Transcript File

AN OVERVIEW OF RELAPSE
PREVENTION
1
LUIS LABOY, MPA, CASAC
DEFINITIONS, PERSPECTIVES, AND THE PSYCHO EDUCATIONAL
RELAPSE PREVENTION MODEL
2
GOAL: Participants will gain an understanding of historical perspectives
of relapse definitions, the basic problems associated with reported
relapse/recovery rates, a multi-perspective view of relapse prevention,
and the psycho educational model of relapse prevention.
OBJECTIVES: Upon completion of this section participants will be able
to:
1. Describe the traditional definition of relapse.
2. Discuss definitions of relapse with a historical perspective.
3. Discuss at least two problems with relapse/statistics.
4. Identify at least three systems which have an impact on relapse.
5. Describe at least three variables associated with client relapse.
6. Discuss the Psycho educational model of relapse prevention.
Goal of addiction treatment and relapse definitions
3
 The primary goal of addictions treatment, as in other areas of medicine,
is to help the patient to achieve and maintain long-term remission of
disease. In the addictions field there has been continuing and growing
concern among clinicians about the rates of relapse in the client
population. For this reason, it is important to understand the issue of
relapse and relapse prevention.
 WHAT STATISTICS DO YOU REPORT TO CLIENTS?
STATISTICS
4
1980 classic AA survey (25,000 individuals) found relapse rate of 60% for those
sober under one year, drops to 10% for those with 5 or more years of sobriety.
1980 AA-50% of newcomers to AA drop out within one month. Of the remaining
50%, 41% were attending a year later.
1982 Gorski reported that 60% of those clients treated privately relapsed.
1989 NIAAA reported 90% of alcoholics will have one relapse over the four year
period following treatment.
BE CAUTIOUS DUE TO POSSIBLE ERRORS IN VARIOUS STATISTICS
REPORTED.
5
 No standard measure
 Different treatment populations
 Cumulative effects of multiple treatments over time
is difficult to measure.
 Individuals with dependence vary significantly in
length and severity of dependence and related
physical, psychological, social, familial, and spiritual
problems.
DEFINITION OF RELAPSE
6
To fall back or revert to a former state , regress after a period of recovery from
illness, to slip back to bad ways.
A tendency to revert back to criminal behavior.
Relapse was initially viewed as use of alcohol, then expanded to include the use of
any sedatives. In the 1960’s it was expanded to include use of any mind altering
substances.
In the 1980’s relapse started to be viewed as a process, not the event of drinking
and drugging.
FIVE PERSPECTIVES ON RELAPSE
SEE HANDOUT PP 2-4
Perspective 1- The Chemically Dependent Person
7
 This involves understanding relapse from the point of view of the client
which involves:



Gaining insight into the experience and impact of relapse (Learn from it).
Identifying relapse triggers(internal and external).
Knowing relapse prevention skills. (PP &T, saying no…)
Relapse is confusing to the client and it does occur with those who are motivated to
change.
Twelve step programs like AA and NA address relapse in their literature.
Relapse occurs due to the interaction of many variables including;
affective; behavioral; cognitive; environmental; relationship;
physiological; psychiatric; and spiritual.
8
AFFECTIVE VARIABLES: + and – mood states have an impact on relapse
BEHAVIORAL VARIABLES: few effective ways to deal with situations that
threaten sobriety. There is a positive correlation between abstinence and the
acquisition of coping skills. Clients need to be taught alternative coping skills to
increase ability to manage high risk situations.
COGNITIVE VARIABLES: attitude towards addiction and recovery.
 Self-efficacy or the persons perception of his or her ability to cope with
prospective high risk situation.
 Outcome expectancy or anticipated effects of picking-up.
 Attribution of casualty which determines whether a lapse will eventuate in a full
blown relapse.
 Decision making.
 Level of cognitive functioning.
 Learning differences.
 Head Trauma.
Relapse occurs due to the interaction of many variables including;
affective; behavioral; cognitive; environmental; relationship;
physiological; psychiatric; and spiritual. Cont.
9
ENVIRONMENTAL AND RELATIONSHIP VARIABLES:
 The lack of social and family stability.
 Primary relationships with people who are addicted. (partners)
 Social pressure to use.
 Major life changes.
 Lack of productive work, school roles, involvement in leisure or
recreational activities.
PHYSIOLOGICAL VARIABLES:
 craving and conditioned responses elicited by environmental cues.
 Brain chemistry.
 Diet, medications, illness or physical pain.
 Severity of dependence.
 H.A.L.T.
Relapse occurs due to the interaction of many variables including;
affective; behavioral; cognitive; environmental; relationship;
physiological; psychiatric; and spiritual. (Cont.)
10
PSYCHIATRIC VARIABLES: Coexisting psychiatric disorder.
 A second compulsive DO.
 PTSD-combat, rape, child sexual abuse, parental violenece
SPIRITUAL VARIABLES:
 Self-centeredness
 Guilt
 Shame
 lack of meaning for life
 Feeling empty.
PERSPECTIVE 2- THE FAMILY
11
Family can provide an important and positive role in recovery or family
can sabotage recovery.
Relapse affects the family in several ways. The effects are mediated by:
 The nature of relapse (length, severity, medical/behavioral/legal and or
economic problems it causes).
 Family members’ perception of recovery and relapse, and reason for
relapse.
PERSPECTIVE 3- THE ADDICTIONS PROFESSIONAL
12
 The counselors knowledge of addiction, recovery and relapse are





variables affecting the relapse process.
Failure to thoroughly educate their patients about the relapse process
and ways to avoid it.
Poor therapeutic relationship-not engaging the client, canceling
appointments.
Negative feelings towards the client.
Enabling-minimizing or bying into clients defenses.
Failure to make an appropriate referral such as mental health,…
PERSPECTIVE 4 – TREATMENT SYSTEM
13
 Tx. Process-length of time in treatment , completion,
number of episodes, modalities, individualized tx. Plan.
Treatment system factors include:
 Length of waiting list.
 Lack of aftercare services.
 Lack of family services or failure to engage family.
 Limited availability of residential sources.
 Failure to address long term tx. Needs.
PERSPECTIVE 5- OTHER SYSTEMS
14
VIRTUALLY ANY COMMUNITY SYSTEM CAN CONTRIBUTE TO
CLIENT RELAPSE.
 Prescription medications
 Mental Health service provider ignoring addiction.
 Managed care provider denying payment or limiting services
Relapse can best be understood by viewing it from a
number of perspectives since it is a complex process.
Exercise
HOW DO YOU VIEW RELAPSE.
15
 Who’s fault is it?
 Who needs treatment?
 Does Treatment work?
 What are the views of 12 step/Self Help Groups?
DSM-IV TR
SUBSTANCE DEPENDENCE COURSE SPECIFIERS
16
Substance dependence is conceptualized as having different degrees of
remission. The remission specifiers can be applied only after one of the criteria
for Substance Dependence have been present for at least one month. The
specifiers do not apply to individuals “On Agonist Therapy or In A Controlled
Environment.
 Early Full Remission. Used if for at least 1 month but less than 2
months, no criteria for dependence or abuse have been met.
 Early Partial Remission. Used if for at least 1 month, but less than 2
months, one or more criteria for dependence or abuse have been met.
(but the full criteria for dependence have not been met)
 Sustained Full Remission. Used if none of the criteria for
Dependence or Abuse have been met at any time during a period of 12
months or longer.
 Sustained Partial Remission. Used if full criteria for Dependence
have not been met for a period of 12 months or longer; however, one or
more criteria for Dependence or Abuse have been met.
RELAPSE PREVENTION TREATMENT MODELS
Dennis Daley’s Psycho educational Model of Relapse Prevention
17
The goals for this model are :
 to provide information on topics relevant to relapse prevention and
intervention to clients in early recovery.
 To help instill in clients the attitude that sobriety and relapse
prevention are ongoing processes requiring long term commitment to
working a program for change.
 To introduce clients to cognitive/behavioral coping strategies and assist
them in dealing with high risk factors.
 To motivate clients into developing a relapse prevention plan based on
their unique experiences.
 To help clients learn how to interrupt an actual relapse should one
occur.
Daley used developed this model in groups with a workbook in a
residential setting.
Dennis Daley’s Psycho educational Model of Relapse Prevention
GROUP STRUCTURE AND CONTENT
18
Session 1: UNDERSTANDING THE RELAPSE PROCESS:
 Help clients understand relapse as a process and event.
 With use of actual relapse experience clients are taught cues and warning
signs.
 Emphasis is on how clients set themselves up.
 Examine time frame from emergence of symptoms to alcohol/drug use. Also
the when, where and who was involved.
 Devise positive coping strategies in small groups then share in the large
community to teach new clients.
 This material is adaptable to individual and family sessions.
Session 2 & 3: Identifying & handling High Risk Situations:
 Help clients anticipate potential problems or high risk factors and develop a
strategy. Situations to be reviewed include: negative feelings and thoughts,
social pressures, treatment related problems, urges, cravings, and other high
risk situations.
Dennis Daley’s Psycho educational Model of Relapse Prevention
GROUP STRUCTURE AND CONTENT
19
Session 4: Identifying and Handling Urges or Cravings to use Alcohol or
Drugs.
 Help client understand cravings is normal.
 Help recognize internal & external triggers.
 Establish craving management strategies to include:







Labeling the craving and accepting it is normal.
Putting conflicts with cravings into words and talking about them with others.
Using self-talk procedures to change thoughts and talk oneself through the craving.
Evaluating potential negative consequences of giving in to craving.
Reminding oneself of the benefits of abstinence.
Avoiding situations that would exacerbate the cravings.
Maintaining a written craving journal.
Dennis Daley’s Psycho educational Model of Relapse Prevention
GROUP STRUCTURE AND CONTENT
20
Session 5: Identifying and Handling Social Pressure to Use
Substances.
 Identify social pressures.
 Utilize role plays to practice skills.
 Evaluate for AOD dependence with significant others-utilize IC or other
groups for additional support.
Session 6: Anger Management:
 Help clients understand the connection between anger and relapse.
 The problem solving process can involve the following steps:





Learn to recognize one’s anger
Identify factors contributing to these feelings.
Identify effects on self and others.
Review alternative methods of handling anger.
Anticipate positive outcomes of utilizing new responses.
Dennis Daley’s Psycho educational Model of Relapse Prevention
GROUP STRUCTURE AND CONTENT
21
Session 7: Handling Boredom and Using Leizure Time.
 Help clients understand how boredom can impact the relapse process,
identify sources of boredom and the most difficult times of the week or
day.
 Identify leisure interests.
Session 8: Stopping Actual Relapse. (Learn from past relapses)
 Factors associated with relapse
 Warning signs
 Specific thoughts/feelings following the first use.
SECTION II
THE COGNITIVE BEHAVIORAL MODEL OF RELAPSE PREVENTION
22
Goal: Participants will gain a basic understanding of the
cognitive behavioral model of relapse prevention.
Objectives: upon completion of this section participants will
be able to:
Describe the cognitive behavioral definition of relapse.
2. Distinguish between a lapse and a relapse.
3. Describe at least 5 high risk situations.
4. Discuss the issue of a triple column technique.
1.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
23
This approach is a self-control program designed to teach individuals who
are trying to change their addictive behavior, how to anticipate relapse,
cope with it, and prevent it.
This model is not based on the disease model.
Theoretical assumptions:
 addictions are jointly caused by past learning, situational antecedents,
rewards and punishments, beliefs and biological influences.
 The behavior exist in a continuim between social drinking and
dependent drinking.
 Addiction is a maladaptive coping response to life stressors and
problems.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
SEE HANDOUT 8-9
24
With addiction it is useful to view habit change as a multi stage process. The
stages of change by Prochaska and DiClemente is a useful model in this
regard. They studied 900 individuals who gave up smoking, in term of the
process of change and the stages of change. They suggested that an
individuals willingness or preparedness to change would be directly related to
stages of change. And noticed relapse is common. The stages are as follows:
1.
Precontemplation Stage: the individual may not be aware that their
behavior is creating problems and it is not until acknowledgement of the
link between behavior and the problem that they enter the next stage. The
primary defense is denial.
2. Contemplation stage: at this point the individual begins to consider
altering their behavior. Ambivalence is common, “yes but” syndrome.
3. Determination Stage: the individual now makes a serious commitment to
action, this process may be gradual or sudden, but the individual will now
move either on to action back to contemplation.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
25
Action Stage: in this stage the individual makes a choice of strategy
for change and pursues treatment. This indicates a level of
acceptance.
5. Maintenance Stage: this is the real challenge in all of the
addictive/compulsive behaviors. This stage allows the individual to
maintain gains, continue growth, and prevent relapse.
6. Relapse: a very common phenomena. It is important to intervene as
early as possible to prevent further deterioration.
The cognitive behavioral relapse prevention model defines:
 Relapse: a violation of a self-imposed rules towards maintaining
recovery.
 Lapse as a single instance of violating the rule. Since lapse doesn’t
always lead to relapse, it is viewed as a transitional state which can be
valuable for learning.
4.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
26
THERE ARE TWO CONCEPTUAL COMPONENTS MATCHED BY
TWO CORRESPONDING TREATMENT COMPONENTS.
CONCEPTUAL COMPONENT 1: High Risk situation
Begins with the assumption that the individual voluntary chooses to adapt
a rule or set of rules for changing an addictive behavior. The person
experiences perceived control over the behavior until a high risk situation
(HRS) occurs. HRS is any situation which threatens perceived control and
increases the possibility of lapse or relapse.
 71% of relapses studied in 1980 were linked with one of three types of
situations:
1. negative emotional states.
2. interpersonal conflict.
3. social pressure to violate the rule set.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
27
CONCEPTUAL COMPONENT 1: High Risk situation (continued).
 According to CRP, the likelihood of relapse depends on the person’s
ability to cope with HRS.
If the person does lapse, the abstinence (rule) Violation Effect (AVE) was
postulated to depict how the person will react. AVE explains how a lapse
escalates to a relapse.
AVE has two elements:
1. The cognitive dissonence element- refers to the conflict ones prelapse
self-image and self image post lapse.
2. Personal Atribution-describes the tendency to attribute the cause of
the relapse to internal traits such as personal weakness or failure. It
can become a self-fulfilling prophesy if the person has a negative
belief system.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
28
Treatment Component1: Specific Intervention Techniques for HRSs.
If past lapse physical and psychological reactions are perceived as positive
relapse can result. (see handout p. 10).
A combination of behavioral and cognitive skills are taught to help clients deal
with HRS.
Assessment: Remains on going during entire treatment process. Organized
around HRS and skills assessment.
Assessment of HRS: must first identify and anticipate the situations.
Methods:
A. Collect background information
1.
Autobiography-rich source of information, paterns.
2.
Structured interview.(handout p11-13)
3. Relapse fantasies-describe imaged situations, dreams (Reservations).
4. Glow Line-charting alcohol/drug history.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
29
Treatment Component1: Specific Intervention Techniques for HRSs.
B. Self monitoring- keep records of amounts consumed, date, time,
circumstances, rate moods.
If abstinence-monitor cravings, circumstances, times, place, numerical
rating for intensity, rate mood before, during and after the urge.
Two weeks of data collection can quickly highlight influences and internal
states.
Assessment of preexisting coping abilities:
Tools- 1. “situational competency Test”by Chaney, O’leary and
Marlatt(1978). Client presented with a number of written or audio taped
descriptions of potential relapse situations and then needs to respond.
Response are then scored. (See handout P14)
2. Self-efficacy rating-also response to relapse situations. Results lead to
focus of skills training.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
30
Alternative Skills Training (see page 15)
CRP model now begins to teach that the client alternative ways to
cope with HRSs.
1. Risk Recognition – recognition is an important step towards
clients to developing a warning system. It is not always possible
to avoid HRS, so learning coping skills enables the individual to
get through difficult situations.
2. Remedial Skill Training- is the corner stone of the CRP
treatment. It addresses the individuals deficiencies in coping
skills. For instance, if the individual engages in addictive
behavior after an argument with a significant other than
remedial skill training could include:
1. COMMUNICATION SKILLS
2. ANGER MANAGEMENT SKILLS
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
31
Alternative Skills Training (see page 15) CONTINUED…
3. Urge Coping- clients must be prepared for the fact that
urges will occasionally occur:
A. one strategy is to let clients know that the urge does
not indicate treatment failure, but instead represents a
conditioned automatic reaction of either internal or
external cues.
B. Urges also vary in intensity and should not be
viewed
as a linear rise in discomfort. Urges are more
curvilinear. A useful metaphor is “urge surfing” urges are
like ocean
waves, which: rise, crest and fall.
Clients are encouraged to ride out the wave and maintain
balance without wiping out.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
32
3. Urge Copingc. Another cognitive strategy instructs the client to view the urge
with detachment as an external entity that can be defended off. A
useful metaphor is that of a samurai warrior whose task is to
become skilled at recognizing the urge and then fending off until it
decreases.
4. Behavioral Urge Coping Skills are useful in preventing and
managing urges.
 It may target an external cue such as a beer mug which can be
removed. Remove all paraphernalia associated with use.
 Utilize avoidance strategies (People, places and things).
 Label the urge- “here it comes again” (awareness)
 Break the continuity of the urge by changing seats, going for a
walk, calling a friend. It is not possible to think of two things at
the same time.
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
33
5. Coping with Lapse- the clients reaction to having a lapse is pivotal
intervention point in the CRP model because it can determine from a
single lapse if the client moves to full blown relapse. To assist clients in
this area:

Set a therapeutic contract to limit use if it occurs.
 Use cognitive restructuring to help client view the lapse as a mistake, not as an
irreversible failure.
 Utilize wallet cards for emergency plans- should include specific plans with names
and telephone numbers. The text of the wallet card can include the following
antidote:
 A single slip does not indicate full blown relapse.
 A single slip should be viewed as a reasonable mistake that can be evaluated and
learn from.
 A single slip may create disappointment. Do not focus on guilt and conflict that
can lead to further drinking.
 Blame should be placed on HRS and lack of coping skills, not personal weakness.
Conceptual Component II:
Covert antecedents of a relapse situation
34
An important question is: How does a person end up in a HRS?
It may be unexpected or concocted “Set-up”.
In covert antecedents analysis, lifestyle can lead to lapse. Daily routines and
obligations (shoulds) can lead to feelings of stress. Shoulds can lead to
feelings of deprivation. This in turn can lead to thoughts of “I owe myself a
few drinks”. Lifestyle imbalance can lead to the desire for immediate
gratification which can lead to urges/cravings.
CRP conceptual components analyze:
1.
How HRS lead to return to addictive behavior.
2. How people who set out to alter their behavior wind up in HRS.
Based on these analysis the CRP treatment procedures stress two goals
teaching people to:
 Cope effectively with HRS.
 Identify and respond to the early warning signals that steer them towards
HRS
MARLATT & GORDON’S RELAPSE PREVENTION MODEL
GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP)
35
 Treatment Component II-Global lifestyle intervention techniques
An imbalance of lifestyle is characterized by more shoulds (obligations
and duties) than wants (involvement in gratifying activities), which can
lead to a sense of deprivation, which can in turn lead to a desire for
immediate gratification (alcohol/drugs). The final thrust of the CRP
model is teaching the client to achieve and maintain a balanced lifestyle
that will promote mental and physical wellness (Inoculation against being
set up for relapse).
Recognition of lifestyle Balance.
Use of self-monitoring techniques to inventory wants and shoulds.
Daily inventories to record duties/obligations and fulfilling activities.
Discrepancies can be measured.
Treatment Component II-Global lifestyle intervention techniques
36
Restoring lifestyle balance
1.
Involvement in regular exercise, yoga, messages, manicures, dance, etc.
2. Enjoy social activities.
3. Other activities to induce positive feelings such as movies, cooking,
concerts, gardening, music, hobbies, drives.
4. Try new things clean.
Recognition of urges and apparently irrelevant discussions.
1.
Recognizes urges.
2. Utilize urge coping skills,
3. Assess “apparently irrelevant decisions”, such as keeping beer in the
refrigerator in case a friend stops over. These are decisions that place a
clients recovery at risk. Assist client in seeing distortions.
4. Clients can prepare a relapse road map that is metaphorically developing
a map of the journey from initial cessation to prolonged abstinence. This
will help him identify necessary adjustments needed.
The CENAPS Model of Relapse Prevention Planning
By Terrence Gorski (see handout p. 18)
37
The CENAPS relapse process begins when the individual begins to
become dysfunctional in recovery and ends in chemical use.
Assumption of the CENAPS Model of relapse:
7.
Recovery is the process of learning how to live a meaningful and comfortable
life without drugs.
Abstinence is a prerequisite for recovery.
Abstinence alone is insufficient for full recovery to occur.
The relapse progression begins long before the person starts using.
Relapse begins with internal and external dysfunction.
The dysfunction causes such severe pain and life problems that selfmedication may seem like a positive option. The client perceives four options:
insanity, suicide, physical collapse or self-medication.
Use is the last stop on the relapse progression.
8.
The client is usually out of control before drug use begins.
1.
2.
3.
4.
5.
6.
The CENAPS Model of Relapse Prevention Planning
By Terrence Gorski
38
Implications of the CENAPS Model
1.
2.
3.
4.
5.
6.
Treatment must focus on more than simply teaching the client how not to
use.
The long term task of recovery needs to be explained to the client so that he
has a road map to recovery.
Treatments needs to follow client over a long term continuum of recovery, for
a minimum of 3 to 5 years and it must be easily accessible to client who gets
stuck at some point in the recovery process.
People in recovery must learn to recognize and manage early warning signs.
Relapse needs to be viewed as a normal and natural part of recovery.
Specialized relapse prevention techniques needs to be developed for client
rethreads that have been unable to maintain abstinence.
SOBRIETY BASED SYMPTOMS OF ALCOHOLISM
39
Brain dysfunction occurs during periods of intoxication with both cellular death
and withdrawal. As the addiction progresses the client can experience brain
dysfunction that can create problems thinking clearly, managing feelings, memory
problems, sleep problems, increased stress and problems related to psychomotor
coordination. Sobriety based symptoms also present themselves in sobriety. There
are six major sobriety based symptoms of alcoholism:
1. ACUTE ABSTINENCE SYNDROME
 Central nervous system agitation
1. Hangover
2. Tremors
3. Convulsions within 24 hours
4. Hallucinations within 48 hours
5. DTs- about 72 hours after last drink.
 Internal anguish
SOBRIETY BASED SYMPTOMS OF ALCOHOLISM
40
Post-Acute withdrawal: is a bio-psycho-social syndrome. The term
refers to the damage done to the brain central nervous system
particularly the higher cortical regions of the brain. PAW is referred
to as neurotoxicity, sub-organic clinical disorder, “stinking thinking”
“dry drunk” prolonged abstinence syndrome, protracted withdrawal,
and BUD (Build up to drink). Over time it can get better or worst. The
symptoms may come during periods of high stress for the rest of the
patients lives.
Caused by chronic drug use. The symptoms include difficulty
thinking clearly, difficulty managing emotions and feelings, difficulty in
remembering things, difficulty sleeping restfully, difficulty in physical
coordination, and managing stress.
Treatment includes education to remove guilt, shame and fear.
Symptom identification and management. Reversal of predisposing
psychosocial stressors.
2.
SOBRIETY BASED SYMPTOMS OF ALCOHOLISM
41
State dependent learning: that which was learned in one state is
best recalled in that same state, and is difficult or impossible to
perform in a new state until new learning takes place.
4. Adjustment reaction to abstinence: reactions to lifestyle changes
needed in recovery, the changes in habits and daily routines to
become recovery focused rather than alcohol focused.
5. Denial: sobriety based, acceptance of the disease does not necessarily
interrupt all denial patterns, such as personal short comings or
personal problems, denial of the possibility of relapse, denial of the
need to change.
6. Cravings.
3.
THE DEVELOPMENTAL MODEL OF RECOVERY (DMR)
42
The DMR is a roadmap to recovery. All humans pass through
developmental stages from birth through infancy, childhood, adolescence
and adulthood. At the early stages we develop basic skills and then move
through more complicated tasks and skill building.
The DMR is composed of six stages (phases):
1. Pre-treatment-may take a period of months to years.
2. Stabilization- four to eight months.
3. Early Recovery-6 to 18 months.
4. Middle recovery- 12-18 months.
5. Late recovery- 18-24 months.
6. Maintenance- lifetime.
THE DEVELOPMENTAL MODEL OF RECOVERY (DMR)
(handout 24-26)
43
Pre Treatment Phase- theme is giving up the need to control use.
MAJOR TASKS
1.
Recognition of addictive disease, need for abstinence and begin recovery
process.
Stabilization Phases- theme is learning how to abstain.
MAJOR TASKS
1.
RECOVERY FROM ACUTE WITHDRAWALS.
2.
Stabilization of post acute withdrawals.
3.
Resolution of drug related crisis.
Early Recovery Phase- theme is learning to become comfortably clean.
MAJOR TASKS
1.
Compliance with externally regulated recovery program.
2.
Recognition and acceptance of addictive disease.
3.
Learning non-chemical coping skills.
4.
Developing a recovery oriented value system.
THE DEVELOPMENTAL MODEL OF RECOVERY (DMR)
(handout 24-26)
44
Middle Recovery- theme is developing a lifestyle balance.
Major Tasks
1.
Establishing a self-regulated recovery program.
2.
Re establishing major social structure: work, family, intimate, social.
Late Recovery- theme is growing up beyond childhood limitations.
Major Tasks
1.
Identify and correct childhood mistaken beliefs.
2.
Clarify adult value system.
3.
Develop new life goals and plans.
4. Maintenance- Continued growth and development.
Major Tasks
1.
Continued personal growth.
2.
Effective coping with day to day life problems and transitions.
3.
Maintain a recovery program.
CENAPS RELAPSE PREVENTION PLAN
(SEE HANDOUT P. 27)
45
This model incorporates a nine step process.
1. Stabilization: bring relapser back to detox. Identify and manage PAW
2. Assessment: of the presenting problems, current relapse dynamic,
relapse history, levels of treatment completed, unresolved DMR
issues, factors effecting recovery and personalitystyle.
3. Relapse education: recovery process, warning signs and understand
relapse patterns.
4. Warning sign identification: construct individualized list.
5. Warning sign management: teach client to interrupt the dynamic,
develop three strategies for each warning sign.
6. Review recovery Program: address problems that surfaced during
assessment, client may need more meetings, a sponsor or therapy.
CENAPS RELAPSE PREVENTION PLAN
(SEE HANDOUT P. 27)
46
7.
8.
9.
Inventory training: Gorski recommends two daily inventory
procedures. First establish a morning routine of outlining a plan for
the day. Secondly, in the evening, review the tasks of the day to see
what went well and what needs improvement.
Involvement of significant others: assess key players.(Significant
others) request what he would like from invited intervenors.
Follow-up: up date relapse prevention plan as needed.
Discuss counselor wellness, two hatters and causes of relapse.