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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
use allowed.
The 1st Big Question
Is it “relapse” or “continued use”?
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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.
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
The 2nd Big Question
Is it a “slip” or a “relapse”?
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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” _________________________
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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.
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
A Big Resource
National Registry of Evidenced-based Programs and Practices:
www.nrepp.samhsa.gov
“Relapse Prevention Therapy”
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
Traffic Signal Approach
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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.
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
Relapse Prevention and Response in Drug Court:
BONUS SLIDES
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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.
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
Relapse Prevention and Response in Drug Court:
Copyright 2011 by Terrence D. Walton. All rights reserved. Non-commerical educational
use allowed.
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.