Relapse Prevention and Response in Drug Court: Terrence D Walton, MSW, ICADC Director of Treatment Pretrial Services Agency for the District of Columbia Terrence Walton, January 25, 2011 The following presentation may not be copied in whole or in part without the written permission of the author or the National Drug Court Institute. Written permission will generally be given without cost, upon request.
True or False? Research shows that even while in treatment, some addicted people can only stay clean a couple of days before relapsing.
The 1 st Big Question Is it relapse or continued use?
Defining Relapse 1. When a person in recovery returns to the self-prescribed, non-medical use of any mood altering chemical (MAC) and the risk of the problems associated with that use 2. The return to use after a period of abstinence that interrupts the addicts ongoing attempts to recover 3. A return to drug use that is precipitated by and/or leads to lessening of commitment to recover
Defining Recovery In conjunction with a day-by-day commitment to remain abstinent, the ongoing process of overcoming physical and psychological dependence on mood altering chemicals and learning to live in a state of total abstinence, without the need for those substances. In recovery, the individual relies on healthy, constructive activities and experiences for happiness and fulfillment.
The 2 nd Big Question Is it a slip or a relapse?
A Slip Initial episode of alcohol or other drug use after a period of recovery/remission Does not indicate or precipitate a lessening in commitment to change Can end quickly or lead to a relapse of varying degrees
Slipping Neither a slip, nor relapse is accidentally using Both are willful decisions to use Slip = Set Back Relapse = Collapse Slip = Rapidly restored commitment to change Relapse = Recycling back through change stages
Two Secrets 1. No use doesn t mean you re in recovery 2. Use
Research 1. Studies show relapse rates of 40% to 60% at one year follow-up 2. Most relapses occur in the first year of recovery, with two thirds occurring in the first 90 days 3. Clients who remain in treatment longer generally have the better outcomes
Causes Pretreatment Factors Degree of substance dependence Co-occurring disorders Combat related trauma Treatment Factors Type, length and quality of treatment Post Treatment Factors Family/social supports Social/coping Skills
Impact on the Individual Relapse is a persistent risk in recovery Consequences may include: Return to active use Criminal behavior Physical, social, or emotional collapse Re-commitment to recovery
Relapse An unfolding process in which the resumption of substance abuse is the last event in a long series of maladaptive responses to internal or external stressors or stimuli
WHAT IS RELAPSE PREVENTION? Therapy designed to teach people to engage in recovery-supportive activities and to recognize, anticipate, and manage the relapse warning signs so that they can interrupt the relapse process early and return to the process of recovery.
Relapse Prevention Planning 1. Written, specific, and rehearsed plans 2. Reiterates commitment to and rationale for recovery 3. Outlines and schedules recovery supportive activities 4. Identifies warning signs, cues, and high risk situations (triggers) 5. Details preventive and progressive responses to all triggers
A Big Resource National Registry of Evidenced-based Programs and Practices: www.nrepp.samhsa.gov Relapse Prevention Therapy
Traffic Signal Approach
Green Light Problems Failing to engage fully in recovery-supportive activities 1. Skipping or coming late to meetings 2. Neglecting spiritual activities and readings 3. Skipping work or cutting class 4. Failing to plan and participate in leisure activities 5. Neglecting physical exercise, adequate sleep, or healthy diet
Yellow Light Problems Situations requiring caution, extra support, and/or prompt resolution 1. Negative moods & attitudes (angry, afraid, sad, lonely, hurt, guilty, bored, anxious, embarrassed, frustrated, rebellion, resentful, stubborn) 2. Fleeting cravings, urges, or euphoric recall 3. Holidays, celebrations; vacations, and other down-time ; Sleeping (using dreams) 4. Dishonesty, greed, or having extra money 5. Feeling depleted, deprived, entitled or exhausted 6. Sobriety milestones 7. Re-entering from institutions
Red Light Problems Situations to avoid, persistently resist, and/or requiring urgent external support 1. Offers to use or drink 2. Persistent cravings, urges, or euphoric recall 3. Feeling hopeless, like giving up, or not caring 4. Euphoric recall 5. Sudden, unexpected external triggers (sound, sight, smell, taste, sensation) 6. Trauma reactions 7. A slip
Relapse Response Planning 1. Written & specific plans 2. Detailing immediate post-use actions 3. Full disclosure Who is to be informed immediately Program to be informed at first opportunity 4. Expected & accepted consequences 5. Plan for re-evaluation and intervention
Honesty Matters 1. Participant lies about using even after testing positive. 2. Participant readily acknowledges using after testing positive. 3. Participant acknowledges using before testing positive. 4. Participant acknowledges thoughts of using before doing so.
Responses to Relapse 1. Reassess Continued Use Potential and Change Readiness 2. Conduct Functional Analysis of Relapse 3. Determine Whether Continued Use, Slip, Relapse 4. Apply Planned Court-related or Supervision- Related Responses (e.g. sanction, phase freeze, staffing) 5. Apply Planned Clinical Responses (e.g., enhancing treatment, increase drug/alcohol testing) 6. Re-stabilize and Re-engage (e.g. detoxification, treatment readiness); Re-instill hope
Program Response Tips 1. Continued use or dishonesty usually sanctioned more severely than a readily acknowledged relapse/slip 2. Relapse prevention and response planning should be implemented early in the treatment process 3. Prepare to respond to repeated continuing use or relapses/slips in some participants, especially early in treatment
Relapse Prevention and Response in Drug Court: BONUS SLIDES
8 Relapse Precipitating Variables 1. Affective variables e.g. depression, anxiety 2. Behavioral variables e.g. inadequate coping skills or leisure management skills 3. Cognitive variables e.g. attitudes and beliefs about recovery/relapse; self efficacy 4. Environmental and relationship variables e.g. lack of social support, poor role models, social pressures to use
8 Relapse Precipitating Variables 5. Physiological variables post acute withdrawal, cravings, pain, medication use 6. Psychological/psychiatric variables level of motivation to change, co-occurring disorder 7. Spiritual variables excessive guilt or shame, feeling empty, meaninglessness 8. Treatment system variables clinician s knowledge and skills; access to needed services; quality and appropriateness of interventions
How to help 1. Help clients anticipate their high risk relapse factors and develop strategies to manage them. 2. Help clients identify and manage relapse warning signs. 3. Help clients identify feelings and manage negative emotions. 4. Help clients identify and prepare to handle direct and indirect social pressure to use. 5. Help clients improve their interpersonal communications and relationships and to develop a recovery support system.
How to help 6. Assess clients for psychiatric conditions and facilitate treatment. 7. Help clients understand and manage their cravings to use, as well as cues that trigger cravings. 8. Help clients identify and manage patterns of thinking that increase relapse risk. 9. Help clients work toward a more balanced lifestyle. 10. Include pharmacologic interventions
How to help 11. Facilitate transition between levels of care 12. Incorporate strategies to improve adherence to treatment 13. Prepare clients to interrupt lapses and relapses as early as possible; Relapse Response Planning
Green Light Problems Failing to engage fully in recovery-supportive activities 1. Skipping or coming late to meetings 2. Neglecting recovery related readings 3. Isolating from supportive people 4. Neglecting spiritual activities and readings 5. Skipping work or cutting class 6. Failing to plan and participate in leisure activities 7. Neglecting physical exercise 8. Avoiding the doctor, dentist, or therapist 9. Failing to eat well 10. Refusing to confide in trustworthy others
Yellow Light Problems Situations requiring caution, extra support, and/or prompt resolution 1. Stress; Negative moods or attitude (resentment, rebellion, angry, afraid, sad, lonely, hurt, guilty, bored, anxious, embarrassed, frustrated) 2. Fleeting cravings, urges, or euphoric recall 3. Holidays, vacations, and other moments of celebration 4. Life instability, conflicts, drama, or crisis 5. Experiencing loss, grief, or illness; emotional or physical pain 6. Dishonesty, greed, or having extra money 7. Focusing on someone else s problems 8. Feeling depleted, deprived, entitled or exhausted 9. Defensiveness, argumentative, or defiant 10. Sobriety milestones
Red Light Problems Situations to avoid, persistently resist, and/or requiring urgent external support 1. Offers to use or drink 2. Encountering old using associates or areas 3. Persistent cravings 4. Doubting the need to avoid use all together 5. Feeling hopeless, like giving up, or not caring 6. Euphoric recall 7. Obsessive use-related thoughts or negative feelings after having a using dream 8. Unexpected external triggers (sound, sight, smell, taste, sensation) 9. Trauma reactions 10. A slip
Relapse Prevention and Response in Drug Court: Terrencewalton@aol.com
This project was supported by Grant No. 2009-DD-BX-K003 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. Points of view or opinions in this document are those of the author and do not represent the official position or policies of the United States Department of Justice.