Relapse Prevention and Response in Drug Court:

Relapse Prevention and Response in Drug Court:

Terrence D Walton, MSW, ICADCDirector of Treatment

Pretrial Services Agency for the District of Columbia

© Terrence Walton, January 25, 2011The 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.

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

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The 1st Big Question

Is it “relapse” or “continued use”?


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Defining Relapse1. 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


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Defining 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.


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The 2nd Big Question

Is it a “slip” or a “relapse”?


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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


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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 stagesCopyright 2011 by Terrence D. Walton. All

rights reserved. Non-commerical educational use allowed.

Two Secrets

1. “No use” doesn’t mean you’re in recovery

2. “Use” _________________________


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Research1. Studies show relapse rates of 40% to 60% at one

year follow-up2. Most relapses occur in the first year of recovery,

with two thirds occurring in the first 90 days3. Clients who remain in treatment longer generally

have the better outcomes


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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


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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


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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


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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.


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Relapse Prevention Planning

1. Written, specific, and rehearsed plans2. Reiterates commitment to and rationale

for recovery3. Outlines and schedules recovery

supportive activities4. Identifies warning signs, cues, and high

risk situations (triggers)5. Details preventive and progressive

responses to all triggers


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A Big Resource

National Registry of Evidenced-based Programs and Practices:

www.nrepp.samhsa.gov

“Relapse Prevention Therapy”


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http://www.nrepp.samhsa.gov/�

Traffic Signal Approach


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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


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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


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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


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Relapse Response Planning

1. Written & specific plans2. Detailing immediate post-use actions3. Full disclosure

Who is to be informed immediately Program to be informed at first

opportunity

4. Expected & accepted consequences5. Plan for re-evaluation and intervention


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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.


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Responses to Relapse

1. Reassess Continued Use Potential and Change Readiness

2. Conduct Functional Analysis of Relapse3. 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


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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


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BONUS SLIDES


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

anxiety2. 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


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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


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How to help1. 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.


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How to help6. 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


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How to help

11. Facilitate transition between levels of care 12. Incorporate strategies to improve adherence

to treatment13. Prepare clients to interrupt lapses and

relapses as early as possible; Relapse Response Planning


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Green Light Problems– Failing to engage fully in recovery-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


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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 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


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

1. Offers to use or drink2. Encountering old using associates or areas3. Persistent cravings4. Doubting the need to avoid use all together5. Feeling hopeless, like giving up, or not caring6. Euphoric recall7. Obsessive use-related thoughts or negative

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

taste, sensation)9. Trauma reactions10. A slip


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[email protected]


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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.

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