Relapse Prevention Inservice VA Prescott

Relapse PreventionRelapse Prevention

VA Prescott VA Prescott

Guy C. Lamunyon MSN, RN, CASGuy C. Lamunyon MSN, RN, CAS(Certified Addiction Specialist) (Certified Addiction Specialist)

An evidence based practice for An evidence based practice for substance abuse treatment substance abuse treatment

Relapse PreventionRelapse Prevention

““Insanity: Insanity: doing the same thingdoing the same thing over and over over and over again again and expectingand expecting different results.” Albert different results.” Albert EinsteinEinstein

““The most predictable outcome from rehabilitation The most predictable outcome from rehabilitation is relapse.”is relapse.”

““If you don’t understand relapse, you don’t If you don’t understand relapse, you don’t understand addiction.” understand addiction.”

Relapse is part of recovery for severely relapse Relapse is part of recovery for severely relapse prone individualsprone individuals

AwardsAwards

HALL OF FAME – California Association of Alcohol HALL OF FAME – California Association of Alcohol and Drug Abuse Counselors (2002)and Drug Abuse Counselors (2002)

VA BEST PRACTICE – MHICM PROGRAM VA BEST PRACTICE – MHICM PROGRAM DEVELOPMENT (2003)DEVELOPMENT (2003)

SECRETARYS AWARD – Advanced Practice Nursing – SECRETARYS AWARD – Advanced Practice Nursing – VA Long Beach (2006) VA Long Beach (2006)

VA BEST PRACTICE – OIF/OEF Outreach – VA Head VA BEST PRACTICE – OIF/OEF Outreach – VA Head Nurse Conference Wash DC (2007)Nurse Conference Wash DC (2007)

Addiction Medicine Addiction Medicine SpecialistsSpecialistsJoseph Zuska – Navy Alcohol Rehabilitation ProgramsJoseph Zuska – Navy Alcohol Rehabilitation Programs

Paul Ohligher – ARS, DOCTOR, ALCOHOLIC, ADDICT Paul Ohligher – ARS, DOCTOR, ALCOHOLIC, ADDICT chapter in the AA Big Bookchapter in the AA Big Book

Max Schneider – CareManor and Educational VideosMax Schneider – CareManor and Educational Videos

Joseph Pursch – treated Betty Ford - author and Joseph Pursch – treated Betty Ford - author and columnistcolumnist

Walter Ling – Matrix Institute and research Walter Ling – Matrix Institute and research

PsychiatristsPsychiatrists

Robert Gerner – Mood Disorders ResearchRobert Gerner – Mood Disorders Research

William Wirshing – Schizophrenia/Medication William Wirshing – Schizophrenia/Medication DevelopmentDevelopment

Andrew Shaner – Dual Diagnosis ResearchAndrew Shaner – Dual Diagnosis Research

Stephen Marder – Schizophrenia, MIRECC22Stephen Marder – Schizophrenia, MIRECC22

Confrontational Styles Confrontational Styles and Outcome and Outcome

STYLE OUTCOMESTYLE OUTCOME

HIGHHIGH WORST WORST

MEDIUMMEDIUM IN BETWEEN IN BETWEEN

LOWLOW BEST BEST

Project MATCH OutcomeProject MATCH Outcome

Compared Motivational Enhancement Compared Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (MET), Cognitive Behavioral Therapy (CBT) and 12 Step Therapy (CBT) and 12 Step Facilitation (TSF).Facilitation (TSF).

Twelve Step Facilitation was slightly Twelve Step Facilitation was slightly but not significantly more effective but not significantly more effective than MET and CBTthan MET and CBT

Relapse by AddictionRelapse by Addiction

Relapse by diseaseRelapse by disease

Gorski/CENAPS Model Gorski/CENAPS Model (1982)(1982)

Marlatt Relapse Prevention Marlatt Relapse Prevention (1985)(1985)

Professor of Psychology at the Professor of Psychology at the University of Washington and Director of and Director of the Addictive Behaviors Research Center the Addictive Behaviors Research Center

http://en.wikipedia.org/wiki/University_of_Washington

Marlatt Mindfulness Based Marlatt Mindfulness Based Relapse PreventionRelapse Prevention

Marlatt: Harm Marlatt: Harm ReductionReduction

Relapse TheoryRelapse Theory

1. Relapse is part of the management of any 1. Relapse is part of the management of any chronic lifestyle related diseasechronic lifestyle related disease

2. It is unrealistic to expect a zero relapse 2. It is unrealistic to expect a zero relapse rate as an outcome standardrate as an outcome standard

3. It is realistic to3. It is realistic toA. To reduce the relapse rateA. To reduce the relapse rateB. Manage relapse episodes more efficient B. Manage relapse episodes more efficient

Critical indicators of effective Critical indicators of effective relapse managementrelapse management

1. Frequency. Occurring less often1. Frequency. Occurring less often

2. Duration. Getting shorter2. Duration. Getting shorter

3. Severity. Having fewer consequences3. Severity. Having fewer consequences

4. Getting less expensive to manage4. Getting less expensive to manage

The Phases and 37 Warning The Phases and 37 Warning Signs of RelapseSigns of Relapse

A Reliable & Valid Predictor of Alcohol Relapses

Miller, W. R., & Harris, R. J. (2000). A simple scale of Gorski’s warning signs for relapse. Journal of Studies on Alcohol, 61, 759-765.


Phase1: The Return of Denial Phase1: The Return of Denial

1. Concern about Well Being 1. Concern about Well Being

2. Denial of the Concern2. Denial of the Concern


Phase2: Avoidance and Defensive Phase2: Avoidance and Defensive Behaviour. Behaviour.

3. Believing “I’ll never drink again” 3. Believing “I’ll never drink again”

4. Worrying about Others Instead of Self 4. Worrying about Others Instead of Self

5. Defensiveness.5. Defensiveness.

6. Compulsive Behaviour. 6. Compulsive Behaviour.

7. Impulsive Behaviour.7. Impulsive Behaviour.

8. Tendencies towards Loneliness.8. Tendencies towards Loneliness.


Phase 3: Crisis Building. Phase 3: Crisis Building.

9. Tunnel Vision 9. Tunnel Vision

10. Minor Depression 10. Minor Depression

11. Loss of Constructive Planning11. Loss of Constructive Planning

12. Plans Begin to Fail12. Plans Begin to Fail


Phase 4: Immobilization Phase 4: Immobilization

13. Daydreaming and Wishful Thinking. 13. Daydreaming and Wishful Thinking.

14. Feelings that nothing can be solved. 14. Feelings that nothing can be solved.

15. Immature wish to be happy.15. Immature wish to be happy.


Phase 5: Confusion and Phase 5: Confusion and Overreaction. Overreaction.

16. Periods of confusion. 16. Periods of confusion.

17. Irritation with friends 17. Irritation with friends

18. Easily Angered18. Easily Angered


Phase 6: DepressionPhase 6: Depression

19. Irregular Eating Habits. 19. Irregular Eating Habits.

20. Lack of desire to take action20. Lack of desire to take action

21. Irregular sleeping habits21. Irregular sleeping habits..

22. Loss of daily structure.22. Loss of daily structure.

23. Periods of deep depression.23. Periods of deep depression.


Phase 7: Behavioural Loss of Control.

24. Irregular attendance at AA and Treatment meetings 25. Development of an “I don’t care” attitude. 26. Open Rejection of Help. 27. Dissatisfaction with life. 28. Feelings of powerlessness and helplessness


Phase 8: Recognition of Loss of control Phase 8: Recognition of Loss of control

29. Self Pity. 29. Self Pity.

30. Thoughts of social drinking.30. Thoughts of social drinking.

31. Conscious Lying.31. Conscious Lying.

32. Complete loss of self confidence.32. Complete loss of self confidence.


Phase 9: Option reduction Phase 9: Option reduction

33. Unreasonable Resentment. 33. Unreasonable Resentment. 34. Discontinuance of all 34. Discontinuance of all treatment and AA treatment and AA 35. Overwhelming Loneliness, 35. Overwhelming Loneliness, Frustration, Anger and Tension.Frustration, Anger and Tension.


Phase 10: Acute Relapse Episode. Phase 10: Acute Relapse Episode.

36. Loss of behaviour control. 36. Loss of behaviour control.

37. Acute Relapse Episode. 37. Acute Relapse Episode.


37. Acute Relapse Episode. 37. Acute Relapse Episode.

A. Degeneration of all life areas. A. Degeneration of all life areas. B. Alcohol or drug Use. B. Alcohol or drug Use. C. Emotional Collapse.C. Emotional Collapse.D. Physical Exhaustion D. Physical Exhaustion E. Stress Related Illnesses. E. Stress Related Illnesses. F. Psychiatric Illness. F. Psychiatric Illness. G. Suicide. G. Suicide. H.H. Accident Proneness.Accident Proneness. I.I. Disruption of Social Structure. Disruption of Social Structure.

Constructing a Personalized Constructing a Personalized Warning Sign ListWarning Sign List1. Check three to five warning signs from the list above 1. Check three to five warning signs from the list above

that you find most interesting for you. that you find most interesting for you.

2. In your own words, rewrite the summary title of the 2. In your own words, rewrite the summary title of the warning sign that you have checked. The summary warning sign that you have checked. The summary title is the word or short phrase at the beginning of title is the word or short phrase at the beginning of each warning sign. each warning sign.

3. Write a brief paragraph that describes in your own 3. Write a brief paragraph that describes in your own words each of the warning signs that you have words each of the warning signs that you have selected. selected.

4. Read your warning signs (as you have written them) to 4. Read your warning signs (as you have written them) to an addictions counsellor, your A.A. sponsor, or a friend, an addictions counsellor, your A.A. sponsor, or a friend, and ask for feedback. Rewrite the warning signs if they and ask for feedback. Rewrite the warning signs if they are unable to understand clearly what you mean. are unable to understand clearly what you mean.

Constructing a Personalized Constructing a Personalized Warning Sign ListWarning Sign List

5. Review the list every morning and every 5. Review the list every morning and every evening to remind yourself to look for the evening to remind yourself to look for the presence of these warning signs. presence of these warning signs.

6. Discuss the list with your friends and 6. Discuss the list with your friends and family and ask them to tell you if they see family and ask them to tell you if they see any of the warning signs appearing in your any of the warning signs appearing in your life. life.

7. If you notice a warning sign, evaluate 7. If you notice a warning sign, evaluate your need to get help. your need to get help.

Relapse AssessmentRelapse Assessment

1.1. Begin with a period of solid sobrietyBegin with a period of solid sobriety2.2. Review progression of relapse Review progression of relapse

warning signswarning signs3.3. Discuss the thoughts, feelings and Discuss the thoughts, feelings and

actions leading up to the first useactions leading up to the first use4.4. Determine relapse dynamicsDetermine relapse dynamics5.5. Educate client about their unique Educate client about their unique

relapse dynamicsrelapse dynamics

Development Model of Development Model of RecoveryRecovery

1.1. Tasks must be completed in orderTasks must be completed in order

2.2. Recovery task incompletion causes Recovery task incompletion causes “stuck points” in recovery“stuck points” in recovery

3.3. Stuck points in recovery may cause Stuck points in recovery may cause relapserelapse

4.4. Completing recovery tasks out of Completing recovery tasks out of order may cause relapseorder may cause relapse

Development Model of Development Model of RecoveryRecoveryActive Addiction: Active Addiction: During this stage During this stage

substance abusers are actively using substance abusers are actively using alcohol and other drugs, receiving alcohol and other drugs, receiving substantial perceived benefits from their substantial perceived benefits from their use, experiencing few perceived adverse use, experiencing few perceived adverse consequences, and as a result see no consequences, and as a result see no reason to seek treatmentreason to seek treatment

Prochaska/DiClemente Prochaska/DiClemente (Precontemplation):(Precontemplation):

Development Model of Development Model of RecoveryRecoveryTransition:Transition: During this stage patients During this stage patients

recognize that they are experiencing recognize that they are experiencing alcohol and drug related problems and alcohol and drug related problems and need to pursue abstinence as a life style need to pursue abstinence as a life style goal in order to resolve these problems.goal in order to resolve these problems.

Prochaska/DiClemente: ContemplationProchaska/DiClemente: Contemplation

Development Model of Development Model of RecoveryRecovery

Stabilization: Stabilization: During this stage During this stage patients recover from acute and post patients recover from acute and post acute withdrawal and stabilize their acute withdrawal and stabilize their psychosocial life crisis.psychosocial life crisis.

Prochaska/DiClemente: Prochaska/DiClemente: PreparationPreparation

Development Model of Development Model of RecoveryRecoveryEarly Recovery:Early Recovery: During this stage patients During this stage patients

identify and learn how to replace addictive identify and learn how to replace addictive thoughts, feelings, and behaviors with thoughts, feelings, and behaviors with sobriety-centered thoughts, feelings, and sobriety-centered thoughts, feelings, and behaviors.behaviors.

THEME: SELF AND SOBRIETYTHEME: SELF AND SOBRIETY

Prochaska/DiClemente: ActionProchaska/DiClemente: Action

Development Model of Development Model of RecoveryRecoveryMiddle Recovery:Middle Recovery: During this stage During this stage

patients repair the life style damaged patients repair the life style damaged caused by the addiction and develop caused by the addiction and develop a balanced and healthy life style.a balanced and healthy life style.

THEME: SELF AND SOCIETYTHEME: SELF AND SOCIETY


Development Model of Development Model of RecoveryRecoveryLate Recovery:Late Recovery: During this stage During this stage

patients resolve family of origin issues patients resolve family of origin issues which impair the quality of recovery which impair the quality of recovery and act as long-term relapse triggers and act as long-term relapse triggers (PTSD here). (PTSD here).

THEME: SELF AND HISTORYTHEME: SELF AND HISTORY


Development Model of Development Model of RecoveryRecoveryMaintenance:Maintenance: During this stage During this stage

patients continue a program of growth patients continue a program of growth and development and maintain an and development and maintain an active recovery program to assure active recovery program to assure that they don't slip back into old that they don't slip back into old addictive patterns.addictive patterns.

Prochaska/DiClemente: Prochaska/DiClemente: MaintenanceMaintenance

Addicted Self versus Sober Addicted Self versus Sober SelfSelf

Addicted Self versus Sober Addicted Self versus Sober SelfSelfADDICTED SELF – mean, angry, lonely, ADDICTED SELF – mean, angry, lonely,

greedy, hates for you to succeed, greedy, hates for you to succeed, always wants the easy way out, is always wants the easy way out, is interested in short-term kicks interested in short-term kicks regardless of the price, is willing to kill regardless of the price, is willing to kill you to get what it wants, doesn’t care you to get what it wants, doesn’t care about anyone or anything except about anyone or anything except getting more booze and drugs and is getting more booze and drugs and is angry when you get sober and try to angry when you get sober and try to stay that way. stay that way.


SOBER SELF – is intelligent, warm, SOBER SELF – is intelligent, warm, caring, sober, in touch with higher caring, sober, in touch with higher power, can be strong at times, feels power, can be strong at times, feels comfortable with your faults and comfortable with your faults and weaknesses, is able to ask for help, is weaknesses, is able to ask for help, is willing and able to help others and willing and able to help others and gets involved with other peoplegets involved with other people



““The goal of recovery is to put The goal of recovery is to put the sober self back in the sober self back in charge.”charge.”

Coping with PAW/PAWSCoping with PAW/PAWS

1.1. Educate clients about PAW symptomsEducate clients about PAW symptoms

2.2. Identify PAW symptoms for clientsIdentify PAW symptoms for clients

3.3. Relate PAW symptoms to drugs of Relate PAW symptoms to drugs of abuseabuse

4.4. Avoid stimulants and sedativesAvoid stimulants and sedatives

5.5. Stress reductionStress reduction

6.6. Encourage recoveryEncourage recovery

Coping with cravingsCoping with cravings

1.1. Stress ReductionStress Reduction

2.2. ExerciseExercise

3.3. Diversion (reading, television)Diversion (reading, television)

4.4. Sharing with others (peers, Sharing with others (peers, professional staffprofessional staff

5.5. PrayerPrayer

6.6. One Day At A TimeOne Day At A Time

DOM Relapse Prevention DOM Relapse Prevention ProgramProgram

Criteria:Criteria:

1. Four or more previous treatments1. Four or more previous treatments

oror

2. History of alcohol/drug use in treatment2. History of alcohol/drug use in treatment


1. More restrictions – must have a 1. More restrictions – must have a safety plan to leave the DOMsafety plan to leave the DOM

2. Use of Relapse Prevention Therapy2. Use of Relapse Prevention Therapy



ASSIGNMENTS:ASSIGNMENTS:

1.1. Alcohol/Drug HistoryAlcohol/Drug History

2.2. Relapse HistoryRelapse History

3.3. 37 Relapse Warning Signs Exercise37 Relapse Warning Signs Exercise

4.4. Relapse Prevention PlanRelapse Prevention Plan

5.5. Lapse/Relapse Intervention PlanLapse/Relapse Intervention Plan

RELAPSE PREVENTION RELAPSE PREVENTION PROGRAM OUTCOMEPROGRAM OUTCOME

IRREGULAR DISCHARGES - 2010IRREGULAR DISCHARGES - 2010

MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACK

APR 9 6APR 9 6

MAY 5 5MAY 5 5



MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACK

JUN 12 0JUN 12 0JUL 11 2JUL 11 2AUG 6 1AUG 6 1SEP 10 1SEP 10 1OCT 13 1OCT 13 1



MONTH ALL DOM RP TRACKMONTH ALL DOM RP TRACKNOV 15 9NOV 15 9DEC 14 8DEC 14 8IRREGULAR DISCHARGES – 2011IRREGULAR DISCHARGES – 2011JAN 2011 12 EST 9JAN 2011 12 EST 9FEB 12 EST 5FEB 12 EST 5MAR 12 EST 5MAR 12 EST 5

SECOND CHANCE PROGRAMSECOND CHANCE PROGRAM

RELAPSE IN TREATMENTRELAPSE IN TREATMENT

N = 10N = 10

Irregular Discharge = 80 percentIrregular Discharge = 80 percent

Regular Discharge = 20 percentRegular Discharge = 20 percent

SECOND CHANCE PROGRAMSECOND CHANCE PROGRAM

RELAPSE IN TREATMENTRELAPSE IN TREATMENT

New criteria:New criteria:

1.1. Relapse and ask for help may continueRelapse and ask for help may continue

2.2. Found in relapse by UDS, breath test or Found in relapse by UDS, breath test or clinical observations are dischargedclinical observations are discharged

12 Step Resistance ? ? ?12 Step Resistance ? ? ?

(When the only tool you have is a hammer, (When the only tool you have is a hammer, everything looks like a nail)everything looks like a nail)

Suggest SMART RecoverySuggest SMART Recovery

No stepsNo stepsNo higher powersNo higher powersNo lifelong commitmentNo lifelong commitmentUses CBT/RET methodsUses CBT/RET methods

Stop trying to shove square pegs in round holesStop trying to shove square pegs in round holes

QUESTIONS ? ? ? ?QUESTIONS ? ? ? ?

Email: [email protected]: [email protected]

Google Profile: Guy LamunyonGoogle Profile: Guy Lamunyon

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Relapse Prevention Inservice VA Prescott