1. Relapse Prevention and Multi- Agency Working Liz Hughes

2. Your relapse  Triggers- influence of alcohol-forgetting; association; loss of control; disinhibition  Stress-unable to cope, can’t sleep, swamped, nervous energy- need to do “something”; anxiety  Lack of time-lifestyle constraint  Peer influence- “permission”; persuasion; coercion; threatening when others change  Environmental/routine- cues habits to triggers e.g certain times places in which you do something; nostalgic- associate with exciting times; reaction against more global change  Isolation loneliness unpleasant feelings  Life events- significant events good/not so good

3.  Guilty, dishonest, ashamed, relieved, unsuprised (not sure if able to do it)  Frustrated, disappointed, failure  Went on a binge-life is too short, why not? Rationalising, reminder of how nice it was  Some were encouraging if they did the same thing  Ridicule, judgemental, angry, blaming, no will- power, rubbish, reinforcing how you feel already, optimistic-positive reframe the lapse

4. 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  To be able to develop a multi-agency response

5. Dual Diagnosis Capabilities  Therapeutic Optimism: Be able develop and maintain therapeutic optimism and a sense of hope and generate this in the service user, their carers and other professionals. Dual Diagnosis Capability 2, level 2.  Non-Judgemental Attitude: Be aware of ones own attitudes and values in relation to dual diagnosis and be able to suspend judgement when working with service users, and carers. Challenge others’ attitudes in an appropriate and useful manner. Dual Diagnosis Capability 4 level 2  Empathy: To be able to understand the unique experiences a person with dual diagnosis may have had, and be able to communicate this understanding effectively and empathically to service users, and their carers. Dual Diagnosis Capability 5, level 2  Delivering Evidence and Values Based Interventions: Be able to utilise knowledge and skills to deliver evidence-based interventions including brief interventions, motivational interviewing, relapse prevention and cognitive behaviour therapy to people with combined mental health problems within own limits and capacity and remit of ones own organisation. To know where else a service use can access appropriate specialist care and facilitate that access. To be able to access support and supervision to perform such interventions. Dual Diagnosis Capability 13, level 2.

6. Transtheoretical Model Osher and Kofoed’s Four Stages Precontemplation Engagement/early persuasion Contemplation Early persuasion Preparation Late persuasion Action Active Treatment Maintenance Relapse prevention

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

8. 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.

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

10. 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?

11. 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

12. 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

13. 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”

14. 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

15. 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

16. Sheila  Diagnosis? Schizophrenia? Psychotic/ korsakoffs/ borderline/ psychotic depression/ alcohol hallucinosis  Concerns-relapse of drinking, worsening depression, suicidality, not stable, accidental harm, agitated and irritable  Alcohol team and community team; how much can she take; one worker ideally to look across all problems, or 2 workers; goal setting for here and now issues, abuse issues are more of a long term plan; assertively engage her, not enough to offer appointments; inpatient admission? Or close monitoring, Review anti-depressants,  Timeline- review history, decision matrix; motivational interviewing  Structure to day- turning point- social inclusion- housing, training, education, work experience, outreach

17. Application to practice  Think about how you are using the course in practice  What will you need to modify/adapt  Other learning needs?  Where next?