Relapse Prevention and Multi-Relapse Prevention and Multi-Agency WorkingAgency Working

Liz HughesLiz Hughes

Your relapseYour relapse

Triggers- influence of alcohol-forgetting; association; loss Triggers- influence of alcohol-forgetting; association; loss of control; disinhibitionof control; disinhibition

Stress-unable to cope, can’t sleep, swamped, nervous Stress-unable to cope, can’t sleep, swamped, nervous energy- need to do “something”; anxietyenergy- need to do “something”; anxiety

Lack of time-lifestyle constraintLack of time-lifestyle constraint Peer influence- “permission”; persuasion; coercion; Peer influence- “permission”; persuasion; coercion;

threatening when others changethreatening when others change Environmental/routine- cues habits to triggers e.g certain Environmental/routine- cues habits to triggers e.g certain

times places in which you do something; nostalgic- times places in which you do something; nostalgic- associate with exciting times; reaction against more global associate with exciting times; reaction against more global changechange

Isolation loneliness unpleasant feelingsIsolation loneliness unpleasant feelings Life events- significant events good/not so goodLife events- significant events good/not so good

Guilty, dishonest, ashamed, relieved, unsuprised Guilty, dishonest, ashamed, relieved, unsuprised (not sure if able to do it)(not sure if able to do it)

Frustrated, disappointed, failureFrustrated, disappointed, failure Went on a binge-life is too short, why not? Went on a binge-life is too short, why not?

Rationalising, reminder of how nice it wasRationalising, reminder of how nice it was Some were encouraging if they did the same thingSome were encouraging if they did the same thing Ridicule, judgemental, angry, blaming, no will-Ridicule, judgemental, angry, blaming, no will-

power, rubbish, reinforcing how you feel already, power, rubbish, reinforcing how you feel already, optimistic-positive reframe the lapseoptimistic-positive reframe the lapse

ObjectivesObjectives

To recognise that maintaining change is difficultTo recognise that maintaining change is difficult To be able to identify things that help maintain To be able to identify things that help maintain

changechange To be able to identify what things trigger relapseTo be able to identify what things trigger relapse To be able to help someone develop a To be able to help someone develop a

contingency plan contingency plan To be able to develop a multi-agency responseTo be able to develop a multi-agency response

Dual Diagnosis CapabilitiesDual Diagnosis Capabilities Therapeutic Optimism: Therapeutic Optimism: Be able develop and maintain therapeutic optimism and a Be able develop and maintain therapeutic optimism and a

sense of hope and generate this in the service user, their carers and other professionals. sense of hope and generate this in the service user, their carers and other professionals. Dual Diagnosis Capability 2, level 2.Dual Diagnosis Capability 2, level 2.

Non-Judgemental Attitude: Non-Judgemental Attitude: Be aware of ones own attitudes and values in relation to 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 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 carers. Challenge others’ attitudes in an appropriate and useful manner. Dual Diagnosis Capability 4 level 2 Capability 4 level 2

Empathy: Empathy: To be able to understand the unique experiences a person with dual 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 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 2empathically to service users, and their carers. Dual Diagnosis Capability 5, level 2

Delivering Evidence and Values Based Interventions: Delivering Evidence and Values Based Interventions: Be able to utilise knowledge Be able to utilise knowledge and skills to deliver evidence-based interventions including brief interventions, and skills to deliver evidence-based interventions including brief interventions, motivational interviewing, relapse prevention and cognitive behaviour therapy to people motivational interviewing, relapse prevention and cognitive behaviour therapy to people with combined mental health problems within own limits and capacity and remit of ones 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 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 care and facilitate that access. To be able to access support and supervision to perform such interventions. Dual Diagnosis Capability 13, level 2.such interventions. Dual Diagnosis Capability 13, level 2.

Transtheoretical ModelTranstheoretical Model Osher and Kofoed’s Four Osher and Kofoed’s Four Stages Stages

PrecontemplationPrecontemplation Engagement/early persuasionEngagement/early persuasion

ContemplationContemplation Early persuasionEarly persuasion

PreparationPreparation Late persuasionLate persuasion

ActionAction Active TreatmentActive Treatment

MaintenanceMaintenance Relapse preventionRelapse prevention

Relapse PreventionRelapse Prevention

Not experienced negative consequences of Not experienced negative consequences of substances for 6 monthssubstances for 6 months

Maintaining abstinence (maintaining Maintaining abstinence (maintaining change)change)

Relapse PreventionRelapse Prevention Increased vulnerability as people are trying to cope without substances Increased vulnerability as people are trying to cope without substances

(or with reduced supply) and, for some people, being drug free means (or with reduced supply) and, for some people, being drug free means that their mental health problems may escalate. that their mental health problems may escalate.

Building on lifestyle changes that support stability in both mental health Building on lifestyle changes that support stability in both mental health and substance use problems. and substance use problems. – HousingHousing– WorkWork– ActivityActivity– Supportive peer groups Supportive peer groups

Relapse can’t be prevented, but risks of lapse can be minimised.Relapse can’t be prevented, but risks of lapse can be minimised. Interventions aim to equip the person with:Interventions aim to equip the person with:

– an awareness of their own personal triggers to lapse.an awareness of their own personal triggers to lapse.– appropriate skills (e.g. assertiveness trainingappropriate skills (e.g. assertiveness training))– contingency strategies to cope with such triggers. contingency strategies to cope with such triggers. – Self help groups.Self help groups.

Interventions For Relapse Interventions For Relapse Prevention StagePrevention Stage

Supported or independent employmentSupported or independent employment Independent housingIndependent housing Family problem solvingFamily problem solving Self helpSelf help Peer support groupsPeer support groups Social skills trainingSocial skills training

Exercise 1: Your relapsesExercise 1: Your relapses

Discuss in pairs: (10 minutes)Discuss in pairs: (10 minutes) Think about a behaviour you changed, that Think about a behaviour you changed, that

you relapsed back into (e.g. stopping you relapsed back into (e.g. stopping smoking, starting regular exercise etc)smoking, starting regular exercise etc)

What triggered the relapse? What triggered the relapse? How did you feel about the relapse? How did you feel about the relapse? What happened as a result? What happened as a result? How did other people react to your relapse?How did other people react to your relapse?

Marlatt & Gordon Model of Relapse Marlatt & Gordon Model of Relapse PreventionPrevention

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 ModelMarlatt & 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 relapseRisks for relapse

Lifestyle Imbalance – “shouldn’t > want to”, “duty vs. Lifestyle Imbalance – “shouldn’t > want to”, “duty vs. Pleasure”Pleasure”

Desire for Indulgence/ Feeling of DeprivationDesire for Indulgence/ Feeling of Deprivation Cravings & UrgesCravings & Urges Rationalisation/ JustificationRationalisation/ Justification Seemingly Irrelevant Decisions – series of “mini-decisions” Seemingly Irrelevant Decisions – series of “mini-decisions”

that take a person into a High-Risk Situationthat take a person into a High-Risk Situation High-Risk Situation – “downers”, “rows” and “join the club”High-Risk Situation – “downers”, “rows” and “join the club”

Relapse and Dual DiagnosisRelapse and Dual Diagnosis

Relapse is highly likelyRelapse is highly likely Change is very hard to maintain due to Change is very hard to maintain due to

complexity of problemscomplexity of problems Workers need to remain positive when Workers need to remain positive when

lapses occur (Therapeutic optimism)lapses occur (Therapeutic optimism) Help person to think about why it happened Help person to think about why it happened

and what could help in the futureand what could help in the future

Factors Associated with Factors Associated with RecoveryRecovery

Positive factors:Positive factors: Social support networksSocial support networks Stable living situationStable living situation Safe, structured environmentSafe, structured environment Sense of purpose – job/hobbiesSense of purpose – job/hobbies Therapeutic discussionTherapeutic discussion Practical helpPractical help Insight & awarenessInsight & awareness Physical well-beingPhysical well-being Medication (maximum Medication (maximum

effectiveness, minimal effectiveness, minimal inconvenience and side-effectsinconvenience and side-effects

HopeHope

Negative factors:Negative factors: Difficulties with any of the Difficulties with any of the

+ve factors+ve factors Excessive stressExcessive stress Interpersonal conflictInterpersonal conflict Substance useSubstance use Persistent symptomsPersistent symptoms

SheilaSheila Diagnosis? Schizophrenia? Psychotic/ korsakoffs/ borderline/ Diagnosis? Schizophrenia? Psychotic/ korsakoffs/ borderline/

psychotic depression/ alcohol hallucinosispsychotic depression/ alcohol hallucinosis Concerns-relapse of drinking, worsening depression, suicidality, not Concerns-relapse of drinking, worsening depression, suicidality, not

stable, accidental harm, agitated and irritablestable, accidental harm, agitated and irritable Alcohol team and community team; how much can she take; one Alcohol team and community team; how much can she take; one

worker ideally to look across all problems, or 2 workers; goal setting for 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; here and now issues, abuse issues are more of a long term plan; assertively engage her, not enough to offer appointments; inpatient assertively engage her, not enough to offer appointments; inpatient admission? Or close monitoring, Review anti-depressants,admission? Or close monitoring, Review anti-depressants,

Timeline- review history, decision matrix; motivational interviewingTimeline- review history, decision matrix; motivational interviewing Structure to day- turning point- social inclusion- housing, training, Structure to day- turning point- social inclusion- housing, training,

education, work experience, outreach education, work experience, outreach

Application to practiceApplication to practice

Think about how you are using the course in Think about how you are using the course in practicepractice

What will you need to modify/adaptWhat will you need to modify/adapt Other learning needs?Other learning needs? Where next?Where next?