Adult Assessment & Intervention with Substance Abuse

5. Relapse Prevention and Relapse Management

Relapse should be viewed as a normal part of change and an opportunity for new learning. Rather than relying on client will-power, relapse prevention training emphasises skill-power.

Following are prevention and management strategies to maximise the possibility of maintaining successful change.  Change can refer to reducing or stopping drug use, reducing harms associated with drug use or improvements to general well-being.

Seven Relapse management steps

1. Enhance resolution to change

• Relapse prevention begins at the beginning of intervention with a meaningful assessment process and clear goal setting. Goal setting can be enhanced by:
• Motivational interviewing
• Writing down goals and putting them in a prominent place
• Having both short-term and longer-term goals
• Making the commitment public - telling drug using and other friends & family
• Knowing the rewards of change and the costs of not changing

2. Maximise the possibility of change

• Provide the best chance for change by:
• Identifying the helps and hinders of change
• Work with client to enhance helps and reduce hinders
• Maximise external supports
• Focus on those behaviours which replace and compete with problematic drug use (eg if drugs are used to manage relationship problems, provide relationship enhancement skills - provide positive alternatives such as recreation, vocational training).
• Support environmental change (eg accommodation, employment & recreation opportunities).

3. Manage high risk triggers/situations

• Just the process of identifying situations which can undermine resolution to change may reduce their effect. Subsequent strategies to either avoid or manage these situations will help.
• It's useful to think of high risk triggers/situations using the Drug, Individual, Environment - DIE model:

  Drug - Availability, advertising, drug talk, use of a drug, etc.

  Individual - negative emotional states, celebrating, negative thinking, drug thoughts, etc.

  Environment - drug using friends, relationship/family problems, money (too much or too little) etc.

4. Steps in managing high risk situations

• Ask client to think of a times when they have either been very tempted to use or have used.
• Draw a scale of 1 to 10 and ask to categorise with 1 being least risky and 10 being most risky. (possibly prompt for situations from the DIE model if not many)
• Ask about situations which have been described where client successfully resisted temptation. List these as helps.
• Ask what was different when client did succumb to temptation and list as hinders.
• Identify the risky situations which were most likely to happen and problem solve solutions based on the helps and hinders already developed - the best solutions tend to be those which have already proven to be successful.
• Develop an action plan and if possible rehearse responses and actions where indicated.

5. Manage cravings and develop impulse control

Ask the client how he/she manages cravings and impulses.

Do more of what works.

Cravings and urges are normal and should be seen as a helpful warning sign. Explain that they are like a wave. Choices include being swept along by the wave out of control (giving in); going under the wave and letting it pass over; or riding the wave out (urge surfing). Skills required for dealing with cravings are relaxation, diversionary and escape techniques while the wave passes. Cue exposure (controlled exposure to triggers) can also be used by those with knowledge of this technique.

Impulses have been described as "A sudden tendency to act without reflection." It is not an impulse if:

Time - it is not sudden. Ask the client if the consequences of a relapse are important and if they will give at least 20 minutes before they act.

Act - explain that there is a big difference between having impulsive thoughts (which are common) and acting on impulses (which can be controlled). Get them to give examples where they have had thoughts but not acted on them.

Reflection - thinking about the short and longer term consequences may help. To assist, it can be helpful if the client carries around a reminder with them of what they have to lose (e.g. a photograph of their partner/child and/or a small decisional balance sheet with what they have to lose if they use and what they have to gain if they do not - see motivatinal interviewing).

Teach the 4 Ds:

Delay

Distract

Deep Breathing

Drink Water

Deep breathing and drinking water both assist to reduce anxiety and stress associated with cravings. As they also help to delay and distract, they are simple but powerful interventions.

6. Other skills

Provide further skills training to deal with negative symptoms:

Social pressure (assertiveness training)

Anxiety (anxiety and stress management)

Depression and Anger (depression and anger management interventions)

Relationship pressures (couples counselling)

General problems (problem solving & goal setting skills)

Develop positive life skills

Recreation training

Vocational training

6. Refusal Skills

Refusal skills are a specific set of skills related to dealing with social pressure. Once again, it is useful to find out from the client how they manage this. The following additional tips are only used if required so as not to undermine client self-efficacy:

Strong body language and confident tone of voice

Say 'no' first

Suggest alternative

Request the other to stop asking

Change the subject

Avoid excuses.

The client should practice with the counsellor being both a 'refuser' and a 'pusher'. If required, linking this training with assertion training will provide additional reinforcement.

(Refusal skills based on work by Monti, Abrams, Kadden, Cooney (1989) Treating Alcohol Dependence: A Coping Skills Training Guide (pp. 61-63). Guilford Press, New York)

7. Dealing with a Lapse or Relapse

Explain the difference between Lapse & Relapse:

Lapse = a brief slip or lapse in resolution

Relapse = reinstatement of former behaviour or collapse in resolution

Prepare the client for the possibility of a lapse or relapse. Using the analogy of a fire drill, (preparation, even though it may not happen) may help reassure the client of your faith in him/her. However, explain that trying new things may involve occasional mistakes which can be useful to learn from. Some key points to discuss:

One drink does not necessarily mean one drunk - or one 'hit' an addict (NB: caution if the client is following an AA or NA 12 step treatment plan)

Include in the 'fire emergency plan' someone to telephone or speak to as soon as possible.

Express your interest in discussing any lapses or relapses as part of mutual learning. Emphasise your availability in the event of a relapse.

Explain the consequences of a lapse or relapse in the context of statutory issues and their willingness to continue working on issues. If there are limits on degree and number of relapses regarding statutory issues, these should be restated.