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Module 14: Relapse Prevention
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Objectives
• To recognise that maintaining change is difficult
• To be able to identify things that help maintain change
• To be able to identify what things trigger relapse
• To be able to help someone develop a contingency plan
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Dual Diagnosis Capabilities
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Transtheoretical Model Osher and Kofoed’s Four Stages
Precontemplation Engagement/early persuasion
Contemplation Early persuasion
Preparation Late persuasion
Action Active Treatment
Maintenance Relapse prevention
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Relapse Prevention
• Not experienced negative consequences of substances for 6 months
• Maintaining abstinence (maintaining change)
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Relapse Prevention• Increased vulnerability as people are trying to cope without
substances (or with reduced supply) and, for some people, being drug free means that their mental health problems may escalate.
• Building on lifestyle changes that support stability in both mental health and substance use problems. – Housing– Work– Activity– Supportive peer groups
• Relapse can’t be prevented, but risks of lapse can be minimised.• Interventions aim to equip the person with:
– an awareness of their own personal triggers to lapse.– appropriate skills (e.g. assertiveness training)– contingency strategies to cope with such triggers. – Self help groups.
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Interventions For Relapse Prevention Stage
• Supported or independent employment• Independent housing• Family problem solving• Self help• Peer support groups• Social skills training
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Marlatt & Gordon Model of Relapse Prevention
High-risk situation
Coping response
Increased self-efficacy
Decreased probability of relapse
No coping response
Decreased self-efficacy
Positive outcome expectancy of behaviour
Slip
Rule Violation Effect – dissonance, conflict & self-attribution – guilt & perceived loss of control
Increased probability of relapse
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Marlatt & Gordon Model
Going to pub, friend offers a cigarette
“Thanks but I have stopped smoking”
Increased self-efficacy
Decreased probability of relapse
“Oh go on then, I’ve had a bad day”
Decreased self-efficacy- I am too weak to resist and anyway, I’m in a really bad mood, this will cheer me up
Slip-smokes
Rule Violation Effect – I am hopeless, I promised I would never smoke again. Might as well go an get a packet- I’ll never be able to give up!
Increased probability of relapse
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Risks for relapse
• Lifestyle Imbalance – “shouldn’t > want to”, “duty vs. Pleasure”
• Desire for Indulgence/ Feeling of Deprivation• Cravings & Urges• Rationalisation/ Justification• Seemingly Irrelevant Decisions – series of “mini-
decisions” that take a person into a High-Risk Situation
• High-Risk Situation – “downers”, “rows” and “join the club”
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Exercise 1: Your relapses
Discuss in pairs: (10 minutes)• Think about a behaviour you changed, that
you relapsed back into (e.g. stopping smoking, starting regular exercise etc)
• What triggered the relapse? • How did you feel about the relapse? • What happened as a result? • How did other people react to your
relapse?
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Relapse and Dual Diagnosis
• Relapse is highly likely
• Change is very hard to maintain due to complexity of problems
• Workers need to remain positive when lapses occur (Therapeutic optimism)
• Help person to think about why it happened and what could help in the future
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Exercise 2: Relapse for people with dual diagnosis
• Make two lists of things that:– trigger relapse in people with dual diagnosis– things that help prevent relapse
• What do you and your service offer in terms of relapse prevention work, or who would you refer to for this?
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Factors Associated with Recovery
Positive factors:• Social support networks• Stable living situation• Safe, structured environment• Sense of purpose – job/hobbies• Therapeutic discussion• Practical help• Insight & awareness• Physical well-being• Medication (maximum
effectiveness, minimal inconvenience and side-effects
• Hope
Negative factors:• Difficulties with any of the
+ve factors• Excessive stress• Interpersonal conflict• Substance use• Persistent symptoms
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Further Reading
• Marlatt GA & Gordon JR (1985) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours Guilford Press, New York
• Miller WR (1996) What is a relapse? Fifty ways to leave the wagon Addiction 91 Supplement, S15-S27
• Rassool GH (1998) Substance Use and Misuse – Nature, Context and Clinical Interventions Blackwell Science, Oxford
• Wanigaratne S, Wallace W, Pullin J, Keaney F & Farmer R (1990) Relapse Prevention for Addictive Behaviours – A Manual for Therapists Blackwell Science, Oxford