Module 14: Relapse Prevention

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

Dual Diagnosis Capabilities

Transtheoretical Model Osher and Kofoed’s Four Stages

Precontemplation Engagement/early persuasion

Contemplation Early persuasion

Preparation Late persuasion

Action Active Treatment

Maintenance Relapse prevention

Relapse Prevention

• Not experienced negative consequences of substances for 6 months

• Maintaining abstinence (maintaining change)

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.

Interventions For Relapse Prevention Stage

• Supported or independent employment• Independent housing• Family problem solving• Self help• Peer support groups• Social skills training

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

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

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”

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?

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

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?

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

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