Relapse Prevention and Response in Drug Court: Terrence D Walton, MSW, ICADC Director of Treatment Pretrial Services Agency for the District of Columbia

Relapse Prevention and Relapse Prevention and Response in Drug Response in Drug

Court:Court:

Terrence D Walton, MSW, ICADC

Director of Treatment

Pretrial Services Agency for the District of Columbia

Copyright 2011 by Terrence D. Walton. All Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational rights reserved. Non-commerical educational

use allowed. use allowed.

True or False?True or False?Research shows that even Research shows that even while in treatment, some while in treatment, some addicted people can only addicted people can only

stay clean a couple of days stay clean a couple of days before relapsing.before relapsing.



The 1The 1stst Big Question Big Question

Is it “Is it “relapserelapse” or ” or ““continued usecontinued use”?”?



Defining RelapseDefining Relapse1.1. When a person in When a person in recoveryrecovery returns to the returns to the

self-prescribed, non-medical use of any self-prescribed, non-medical use of any mood altering chemical (MAC) and the mood altering chemical (MAC) and the risk of the problems associated with that risk of the problems associated with that use use

2.2. The return to use after a period of The return to use after a period of abstinence that interrupts the addicts abstinence that interrupts the addicts ongoing attempts to ongoing attempts to recoverrecover

3.3. A return to drug use that is precipitated A return to drug use that is precipitated by and/or leads to lessening of by and/or leads to lessening of commitment to commitment to recoverrecover



Defining RecoveryDefining RecoveryIn 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 2The 2ndnd Big Question Big Question

Is it a “Is it a “slipslip” or a ” or a ““relapserelapse”?”?



A SlipA Slip Initial episode of alcohol or other drug use Initial episode of alcohol or other drug use

after a period of recovery/remissionafter a period of recovery/remission Does not indicate or precipitate a Does not indicate or precipitate a

lessening in lessening in commitment to changecommitment to change Can end quickly or lead to a relapse of Can end quickly or lead to a relapse of

varying degreesvarying degrees



SlippingSlipping

Neither a slip, nor relapse is accidentally Neither a slip, nor relapse is accidentally usingusing

Both are willful decisions to use Both are willful decisions to use SlipSlip = Set Back = Set Back RelapseRelapse = Collapse = Collapse SlipSlip = Rapidly restored commitment to = Rapidly restored commitment to

changechange RelapseRelapse = Recycling back through = Recycling back through

change stageschange stagesCopyright 2011 by Terrence D. Walton. All Copyright 2011 by Terrence D. Walton. All

rights reserved. Non-commerical educational rights reserved. Non-commerical educational use allowed. use allowed.

Two SecretsTwo Secrets

1.1. ““No use”No use” doesn’t mean you’re in doesn’t mean you’re in recoveryrecovery

2.2. ““Use”Use” _________________________ _________________________



ResearchResearch1.1. Studies show Studies show relapse rates of 40% to 60% relapse rates of 40% to 60% at at

one year follow-upone year follow-up

2.2. Most relapses occur in the first year of Most relapses occur in the first year of recovery, with two thirds occurring in the first recovery, with two thirds occurring in the first 90 days90 days

3.3. Clients who remain in treatment longer Clients who remain in treatment longer generally have the better outcomesgenerally have the better outcomes



CausesCauses Pretreatment FactorsPretreatment Factors

Degree of substance dependenceDegree of substance dependence Co-occurring disordersCo-occurring disorders Combat related traumaCombat related trauma

Treatment FactorsTreatment Factors Type, length and quality of treatmentType, length and quality of treatment

Post Treatment FactorsPost Treatment Factors Family/social supportsFamily/social supports Social/coping SkillsSocial/coping Skills



Impact on the IndividualImpact on the Individual

Relapse is a persistent risk in Relapse is a persistent risk in recoveryrecovery

Consequences may include:Consequences may include: Return to active useReturn to active use Criminal behaviorCriminal behavior Physical, social, or emotional Physical, social, or emotional

collapsecollapse Re-commitment to recoveryRe-commitment to recovery



RelapseRelapse

An unfolding process in which the An unfolding process in which the resumption of substance abuse is resumption of substance abuse is the last event in a long series of the last event in a long series of

maladaptive responses to internal or maladaptive responses to internal or external stressors or stimuliexternal stressors or stimuli



WHAT IS RELAPSE PREVENTION?WHAT IS RELAPSE PREVENTION?

Therapy designed to teach people to Therapy designed to teach people to engage in recovery-supportive activities engage in recovery-supportive activities and to recognize, anticipate, and manage and to recognize, anticipate, and manage the relapse warning signs so that they the relapse warning signs so that they can interrupt the relapse process early can interrupt the relapse process early and return to the process of recovery. and return to the process of recovery.



Relapse Prevention Planning

1.1. Written, specific, and rehearsed plansWritten, specific, and rehearsed plans2.2. Reiterates commitment to and Reiterates commitment to and

rationale for recoveryrationale for recovery3.3. Outlines and schedules recovery Outlines and schedules recovery

supportive activitiessupportive activities4.4. Identifies warning signs, cues, and Identifies warning signs, cues, and

high risk situations (triggers)high risk situations (triggers)5.5. Details preventive and progressive Details preventive and progressive

responses to all triggersresponses to all triggers



A Big ResourceA Big Resource

National Registry of Evidenced-based National Registry of Evidenced-based Programs and Practices:Programs and Practices:

www.nrepp.samhsa.gov

““Relapse Prevention Relapse Prevention Therapy”Therapy”



Traffic Signal ApproachTraffic Signal Approach



Green Light Problems– Failing to engage fully in recovery-supportive activities

1. Skipping or coming late to meetings2. Neglecting spiritual activities and

readings3. Skipping work or cutting class4. Failing to plan and participate in

leisure activities5. 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 recall3. Holidays, celebrations; vacations, and other

“down-time”; Sleeping (using dreams)4. Dishonesty, greed, or having extra money5. Feeling depleted, deprived, entitled or exhausted6. Sobriety milestones7. Re-entering from institutions



Red Light Problems– Situations to avoid, persistently resist, and/or requiring urgent

external support

1. Offers to use or drink2. Persistent cravings, urges, or euphoric recall3. Feeling hopeless, like giving up, or not

caring4. Euphoric recall5. Sudden, unexpected external triggers

(sound, sight, smell, taste, sensation)6. Trauma reactions7. A slip



Relapse Response Planning

1.1. Written & specific plansWritten & specific plans

2.2. Detailing immediate post-use actionsDetailing immediate post-use actions

3.3. Full disclosureFull disclosure Who is to be informed immediatelyWho is to be informed immediately Program to be informed at first opportunityProgram to be informed at first opportunity

4.4. Expected & accepted consequencesExpected & accepted consequences

5.5. Plan for re-evaluation and interventionPlan for re-evaluation and intervention



Honesty Matters

1.1. Participant lies about using even after Participant lies about using even after testing positive.testing positive.

2.2. Participant readily acknowledges using Participant readily acknowledges using after testing positive.after testing positive.

3.3. Participant acknowledges using before Participant acknowledges using before testing positive.testing positive.

4.4. Participant acknowledges thoughts of Participant acknowledges thoughts of using before doing so.using before doing so.



Responses to RelapseResponses to Relapse

1.1. Reassess Continued Use Potential and Change Reassess Continued Use Potential and Change ReadinessReadiness

2.2. Conduct Functional Analysis of RelapseConduct Functional Analysis of Relapse3.3. Determine Whether “Continued Use”, “Slip”, Determine Whether “Continued Use”, “Slip”,

“Relapse”“Relapse”4.4. Apply Planned Court-related or Supervision-Apply Planned Court-related or Supervision-

Related Responses (e.g. sanction, phase freeze, Related Responses (e.g. sanction, phase freeze, staffing)staffing)

5.5. Apply Planned Clinical Responses (e.g., enhancing Apply Planned Clinical Responses (e.g., enhancing treatment, increase drug/alcohol testing)treatment, increase drug/alcohol testing)

6.6. Re-stabilize and Re-engage (e.g. detoxification, Re-stabilize and Re-engage (e.g. detoxification, treatment readiness); Re-instill hopetreatment readiness); Re-instill hope



Program Response TipsProgram Response Tips

1.1. ““Continued use” or dishonesty usually Continued use” or dishonesty usually sanctioned more severely than a readily sanctioned more severely than a readily acknowledged “relapse/slip”acknowledged “relapse/slip”

2.2. Relapse prevention and response Relapse prevention and response planning should be implemented early in planning should be implemented early in the treatment processthe treatment process

3.3. Prepare to respond to repeated Prepare to respond to repeated “continuing use” or relapses/slips in some “continuing use” or relapses/slips in some participants, especially early in treatment participants, especially early in treatment




Court:Court:

BONUS SLIDES



8 Relapse Precipitating Variables8 Relapse Precipitating Variables1.1. Affective variablesAffective variables —e.g. depression, —e.g. depression,

anxietyanxiety

2.2. Behavioral variablesBehavioral variables —e.g. inadequate —e.g. inadequate coping skills or leisure management coping skills or leisure management skillsskills

3.3. Cognitive variablesCognitive variables —e.g. attitudes and —e.g. attitudes and beliefs about recovery/relapse; self beliefs about recovery/relapse; self efficacyefficacy

4.4. Environmental and relationship variablesEnvironmental and relationship variables —e.g. lack of social support, poor role —e.g. lack of social support, poor role models, social pressures to usemodels, social pressures to use



8 Relapse Precipitating Variables8 Relapse Precipitating Variables

5.5. Physiological variablesPhysiological variables —post acute —post acute withdrawal, cravings, pain, medication withdrawal, cravings, pain, medication useuse

6.6. Psychological/psychiatric variablesPsychological/psychiatric variables —level —level of motivation to change, co-occurring of motivation to change, co-occurring disorderdisorder

7.7. Spiritual variablesSpiritual variables —excessive guilt or —excessive guilt or shame, feeling empty, meaninglessnessshame, feeling empty, meaninglessness

8.8. Treatment system variablesTreatment system variables —clinician’s —clinician’s knowledge and skills; access to needed knowledge and skills; access to needed services; quality and appropriateness of services; quality and appropriateness of interventionsinterventions



How to helpHow to help

1.1. Help clients anticipate their high risk relapse Help clients anticipate their high risk relapse factors and develop strategies to manage factors and develop strategies to manage them.them.

2.2. Help clients identify and manage relapse Help clients identify and manage relapse warning signs.warning signs.

3.3. Help clients identify feelings and manage Help clients identify feelings and manage negative emotions.negative emotions.

4.4. Help clients identify and prepare to handle Help clients identify and prepare to handle direct and indirect social pressure to use.direct and indirect social pressure to use.

5.5. Help clients improve their interpersonal Help clients improve their interpersonal communications and relationships and to communications and relationships and to develop a recovery support system.develop a recovery support system.




6.6. Assess clients for psychiatric conditions and Assess clients for psychiatric conditions and facilitate treatment.facilitate treatment.

7.7. Help clients understand and manage their Help clients understand and manage their cravings to use, as well as cues that trigger cravings to use, as well as cues that trigger cravings.cravings.

8.8. Help clients identify and manage patterns of Help clients identify and manage patterns of thinking that increase relapse risk.thinking that increase relapse risk.

9.9. Help clients work toward a more balanced Help clients work toward a more balanced lifestyle.lifestyle.

10.10. Include pharmacologic interventionsInclude pharmacologic interventions




11.11. Facilitate transition between levels of care Facilitate transition between levels of care

12.12. Incorporate strategies to improve adherence Incorporate strategies to improve adherence to treatmentto treatment

13.13. Prepare clients to interrupt lapses and Prepare clients to interrupt lapses and relapses as early as possible; Relapse relapses as early as possible; Relapse Response PlanningResponse Planning



Green Light ProblemsGreen Light Problems– Failing to engage fully in – Failing to engage fully in recovery-supportive activitiesrecovery-supportive activities

1. Skipping or coming late to meetings2. Neglecting recovery related readings3. Isolating from supportive people4. Neglecting spiritual activities and readings5. Skipping work or cutting class6. Failing to plan and participate in leisure

activities7. Neglecting physical exercise8. Avoiding the doctor, dentist, or therapist9. Failing to eat well10. Refusing to confide in trustworthy others



Yellow Light ProblemsYellow Light Problems– Situations requiring caution, – Situations requiring caution, extra support, and/or prompt resolutionextra 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 recall3. Holidays, vacations, and other moments of

celebration4. Life instability, conflicts, drama, or crisis5. Experiencing loss, grief, or illness; emotional or

physical pain6. Dishonesty, greed, or having extra money7. Focusing on someone else’s problems8. Feeling depleted, deprived, entitled or exhausted9. Defensiveness, argumentative, or defiant10. Sobriety milestones



Red Light ProblemsRed Light Problems– Situations to avoid, persistently – Situations to avoid, persistently resist, and/or requiring urgent external supportresist, and/or requiring urgent external support

1.1. Offers to use or drinkOffers to use or drink2.2. Encountering old using associates or areasEncountering old using associates or areas3.3. Persistent cravingsPersistent cravings4.4. Doubting the need to avoid use all togetherDoubting the need to avoid use all together5.5. Feeling hopeless, like giving up, or not caringFeeling hopeless, like giving up, or not caring6.6. Euphoric recallEuphoric recall7.7. Obsessive use-related thoughts or negative Obsessive use-related thoughts or negative

feelings after having a using dreamfeelings after having a using dream8.8. Unexpected external triggers (sound, sight, smell, Unexpected external triggers (sound, sight, smell,

taste, sensation)taste, sensation)9.9. Trauma reactionsTrauma reactions10.10. A slipA slip




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Relapse Prevention and Response in Drug Court: Terrence D Walton, MSW, ICADC Director of Treatment Pretrial Services Agency for the District of Columbia