attitude and a strong therapeutic alliance can make a significant difference in their relapse prevention and management. Health workers need to be aware of the individual needs of their dual diagnosis clients and ensure relapse prevention and management strategies are developed to meet these needs.

26

Conclusion and Course Completion

Relapse prevention and management focuses on preventing a lapse and equipping the client with the skills and strategies to cope effectively in order to prevent a relapse to former substance use patterns. The strategies and techniques discussed in this module can assist the client maintain their treatment goals in line with contemporary relapse prevention and management philosophies.

Course Completion Certificate To complete this module and receive a completion certificate, the following multiple choice questions must be completed and submitted to InSight. Please ensure you follow the guidelines for submission.

Guidelines: •

Your full name

•

Work place address:

•

Date of submission:

•

Module number:

•

Evaluation of the module attached (last page of this module)

Mail, fax or email to:

Senior Clinical Education Coordinator Insight: Centre for AOD Training and Education Alcohol and Drug Service 270 Roma Street Brisbane Qld 4000

FAX NO: (07) 3837 5716 EMAIL: InSight @ health.qld.gov.au

27

Relapse Prevention and Management Module Assessment

ASSESSMENT QUESTIONS Please circle your response to the following multiple choice questions.

1. The aim of relapse prevention is to: a) inform clients that a lapse is inevitable. b) delay or prevent problematic drug use. c) inform clients that a lapse is a relapse. d) assist the clinician manage a lapse.

2. Self-efficacy can be defined as: a) the client’s confidence to manage behaviours in a specific situation. b) the relationship between the clinician and the client. c)

the client’s motivation to change.

d) the client’s ability to present to treatment services.

3. Lapse education does not involve: a) encouraging contact with the clinician when a lapse has occurred. b) providing simple written instructions should a lapse occur. c)

reflecting on triggers that preceded the lapse.

d) informing the client that their treatment has failed. 4. Which of the following is not true about cravings: a) they may occur with a trigger to use. b)

cravings never go away.

c)

an individual craving rarely lasts beyond a few minutes.

d) persons with heavier AOD use may experience stronger urges to use.

28

5. High-risk situations can include: a) negative emotional states. b) special occasions, anniversaries, and celebrations. c)

physical or psychological reminders of past drug use.

d) all of the above.

6. The Abstinence Violation Effect (AVE) can be defined as: a) having positive memories about using. b) enjoying using substances again after a period of abstinence . c)

a thought distortion whereby the client views any form of drug or alcohol use as a complete failure.

d) managing high-risk situations effectively to avoid a relapse.

7. What steps are not involved in problem solving: a) take a deep breath. Step back. Think! b) b) identify the problem and make it specific. c) brainstorm alternatives and evaluate. d) choose any option even if it is not possible, practical, or legal. 8. A relapse prevention plan: a) gives the client permission to lapse in order to practice effective management skills. b) prepares the client to use strategies that will help them manage high risk situations. c)

exposes the client to as many high-risk situations as possible.

d) assist the client hear negative self-talk. 9. The SMART goals acronym stands for: a) small, manageable, achievable, reflective, time limited. b) small, moderated, achievable, realistic, team orientated. c) specific, measurable, adaptive, realistic, time limited. d) small, measureable, achievable, realistic, time limited.

29

10. Which of the following combination of strategies is not used in relapse prevention and management: a) building personal supports, finding alternatives to substance use, assessing highrisk situations, managing cravings. b) Identifying the problem, giving advice, referring the client to another health worker in the team. c)

building self-efficacy, urge surfing, challenging unhelpful thinking, relapse fire drill.

d) goal setting, problem solving, assertiveness skills, identifying seemingly irrelevant decisions.

30

References and Further Reading

Addy, D., & Ritter, A. (2000). Clinical treatment guidelines for alcohol and drug clinicians. No 3: Relapse Prevention. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc.

Daley, D., & Marlatt, G. A. (1997). Relapse prevention. In J. Lowinson, P. Ruiz, R. Millman, & J. Langrod (Eds), Substance Abuse: A comprehensive textbook (3rd ed). Maryland: Williams and Wilkins. Daley, D., & Marlatt, G. A. (2006). Overcoming your Alcohol or Drug Problem (2nd ed). New York: Oxford University Press.

Douaihy, A., Stowell, K. R., Park, T. W., & Daley, D. C. (2007). Relapse prevention: Clinical strategies for substance use disorders. In K. Witkiewitz, K., & G. A. Marlatt, (Eds) (2007). Therapist’s guide to evidence-based relapse prevention, 37-71. New York: Academic Press.

Drake, R.E., Wallach M.A., & McGovern, M.P. (2005). Future Directions in Preventing Relapse to Substance Abuse Among Clients with Severe Mental Illnes. Psychiatric Services. 56,1297-1302.

Jarvis, T.J., Tebbutt, J., Mattick, R.P. & Shand, F. (2005). Treatment Approaches for Alcohol and Drug Dependence: An Introductory Guide (2nd ed.). Sydney: John Wiley & Sons Ltd.

Witkiewitz, K., & G. A. Marlatt, (Eds) (2007). Therapist’s guide to evidence-based relapse prevention. New York: Academic Press.

Larimer, M. E., Palmer, R. S., & G.A. Marlatt (1999). Relapse prevention: An overview of Marlatt’s cognitive-behavioural model. Alcohol Research and Health.

Lloyd, A. (2009) Urge surfing. (pp. 669-673). In: O'Donohue, W.T. & Fisher, J.E. (Eds.). General principles and empirically supported techniques of cognitive behavior therapy. Hoboken, NJ: John Wiley & Sons Inc.

Marlatt, G.A. & Donovan, D.M. (2005). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours (2nd ed.). New York: Guildford Press.

31

Marlatt, G. A., & Gordon, J. R. (Eds.) (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.

Marlatt, G. A., Parks, G. A., & Witkiewitz, K. (2002). Clinical guidelines for implementing relapse prevention therapy. Chicago: Behavioral Health Recovery Management Project, The University of Chicago Center for Psychiatric Rehabilitation. Newring, K.A.B, Loverich, T.M, Harris, C.D & Wheeler, J. (2009). Relapse Prevention in W.T O’Donohue & J.E Fisher’s (Eds) General Principles and Empirically Supported Techniques of Cognitive Behaviour Therapy, pp 520-531. New Jersey: John Wiley & Sons.

Prochaska, J.O. Norcross, J.C. & DiClemente, C.C. (1994). Changing for good: The revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow.

Smith, J.P., Book, S.W. (2008). Anxiety and Substance Use Disorders: A Review. Psychiatric Times 25: 19-23. Skinner, N. (2005). Goal Setting. In N. Skinner, A.M. Roche, J. O’Connor, Y. Pollard, & C. Todd (Eds.), Workforce Development TIPS (Theory Into Practice Strategies): A Resource Kit for the Alcohol and Other Drugs Field. National Centre for Education and Training on Addiction (NCETA), Flinders University, Adelaide, Australia.

Staiger P. K., Richardson B., Long C. M., Carr V., Marlatt G. A. (2012) Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence. Addiction 2012.

Steckler, G., Witkiewitz, K. & Marlatt, G. A. (2013). Relapse and Lapse. Principles of Addiction: Comprehensive Addictive Behaviors and Disorders, 1, 125-132. Witkiewitz, K. & Bowen, S. (2010). Depression, craving and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78, 362-374. Witkiewitz, K., Marlatt, G. A. (Eds.). (2007). Evidence-Based Relapse Prevention. New York: NY, Elsevier Science.

32

Module Evaluation (please attach this evaluation to your assessment)

Your name: Module number:

Date: 6

Module name: Relapse Prevention and Management Please tick the box where appropriate: After completing this module:

None

Limited

Some

Very good

Not at all

Limited

Somewhat

Very

My understanding of relapse prevention and relapse management is: My understanding of interventions to manage a lapse or relapse is: My understanding of Cognition Distortions is: My understanding of problem solving and goal setting is: My understanding of communication skills in managing high-risk situations is: My understanding of the role of relaxation in relapse prevention is:

Was the module useful? Was the eLearning material readily accessible?

As an introductory in-service what other information would have been useful:

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Thank you.

33

2