RELAPSE PREVENTION & EARLY INTERVENTION STRATEGIES

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Relapse – in a broader sense, is the return of signs and symptoms of a disease after a remission.
In the case of some psychiatric disorders, relapse is the worsening of symptoms or the re-occurrence of unhealthy behaviors, such as avoidance or substance use, after a period of improvement.
Relapse Prevention – A set of skills designed to reduce the likelihood that symptoms of the illness in question will worsen or that a person will return to an unhealthy behavior, such as substance use.
Skills include, for example, identifying early warning signs that symptoms may be worsening, recognizing high risk situations for relapse, and understanding how everyday, seemingly mundane decisions may put you on the road to relapse (for example, skipping lunch one day may make you more vulnerable to get in a bad mood).
Relapse can be prevented through the use of specific coping strategies, such as identifying early warning signs.
Early Intervention is simply bridging the gap between prevention and treatment. Early intervention is essential to reducing drug use and its costs to society

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RELAPSE PREVENTION & EARLY INTERVENTION STRATEGIES

  1. 1. RELAPSE PREVENTION & EARLY INTERVENTION STRATEGIES Windsor University School of Medicine Psychiatry Rotation Consultant Psychiatrist – Dr. Sharon Halliday Presentation by:OLADAPO SAMSON OLUWABUKOLA RD
  2. 2. Brief Outline of Topic In the Substance Abusing or Dependent patient  Relapse Prevention Strategies  and Early Intervention Strategies In the Mentally ill patient  Relapse Prevention Strategies  and Early Intervention Strategies
  3. 3. Definition of terms Relapse – in a broader sense, is the return of signs and symptoms of a disease after a remission.  In the case of some psychiatric disorders, relapse is the worsening of symptoms or the reoccurrence of unhealthy behaviors, such as avoidance or substance use, after a period of improvement. Relapse Prevention – A set of skills designed to reduce the likelihood that symptoms of the illness in question will worsen or that a person will return to an unhealthy behavior, such as substance use.  Skills include, for example, identifying early warning signs that symptoms may be worsening, recognizing high risk situations for relapse, and understanding how everyday, seemingly mundane decisions may put you on the road to relapse (for example, skipping lunch one day may make you more vulnerable to get in a bad mood). Relapse can be prevented through the use of specific coping strategies, such as identifying early warning signs. Early Intervention is simply bridging the gap between
  4. 4. Incidence According to recent statistics, relapse rates are approximately 33% for people who gamble pathologically (within three months of treatment), 90% for people who quit smoking, and 50% for people who abuse alcohol. Within one year of treatment, people struggling with obesity typically regain 30% to 50% of the weight they lost. Relapse among people who commit sex offenses is a constant safety concern for those in the community. However, some statistics show that this population has a very low rate of relapse. A recent report by Robin J. Wilson and colleagues indicated rates as low as 3.7% to 6.3%. This same report stated that, among various criminal offenses, those who commit sex offenses relapse at lower rates than those who commit general offenses.
  5. 5. An Overview of the Prevention,Treatment and Maintenance Triad!
  6. 6. An Overview of the Prevention,Treatment and MaintenanceProtractor! In 1994, the Institute of Medicine commissioned an investigation on Mental Health Interventions that resulted in the development of the IOM Model summarized in the IOM ―protractor.‖ Levels of prevention are:  Universal (all populations),  Selective (e.g. populations with high risk factors),  Indicated (individuals with an indication of a problem such as early substance use). Early intervention is appropriate for indicated individuals.
  7. 7. An Overview of the Prevention,Treatment and MaintenanceProtractor! Prevention is a proactive process. This means that we anticipate a problem and address it before it becomes a reality. We dont wait for a problem to surface and then take action. Prevention also involves connecting people and resources with innovative ideas, strategies, and programs. It is important to create partnerships with all sectors of society to create a holistic prevention agenda. The goal is to promote the concept of no use of any illegal drug and no high-risk use of alcohol or other legal drugs. The overall goal of preventing substance abuse problems can be reached by empowering individuals, families, and communities to take action. This means helping them develop problem-solving skills and the ability to manage difficult situations. It also means helping them develop skills to cope with a situation while working to develop long- term solutions. Prevention is different from intervention and treatment in that it is aimed at general population groups with various levels of risk for alcohol and other drug-related problems.
  8. 8. Pathogenesis – Reward Pathway A HEALTHY PATHWAY: The ‗reward pathway ‗ produces feelings of pleasure in response to naturally enjoyable stimuli, such as food and sex. Connected to other brain regions, including memory storage, the pathway motivates us to repeat activities that perpetuate the species. AN ADDICTED PATHWAY: Drinking or doing drugs hijacks the reward pathway. But in genetically vulnerable people, this altered state leads to an addiction that they are, on their own, powerless to overcome. Someone with an addiction can‘t talk herself out of the compulsion any more than someone can talk herself out of depression.
  9. 9. Pathogenesis Electrical and chemical signals pass between neurons in the reward pathway that trigger the release of dopamine. Dopamine is, among other things, the pleasure chemical.  REWARD Activating the reward pathway is a gradual, step-by-step process that first engages the five senses, slowly triggering a dopamine release and making us feel good. For example, in a hungry person the release would start with the anticipation of food and decline as desire is sated.  IN CONTRAST Psychoactive substances such as alcohol, methamphetamines and tobacco bypass the senses to work directly on brain circuitry, launching the pathway to a sudden high.  THE HIGH The result provokes an exaggerated release of dopamine, leading to an over-accumulation of the pleasure chemical in the brain. This produces the feelings of euphoria, increased energy, confidence and relaxation.
  10. 10. Pathogenesis  THE LOWS The brain adjusts for the overabundance of pleasure chemicals by reducing the number of receptors in an effort to moderate dopamine levels.  REPEAT USE The cravings motivate a user to seek drugs to activate the reward pathway again, as memories connecting to past highs feed and reinforce the urge. Research has found that, even decades after a user has been clean, the mere image of a drug can stimulate the pathway.  DAMAGE Due to the shrinking numbers of dopamine receptors, however, users require greater amounts of a drug to achieve the same high. In turn, this again prompts the brain to limit dopamine receptors, creating a vicious circle. ADDICTION The motivation to continue using drugs becomes an addiction, driven more by fear of the negative emotional and physical feelings associated with withdrawal than the desire to be high. ―More and more experts agree … addictions are themselves a mental illness. ‖ – Remi Quirion, professor of psychiatry at McGill University and scientific director of the Institute of Neurosciences for the Canadian Institutes of Health Research
  11. 11. Pathophysiology
  12. 12. Pathophysiology Alcohol and Dopamine  Drugs, such as nicotine, alcohol, opiates and marijuana work indirectly by stimulating neurons that modulate dopamine cell firing through their effects on various dopamine receptors. Alcohol consumption produces very large and rapid dopamine releases enhancing the excitatory effect of dopamine in the nucleus accumbens (NAc) from ventral tegmental neurons. Nerve signals are sent to the cortex, where they are registered as "experience" and memories of the rewarding effects of alcohol, such as its taste or the feelings of relaxation after drinking. The brain responds to the large dopamine release by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the alcohol dependent person incapable of feeling any pleasure even from the substance they seek to feed their addiction. Continual dopamine stimulation of the nucleus accumbens region of the brain from repeated substance use also strengthens the motivational properties of the substance, which does not occur for natural reinforcers of dopamine.
  13. 13. Pathophysiology Specifically, it seems that the reinforcing effects of substances of dependence are due to their ability to surpass the magnitude (at least five- to tenfold) and duration of the fast dopamine increases that occur in the NAc when triggered by natural reinforcers such as food and sex. It seems that increases in dopamine are not directly related to actual reward but rather to the prediction of reward, the ability to affect attention and motivation, and the ability to facilitate conditioned learning (i.e. neutral stimuli like an environment associated with drinking can increase dopamine by itself) and behavior. This conditioned learning and behavior can lead to reward drinking or drinking intended to produce a particular pleasurable outcome by stimulating dopamine activity.
  14. 14. Pathophysiology SUBSTANCE USE EFFECTCaffeine increase adrenaline and dopamine short term increase of dopamine, longNicotine term decrease of dopamine (desensitized receptors)Alcohol increase GABA, increase DopamineMarajuana THC binds to cannabinoid receptors increase dopamine (blocks reuptake),Cocaine increase epinephrine, NE, and 5-HTAmphetamines Increase dopamine increases dopamine (blocks reuptake),Ecstasy initially increases serotonin--2 days later--decreases serotoninOpiates bind to opiate receptorsstimulants caffeine and cocaine/amphetamines
  15. 15. RELAPSE, RELAPSE PREVENTION & EARLY INTERVENTION INSUBSTANCE DEPENDENT PATIENTS
  16. 16. Relapse As earlier mentioned, relapse is the worsening of symptoms or the reoccurrence of unhealthy behaviors, such as avoidance or substance use, after a period of improvement. Relapse is a process, its not an event. In order to understand relapse prevention you have to understand the stages of relapse. Relapse starts weeks or even months before the event of physical relapse. There are three stages of relapse.  Emotional relapse  Mental relapse  Physical relapse
  17. 17. Emotional Relapse In emotional relapse, the patient is not thinking about using the drug, but his emotions and behaviors are setting up for a possible relapse in the future. The signs of emotional relapse are:  Anxiety  Intolerance  Anger  Defensiveness  Mood swings
  18. 18. Emotional Relapse  Isolation  Not asking for help  Not going to meetings  Poor eating habits  Poor sleep habits The signs of emotional relapse are also the symptoms of post-acute withdrawal. Understanding the modalities of post-acute withdrawal makes it easier to avoid relapse, this is because the early stage of relapse is easiest to pull back from. In the later stages the pull of relapse gets stronger and the sequence of events moves faster.
  19. 19. Emotional relapse – Prevention strategies Relapse prevention at this stage has to do more of the patient recognizing that he‘s in emotional relapse and making conscious efforts to change behavior. Recognizing that he‘s isolating and remind himself to ask for help. Recognizing sense of anxiety and practicing relaxation techniques. Recognizing that sleeping and eating patterns are slipping and practice self-care. Staying too long enough in emotional relapse brings exhaustion and trying to break loose from exhaustion takes patient into mental relapse.
  20. 20. Emotional relapse – Prevention strategies Encourage patients about the following:  Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of yourself. Think about why you use. You use drugs or alcohol to escape, relax, or reward yourself. Therefore you relapse when you dont take care of yourself and create situations that are mentally and emotionally draining that make you want to escape.  For example, if you dont take care of yourself and eat poorly or have poor sleep habits, youll feel exhausted and want to escape. If you dont let go of your resentments and fears through some form of relaxation, they will build to the point where youll feel uncomfortable in your own skin. If you dont ask for help, youll feel isolated. If any of those situations continues for too long, you will begin to think about using the substance again. But if you practice self-care, you can avoid
  21. 21. Mental relapse In mental relapse theres a war going on in your mind. Part of you wants to use, but part of you doesnt. In the early phase of mental relapse youre just idly thinking about using. But in the later phase youre definitely thinking about using. The signs of mental relapse are:  Thinking about people, places, and things you used with  Glamorizing your past use  Lying  Hanging out with old using friends  Fantasizing about using  Thinking about relapsing  Planning your relapse around other peoples schedules It gets harder to make the right choices as the pull of addiction gets stronger.
  22. 22. Techniques for Dealing with MentalUrges  Play the tape through. When you think about using, the fantasy is that youll be able to control your use this time. Youll just have one drink. But play the tape through. One drink usually leads to more drinks. Youll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and youll get caught in the same vicious cycle. When you play that tape through to its logical conclusion, using doesnt seem so appealing.  A common mental urge is that you can get away with using, because no one will know if you relapse. Perhaps your spouse is away for the weekend, or youre away on a trip. Thats when your addiction will try to convince you that you dont have a big problem, and that youre really doing your recovery to please your spouse or your work. Play the tape through. Remind yourself of the negative consequences youve already suffered, and the potential consequences that lie around the corner if you relapse again. If you could control your use, you would have done it by now.
  23. 23. Techniques for Dealing with MentalUrges  Tell someone that youre having urges to use. Call a friend, a support, or someone in recovery. Share with them what youre going through. The magic of sharing is that the minute you start to talk about what youre thinking and feeling, your urges begin to disappear. They dont seem quite as big and you dont feel as alone.  Distract yourself. When you think about using, do something to occupy yourself. Call a friend. Go to a meeting. Get up and go for a walk. If you just sit there with your urge and dont do anything, youre giving your mental relapse room to grow.  Wait for 30 minutes. Most urges usually last for less than 15 to 30 minutes. When youre in an urge, it feels like an eternity. But if you can keep yourself busy and do the things youre supposed to do, itll quickly be gone.
  24. 24. Techniques for Dealing with MentalUrges  Do your recovery one day at a time. Dont think about whether you can stay abstinent forever. Thats a paralyzing thought. Its overwhelming even for people whove been in recovery for a long time.  One day at a time, means you should match your goals to your emotional strength. When you feel strong and youre motivated to not use, then tell yourself that you wont use for the next week or the next month. But when youre struggling and having lots of urges, and those times will happen often, tell yourself that you wont use for today or for the next 30 minutes. Do your recovery in bite-sized chunks and dont sabotage yourself by thinking too far ahead.  Make relaxation part of your recovery. Relaxation is an important part of relapse prevention, because when youre tense you tend to do what‘s familiar and wrong, instead of whats new and right. When youre tense you tend to repeat the same mistakes you made before. When youre relaxed you are more open to change.
  25. 25. Physical Relapse  Once you start thinking about relapse, if you dont use some of the techniques mentioned above, it doesnt take long to go from there to physical relapse. Driving to the liquor store. Driving to your dealer. Injecting yourself, sniffing the powder, smoking the weed, and lots more.  Its hard to stop the process of relapse at that point. Thats not where you should focus your efforts in recovery. Thats achieving abstinence through brute force. But it is not recovery.  If you recognize the early warning signs of relapse, and understand the symptoms of post-acute withdrawal, youll be able to catch yourself before its too late.
  26. 26. GOALS of Relapse Prevention The primary goals are to:  Reduce use, limiting the number of users and the types of substances used and  Delay use in those that will use. This means that delaying the start of use reduces harm during a child‘s development and reduces risk for developing addiction and abusive patterns of use.  Preventing the transition from ―use‖ to ―abuse,‖ and  Diminishing harm resulting from use. This does not include only ways to make use safer (e.g., needle exchanges, safer-drinking strategies), but also movement into treatment and prevention of relapse once treatment is completed.
  27. 27. Relapse PreventionBroadly conceived, Relapse Prevention (RP) is acognitive-behavioural treatment (CBT) with a focuson the maintenance stage of addictive behaviourchange that has two main goals:  To prevent the occurrence of initial lapses after a commitment to change has been made and  To prevent any lapse that does occur from escalating into a full-blow relapse
  28. 28. The 5 Ws (functional analysis)The 5 Ws of a person‘s drug use (also called a functional analysis)  When?  Where?  Why?  With / from whom?  What happened?
  29. 29. The 5 Ws (functional analysis)People addicted to drugs do not use them at random. It is important to know:  The time periods when the client uses drugs  The places where the client uses and buys drugs  The external cues and internal emotional states that can trigger drug craving (why)  The people with whom the client uses drugs or the people from whom she or he buys drugs  The effects the client receives from the drugs ─ the psychological and physical benefits (what happened)
  30. 30. Questions clinicians can use to learn the 5Ws What was going on before you used? How were you feeling before you used? How / where did you obtain and use drugs? With whom did you use drugs? What happened after you used? Where were you when you began to think about using?
  31. 31. Triggers & CravingsTrigger Thought Craving Use
  32. 32. Triggers & Cravings Trigger Thought Craving Use
  33. 33. CravingsCraving:  To have an intense desire for  To need urgently; require Many people describe craving as similar to a hunger for food or thirst for water. It is a combination of thoughts and feelings. There is a powerful physiological component to craving that makes it a very powerful event and very difficult to resist.Cravings or urges are experienced in a variety of ways by different clients.For some, the experience is primarily somatic. For example, ―I just get a feeling in my stomach,‖ or ―My heart races,‖ or ―I start smelling it.‖For others, craving is experienced more cognitively. For
  34. 34. Coping Strategies to CravingsCoping with Craving: 1. Engage in non-drug-related activity 2. Talk about craving 3. ―Surf‖ the craving 4. Thought stopping 5. Contact a drug-free friend or counsellor 6. Pray
  35. 35. Levels of Prevention Levels of prevention refer to where in the issue‘s development the focus is: Before it starts, as it develops, or after it has developed as a problem. They are typically categorized as being primary, secondary, or tertiary.  Primary prevention refers to activities undertaken prior to an individual using. Most educational programs fit under this, but so do programs designed to reduce drug availability (e.g., law enforcement).  Secondary prevention refers to activities applied during the early stages of drug use and would encompass attempts to prevent the transition from use to abuse. Early diagnosis, crisis intervention, and economic changes such as increasing alcohol taxes can decrease use and interrupt problematic patterns of use.  Tertiary prevention takes place at later (advanced) stages of drug abuse and refers to actions to avoid relapse and maintain
  36. 36. Relapse Prevention Strategies Learn to willingly accept your mind – The first step to preventing relapse is to understand and accept your mind. The presence of whatever your mind produces such as thoughts, beliefs, images, memories, feelings, or sensations is temporary. Even if you don‘t like them, if you understand that the ideas your mind creates will change, you do not need to act on what your mind is thinking. This goes for urges and cravings. Note how they simply come and go. They may seem like a problem, but avoiding them through addictive behavior appears as the real problem in the long run. Consider learning and practicing ―Mindfulness‖ to increase your ability to ―sit with‖ or ―ride out‖ urges without acting on them. Get psychological and medical help when needed – When needed, seek and get psychological and medical help for psychiatric illnesses and to learn better ways of coping with life events. Treatment options for addiction are not limited to psychotherapy or support groups. Consider using medications like Disulfiram (Antabuse®), Naltrexone (ReVia®), Acamprosate (Campral®), etc., as a sign of positive action and never as a mark of failure or inadequacy. Take your medications as
  37. 37. Relapse Prevention Strategies Stimulus control – Begin to understand and practice stimulus control. Change the ―activating events,‖ cues or ―triggers‖ which can be changed. Accept those which can‘t be changed. They can cue you, but they don‘t rule you. PIG Awareness – Live with awareness of the PIG (Problem of Immediate Gratification). Learn about the PIG concept and of natural penalties for slips, lapses and relapses. Carry, review and update a Cost-Benefit Analysis or list of reasons for sticking to your change plan. AID’s Awareness – Beware of Apparently Irrelevant Decisions (AID‘s) that lead to high risk situations and using. Recovery requires living with greater awareness or mindfulness. Beware of the “Abstinence Violation Effect” (the use of a small slip as an excuse for a major relapse). Carry your how-to- cope reminder instructions. Remember: ―One ‗swallow‘ does not make a summer, nor a relapse.‖
  38. 38. Relapse Prevention Strategies Find valued directions for your life – Develop a balanced life with healthy indulgences and activities that can substitute for unhealthy and undesirable addictive behaviors is a good start. But in the long run we each need to decide what is really important to be doing and commit ourselves to acting on those values, taking us in our own valued life directions. Take better care of yourself – TLC stands for Therapeutic Lifestyle Change. Staying clean from drugs and alcohol or abstaining from unwanted behaviors is part of living a balanced life. Ample evidence exists that you can improve your mental health through exercise, better diet and nutrition (including Omega-3 found in fish oils), getting out in nature, developing and maintaining good human relationships, engaging in recreation and vital absorbing
  39. 39. Relapse Prevention Strategies Learn and apply the SMART Recovery® Four Point Program™ and Recovery Tools – Read, study, learn and apply what you learn. If you don‘t help yourself, who is going to help you? Self-help requires determination and work on your part. That‘s why it‘s called self-help. Reward yourself - Be sure to celebrate successes and reward yourself for successful abstinence, compliance with treatment and follow up.
  40. 40. Levels of Intervention Levels of Intervention are categorized as Universal, Selective, or Indicated.  Universal Intervention refer to efforts focused on every eligible member of a community. These are programs aimed at an entire group (rather than individuals) and include media campaigns, policies that affect all members of a community equally, such as taxes and laws, and educational programs provided to all students regardless their risk level. Potential benefits are expected to outweigh costs for everyone.  Selective Intervention are more focused at a more systems domain where higher-risk subgroups are targeted (e.g., children from homes where family members have a history of drug use or college students in general).  Indicated intervention is individual-focused interventions and represents the most time and financially-intensive programs. These include prevention efforts targeted at individuals, for example those who show signs of developing problems, e.g.,
  41. 41. Early Intervention When a problem has been identified, early intervention is needed to prevent it from getting worse. A key issue is motivating change. Motivation is not just the responsibility of the problem drinker. Motivation is the result of an interaction between the drinker and others. A therapist can increase motivation for change through his or her interactions with the person experiencing or at risk for substance usage and its abuse. Understanding the reasons people stop using drug can help in motivating change.
  42. 42. RELAPSE, RELAPSEPREVENTION & EARLY INTERVENTION IN MENTALLY ILL PATIENTS
  43. 43. Relapse, Relapse Prevention In the course of illness, relapse is a return of symptoms after a period of time when no symptoms are present. Any strategies or treatments applied in advance to prevent future symptoms are known as relapse prevention. When people seek help for mental disorders, they receive treatment that, hopefully, reduces or eliminates symptoms. However, once they leave treatment, they may gradually revert to old habits and ways of living. This results in a return of symptoms known as relapse. Relapse prevention aims to teach people strategies that will maintain the wellness skills they learned while in treatment. Prevention of relapse in mental disorders is crucial—not only because symptoms are detrimental to quality of life but also because the occurrence of relapse increases chances for future relapses. In addition, with each relapse, symptoms
  44. 44. Pathogenesis Relapse is a concern with any disorder, whether physical or psychological. Psychological disorders can follow a similar pattern, and certain psychological disorders tend to have a higher rate of relapse than others. Addictive disorders, such as alcohol and drug abuse, smoking, overeating, and pathological gambling , are well known for high levels of relapse. Many addictions involve a lifestyle centered around the addictive behavior. In such cases, individuals must not only discontinue the addictive habit, they must also restructure their entire lives in order for changes to last. Such vast changes are difficult at best, approaching impossible in the worst scenarios. For example, an individual with a drug addiction may live in a neighborhood where drugs are prevalent but may lack the resources to move.
  45. 45. Relapse Prevention For many types of disorders, initial treatment is often effective at eliminating the unwanted behavior. However, these effects are rarely maintained long- term without some type of preventive planning. Results of medications are similar; symptoms are alleviated, but once the medication is discontinued, symptoms return unless the individual has had some type of training in coping with his or her disorder and that training has been effective. There are various forms of relapse prevention training. Most follow a similar pattern with and employ the following common elements:
  46. 46. Relapse Prevention Identifying high-risk situations: Symptoms are often initiated by particular times, places, people, or events. For example, a person with agoraphobia is more likely to experience symptoms of panic in a crowded building. An essential key to preventing relapse is to be aware of the specific situations where one feels vulnerable. These situations are called "triggers," because they trigger the onset of symptoms. While people with the same mental disorder may share similar triggers, triggers can also be highly individual. People tend to react—sometimes unknowingly—to negative experiences in their past. For example, a woman who was sexually abused as a child may have negative emotions when in the presence of men who resemble her abuser. Because some triggers occur without conscious awareness, individuals may not know all their triggers. Many prevention programs encourage individuals to monitor their behavior closely, reflecting on situations where symptoms occurred and determining what
  47. 47. Relapse Prevention Learning alternate ways to respond to high-risk situations: Once triggers have been identified, one must find new ways of coping with those situations. The easiest coping mechanism for high-risk situations is to avoid them altogether. This may include avoiding certain people who have a negative influence or avoiding locations where the symptom is likely to occur. In some instances, avoidance is a good strategy. For example, individuals who abuse alcohol may successfully reduce their risk by avoiding bars or parties. In other instances, avoidance is not possible or advisable. For example, individuals attempting to lose weight may notice that they are more likely to binge at certain times during the day. One cannot avoid a time of day. Rather, by being aware of this trigger, one can purposely engage in alternate activities during that time. Strategies for coping with unavoidable triggers are generally skills that need to be learned and practiced in order to be effective. Strategies include—but are not limited to—discussion of feelings, whether with a friend, counselor, or via a hotline; distraction, such as music, exercise, or engaging in a hobby; refocusing techniques, such as meditation , deep-breathing exercises, progressive muscle relaxation (focusing on each muscle group separately, and routinely tensing then relaxing that muscle), prayer, or journaling; and cognitive restructuring, such as positive affirmation statements (such as, "I am worthwhile"), active problem solving (defining the problem, generating
  48. 48. Relapse Prevention Creating a plan for healthy living: Besides being prepared for high-risk situations, relapse prevention also focuses on general principles of mental health that, if followed, greatly reduce the likelihood of symptoms. These include factors such as balanced nutrition, regular exercise, sufficient sleep, health education, reciprocally caring relationships, productive and recreational interests, and spiritual development. Developing a support system: Many research studies have demonstrated the importance of social support in maintaining a healthy lifestyle. Individuals who are socially isolated tend to display more symptoms of mental disorders. Conversely, individuals with mental disorders tend to have more difficultly initiating and maintaining relationships due to inappropriate social behavior.
  49. 49. Relapse Prevention Preparing for possible relapse: Although the ultimate goal of relapse prevention is to avoid relapse altogether, statistics demonstrate that relapse potential is very real. Individuals need to be aware that, even when exerting their best efforts, they may occasionally experience lapses (one occurrence of a symptom or behavior) or relapses (return to a previous, undesirable level of symptoms or behavior). Acknowledging the potential for relapse is important, because many people consider a lapse or relapse as evidence of personal failure and give up completely. In their widely acclaimed book for professionals, Motivational Interviewing , William R. Miller and Stephen Rollnick cite a study by Prochaska and DiClemente that found that smokers typically relapse between three and seven times before quitting for good. From the perspective of Miller and Rollnick, each relapse can be a step closer to full recovery if relapse is used as a learning experience to improve prevention strategies. Although some argue that such a tolerant attitude invites relapse, general consensus is that individuals need to forgive themselves if relapse occurs and then move on.
  50. 50. Treatment As with any type of therapeutic treatment, success of relapse prevention programs depend heavily on motivation. If an individual is not interested in making life changes, he or she is not likely to follow a prevention plan. Individuals low in motivation may need to participate in group or individual psychotherapy before deciding whether to enter a relapse prevention program.
  51. 51. PROCHASKA ANDDICLEMENTE’S STAGES OF CHANGE MODEL
  52. 52. Prochaska and DiClemente’s Stagesof Change Model The stages of change are:  Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed)  Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change)  Preparation/Determination (Getting ready to change)  Action/Willpower (Changing behavior)  Maintenance (Maintaining the behavior change) and  Relapse (Returning to older behaviors and abandoning the new changes)
  53. 53. Stages of Change Model
  54. 54. General Idea of the Model ofChange Behavioural change doesn‘t just happen in one step – instead people tend to progress through a series of steps. Cessation is a dynamic process. The pace is individual. Some stay at one step for the rest of their lives. The decision to change and to move through the steps must come from within the individual himself – to force people to change is naive and can be counterproductive.
  55. 55. Stage One: Pre-contemplation In the pre-contemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people‘s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. In AA, this stage is called ―denial,‖ but at Addiction Alternatives, we do not like to use that term. Rather, we like to think that in this stage people just do not yet see themselves as having a problem.
  56. 56. Stage Two – Contemplation In the contemplation stage people are more aware of the personal consequences of their bad habit and they spend time thinking about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are on a teeter-totter, weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. (In fact, some people think and think and think about giving up their bad habit and may die never having gotten beyond this stage) On the plus side, people are more open to receiving information about their bad habit, and more likely to actually use educational interventions and reflect on their own feelings and thoughts
  57. 57. Stage Three -Preparation/Determination In the preparation/determination stage, people have made a commitment to make a change. Their motivation for changing is reflected by statements such as: ―I‘ve got to do something about this — this is serious. Something has to change. What can I do?‖ This is sort of a research phase: people are now taking small steps toward cessation. They are trying to gather information (sometimes by reading things like this) about what they will need to do to change their behavior. Or they will call a lot of clinics, trying to find out what strategies and resources are available to help them in their attempt. Too often, people skip this stage: they try to move directly from contemplation into action and fall flat on their faces because they haven‘t adequately researched or accepted what it is going to take to make this major lifestyle change.
  58. 58. Stage Four: Action/Willpower This is the stage where people believe they have the ability to change their behavior and are actively involved in taking steps to change their bad behavior by using a variety of different techniques. This is the shortest of all the stages. The amount of time people spend in action varies. It generally lasts about 6 months, but it can literally be as short as one hour! This is a stage when people most depend on their own willpower. They are making overt efforts to quit or change the behavior and are at greatest risk for relapse. Mentally, they review their commitment to themselves and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People in this stage also tend to be open to receiving help and are also likely to seek support from others (a very important element). Hopefully, people will then move to the fifth stage.
  59. 59. Stage Five: Maintenance Maintenance involves being able to successfully avoid any temptations to return to the bad habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made. People in maintenance constantly reformulate the rules of their lives and are acquiring new skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance. They remain aware that what they are striving for is personally worthwhile and meaningful. They are patient with themselves and recognize that it often takes a while to let go of old behavior patterns and practice new ones until they are second nature to them. Even though they may have thoughts of returning to their old bad habits, they
  60. 60. References http://www.recoverymonth.gov/~/media/Images/Files/Webcas t%20Transcript/2011_April_DiscussionGuide-508.ashx www.AddictionsAndRecovery.org http://facultypages.morris.umn.edu/~ratliffj/psy1081/Sec5_pr evention.htm http://alcohol.addictionblog.org/relapse-prevention-strategies/ Freese CBT DMH Psychiatry 2009-04-09. Treatnet Training Volume B, Module 3: Updated 10 September 2007 http://pathwayscourses.samhsa.gov/aaap/aaap_6_pg3.htm http://www.minddisorders.com/Py-Z/Relapse-and-relapse- prevention.html http://addictioninfamily.com/addiction_types/healthy-vs- addicted-pathway/ http://www.cpe.vt.edu/gttc/presentations/8eStagesofChange.pdf

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