1. Module 14: Relapse Prevention

2. 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

3. Dual Diagnosis Capabilities

4. Transtheoretical ModelOsher and Kofoed’s Four Stages PrecontemplationEngagement/early persuasion ContemplationEarly persuasion PreparationLate persuasion ActionActive Treatment MaintenanceRelapse prevention

5. Relapse Prevention Not experienced negative consequences of substances for 6 months Maintaining abstinence (maintaining change)

6. 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.

7. Interventions For Relapse Prevention Stage Supported or independent employment Independent housing Family problem solving Self help Peer support groups Social skills training

8. 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

9. 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

10. 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”

11. 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?

12. 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

13. 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?

14. 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

15. 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