Doing the Best for our Patients: Relapse Prevention in SUDs By Prof. Amany Haroun El Rasheed Ain Shams Univ., Cairo, Egypt...
Relapse Prevention in SUDs <ul><li>Chemical dependency is a  chronic condition  that has a tendency toward relapse.  </li>...
Relapse Prevention in SUDs <ul><li>The  worse the damage  in each area, the  greater the chances of relapse  and return to...
<ul><li>Detox alone is not adequate treatment for addictive disease. </li></ul>
Sobriety <ul><li>Abstinence from addictive drugs </li></ul><ul><li>+ </li></ul><ul><li>Abstinence from compulsive behavior...
Compulsive Behaviors <ul><li>Eating/Dieting </li></ul><ul><li>Gambling </li></ul><ul><li>Working/Achieving </li></ul><ul><...
Relapse Prevention in SUDs <ul><li>Gorski and Kelley (1996) suggested that there are  four goals  in the  primary treatmen...
Importance of Relapse Prevention in Addiction   <ul><li>Addiction is  a  chronic relapsing disorder , therefore the  preve...
Importance of Relapse Prevention in Addiction <ul><li>In the  treatment of addiction the proportion of cases that relapse ...
Importance of Relapse Prevention in Addiction <ul><li>Although  relapse  is a symptom of addiction, it is  preventable . <...
Definition of Relapse & Lapse <ul><li>Relapse  can be understood as not only the actual return to the pattern of substance...
Determinants of Lapse & Relapse <ul><li>Intrapersonal Determinants </li></ul><ul><li>1) Self-efficacy. 2) Motivation. </li...
Understanding Relapse <ul><li>Relapse is not an isolated event . Rather, it is a  process of becoming unable to cope with ...
Understanding Relapse <ul><li>Two decades ago, a  relapse  was viewed as a  “failure”.  A person wasn’t trying hard enough...
Understanding Relapse <ul><li>It is often thought that most relapse-prone patients are  not motivated to recover . Clinica...
Understanding Relapse <ul><li>Relapse does not occur in vacuum , so when a patient relapses there is frequently a  collaps...
Understanding Relapse <ul><li>Because   relapse is a common occurrence  during the process of substance abuse recovery, it...
Understanding Relapse <ul><li>So, it is important that professionals work creatively with patients in recovery and  tailor...
Situations that Lead to Relapse <ul><li>These are many  high-risk situations  that increase the likelihood of relapse to a...
Situations that Lead to Relapse <ul><li>However, Rubin et al. (1996) were able to find a  gender   difference  in relapse ...
Situations that Lead to Relapse <ul><li>Moreover,  men  also tend to report more  positive   mood  states during relapse t...
Situations that Lead to Relapse <ul><li>It is also worth mentioning that Kivlahan et al. (1983) found that among patients ...
Situations that Lead to Relapse <ul><li>Understanding of some of the personal factors, which may contribute to substance a...
How Do High Risk Situations  Lead to Relapse? <ul><li>As long as the patient is  abstinent , there is an  increasing   per...
How Do High Risk Situations  Lead to Relapse? <ul><li>1) Negative emotional states </li></ul><ul><li>Situations in which t...
How Do High Risk Situations  Lead to Relapse? <ul><li>2) Interpersonal conflicts </li></ul><ul><li>Situations involving an...
How Do High Risk Situations  Lead to Relapse? <ul><li>3) Social Pressure </li></ul><ul><li>Situations in which the individ...
How Do High Risk Situations  Lead to Relapse? <ul><li>It is worth mentioning that some of the symptoms of  withdrawal  mig...
How Do High Risk Situations  Lead to Relapse? <ul><li>The  Abstinence   Violation   Effect  was described by Marlatt and G...
How Do High Risk Situations  Lead to Relapse? <ul><li>It was hypothesized that  “Abstinence Violation Effect”  is characte...
How Do High Risk Situations  Lead to Relapse? <ul><li>Patients who experience an  intense   “Abstinence   Violation Effect...
How Do High Risk Situations  Lead to Relapse? <ul><li>Cognitive distortions such as  denial  and  rationalization  make it...
How Do High Risk Situations  Lead to Relapse? <ul><li>Addictive   preoccupation  seems to play an important role for some ...
How Do High Risk Situations  Lead to Relapse? <ul><li>These  behaviors  become  programmed  into the patient’s  psychologi...
How Do High Risk Situations  Lead to Relapse? <ul><li>Research findings suggest that the  degree  of  life-style   balance...
How Do High Risk Situations  Lead to Relapse? <ul><li>Also, more recently, Walton et al. (1995) found that after controlli...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase I: Internal Change </li></ul><ul><ul><li>Increased stress </li></ul>...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase II: Denial </li></ul><ul><li>Worrying about myself </li></ul><ul><li...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase III: Avoidance and Defensiveness </li></ul><ul><li>Believing I’ll ne...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase IV: Crisis Building </li></ul><ul><li>Tunnel vision </li></ul><ul><l...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase V: Immobilization </li></ul><ul><li>Daydreaming and wishful thinking...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VI: Confusion and Overreaction </li></ul><ul><li>Difficulty in think...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VII: Depression </li></ul><ul><li>Irregular eating habits </li></ul>...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VIII: Behavioral Loss of Control </li></ul><ul><li>An “I don’t care”...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase IX: Recognition of Loss of Control </li></ul><ul><li>Difficulty with...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase X: Option Reduction </li></ul><ul><li>Unreasonable resentment </li><...
THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase XI: Alcohol and Drug Use </li></ul><ul><li>Attempting controlled use...
Categories of Patients <ul><li>According to Gorski & Miller (1986), chemically addicted patients can be  categorized   acc...
Categories of Patients <ul><li>Patients who are  relapse-prone  can be further divided into three subgroups: </li></ul><ul...
Categories of Patients <ul><li>b) Unstabilized relapse-prone patients </li></ul><ul><li>They have  not  been  taught   ski...
Categories of Patients <ul><li>c) Stabilized relapse-prone patients </li></ul><ul><li>Recognize  and are  aware  of their ...
A Model of Change and Recovery <ul><li>Stage one: The Emergence of Addiction </li></ul><ul><li>Phase 1 : Initiation: Drug ...
A Model of Change and Recovery <ul><li>Stage two: The Evolution of Quitting </li></ul><ul><li>Phase 1 : Turning points. </...
Recovery in Substance Use Disorders <ul><li>Recovery  is a  structured   plan  for  living  that builds a  foundation  upo...
Recovery in Substance Use Disorders <ul><li>It is  not  a  static  condition; it is an  ongoing   process . </li></ul><ul>...
Recovery in Substance Use Disorders <ul><li>Vital components of recovery include </li></ul><ul><li>Support of the family a...
Recovery in Substance Use Disorders <ul><li>Although  relapse   can  occur at  any   time , it is more  likely earlier in ...
The Developmental Model of Recovery <ul><li>Gorski & Kelley, 1996  Phases of recovery  include: </li></ul><ul><li>1- Trans...
The Developmental Model of Recovery <ul><li>1- Transition   stage </li></ul><ul><li>The transition stage begins the  first...
The Developmental Model of Recovery <ul><li>2- Stabilization stage </li></ul><ul><li>During the stabilization period, chem...
The Developmental Model of Recovery <ul><li>3- Early recovery period </li></ul><ul><li>Early recovery is marked by the nee...
The Developmental Model of Recovery <ul><li>4- Middle recovery period </li></ul><ul><li>Middle recovery period is marked b...
The Developmental Model of Recovery <ul><li>5- Late recovery period </li></ul><ul><li>During late recovery, a person makes...
The Developmental Model of Recovery <ul><li>5- Late recovery period </li></ul><ul><li>Development of health self-esteem, s...
The Developmental Model of Recovery <ul><li>6- Maintenance stage </li></ul><ul><li>The maintenance stage is the  lifestyle...
General Principles & Procedures  of Relapse Prevention   <ul><li>1)    Self-regulation and stabilization </li></ul><ul><li...
General Principles & Procedures  of Relapse Prevention <ul><li>1) Self-regulation and stabilization </li></ul><ul><li>Stab...
General Principles & Procedures  of Relapse Prevention <ul><li>2) Integration and self- assessment </li></ul><ul><li>As  u...
General Principles & Procedures  of Relapse Prevention <ul><li>3) Understanding and relapse education </li></ul><ul><li>Un...
General Principles & Procedures  of Relapse Prevention <ul><li>3)  Understanding and relapse education </li></ul><ul><li>I...
General Principles & Procedures  of Relapse Prevention <ul><li>4)Self-knowledge and identification of warning signs </li><...
General Principles & Procedures  of Relapse Prevention <ul><li>5) Coping skills and warning signs management   </li></ul><...
General Principles & Procedures  of Relapse Prevention <ul><li>5) Coping skills and warning signs management </li></ul><ul...
General Principles & Procedures  of Relapse Prevention <ul><li>6) Change and recovery planning </li></ul><ul><li>Recovery ...
General Principles & Procedures  of Relapse Prevention <ul><li>7) Awareness and inventory training </li></ul><ul><li>Inven...
General Principles & Procedures  of Relapse Prevention <ul><li>8) Significant others and involvement of others   </li></ul...
General Principles & Procedures  of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></...
General Principles & Procedures  of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></...
General Principles & Procedures  of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></...
Challenges to Relapse Prevention in Many Developing Countries <ul><li>The most important problem we face in the area of re...
Challenges to Relapse Prevention in Many Developing Countries <ul><li>However,  this attitude  is firmly held against subs...
Challenges to Relapse Prevention in Many Developing Countries <ul><li>Thus, we are badly in need for a  change  in  attitu...
Challenges to Relapse Prevention in Many Developing Countries <ul><li>We are also in need for  further   research  that ad...
Challenges to Relapse Prevention in Many Developing Countries <ul><li>Last but not least, it has become a very well known ...
<ul><li>THANK YOU </li></ul>
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Relapse Prevention.pps

  1. 1. Doing the Best for our Patients: Relapse Prevention in SUDs By Prof. Amany Haroun El Rasheed Ain Shams Univ., Cairo, Egypt M.N.P., D.P.P., M.D. Master in Mental Hygiene (Johns Hopkins Univ.) Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.) APA Membership AMERSA Membership WPA Fellowship ISAM Membership
  2. 2. Relapse Prevention in SUDs <ul><li>Chemical dependency is a chronic condition that has a tendency toward relapse. </li></ul><ul><li>Abstinence from alcohol and other mood-altering drugs is essential in the treatment of chemical dependency. </li></ul><ul><li>Because dependency on alcohol or other drugs creates problems in a person’s physical , psychological , and social functioning , treatment must be designed to work in all three areas . </li></ul>
  3. 3. Relapse Prevention in SUDs <ul><li>The worse the damage in each area, the greater the chances of relapse and return to old behaviors (criminal activity and/or the use of alcohol or drugs). </li></ul><ul><li>Total abstinence (not using any alcohol and drugs) plus personality and lifestyle changes are essential for full recovery. </li></ul>
  4. 4. <ul><li>Detox alone is not adequate treatment for addictive disease. </li></ul>
  5. 5. Sobriety <ul><li>Abstinence from addictive drugs </li></ul><ul><li>+ </li></ul><ul><li>Abstinence from compulsive behaviors </li></ul><ul><li>+ </li></ul><ul><li>Improvements in bio/psycho/social health </li></ul>
  6. 6. Compulsive Behaviors <ul><li>Eating/Dieting </li></ul><ul><li>Gambling </li></ul><ul><li>Working/Achieving </li></ul><ul><li>Exercise </li></ul><ul><li>Sex </li></ul><ul><li>Thrill Seeking </li></ul><ul><li>Escape </li></ul><ul><li>Spending </li></ul>
  7. 7. Relapse Prevention in SUDs <ul><li>Gorski and Kelley (1996) suggested that there are four goals in the primary treatment of dependency on alcohol and other drugs: </li></ul><ul><li>Recognition that chemical dependency is a biopsychosocial disease. </li></ul><ul><li>Recognition of the need for lifelong abstinence from all mood- altering drugs. </li></ul><ul><li>Development and use of an ongoing recovery program to maintain abstinence. </li></ul><ul><li>Diagnosis and treatment of other problems or conditions that can interfere with recovery . </li></ul>
  8. 8. Importance of Relapse Prevention in Addiction <ul><li>Addiction is a chronic relapsing disorder , therefore the prevention of relapse one of the critical elements of effective treatment for alcohol and other drug abuse. </li></ul><ul><li>Many patients go through treatment several times before achieving sustained abstinence (Stout et al., 1996). </li></ul>
  9. 9. Importance of Relapse Prevention in Addiction <ul><li>In the treatment of addiction the proportion of cases that relapse at least once during a year after treatment may be 60% or more, with rates as high as 90% in some instances (Brownell et al., 1986). </li></ul><ul><li>It is not unusual for addicts to relapse within one month following treatment and about two-thirds of people discharged from treatment slip or relapse within 90 days after discharge (Hunt et al., 1971; Armor et al., 1978, Polich et al., 1981), it is also not unusual for addicts to relapse 12 months after treatment . </li></ul>
  10. 10. Importance of Relapse Prevention in Addiction <ul><li>Although relapse is a symptom of addiction, it is preventable . </li></ul><ul><li>Relapse prevention methodologies are critical to the success of substance abuse treatment . </li></ul><ul><li>A key factor in preventing relapse is improved social adjustment and reintegration . </li></ul>
  11. 11. Definition of Relapse & Lapse <ul><li>Relapse can be understood as not only the actual return to the pattern of substance abuse, but also as the process during which indicators appear prior to the patient’s resumption of substance use (Daley, 1987). </li></ul><ul><li>On the other hand, the term lapse refers to the initial episode of alcohol or other drug use following a period of abstinence ( Marlatt & Gordon, 1985). </li></ul>
  12. 12. Determinants of Lapse & Relapse <ul><li>Intrapersonal Determinants </li></ul><ul><li>1) Self-efficacy. 2) Motivation. </li></ul><ul><li>3) Outcome expectancies 4) Coping. </li></ul><ul><li>5) Emotional states. 6) Craving. </li></ul><ul><li>Interpersonal Determinants </li></ul><ul><li>1) Social Support. </li></ul>
  13. 13. Understanding Relapse <ul><li>Relapse is not an isolated event . Rather, it is a process of becoming unable to cope with life in sobriety . The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide. </li></ul><ul><li>The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs (Gorski & Kelley, 1996). </li></ul>
  14. 14. Understanding Relapse <ul><li>Two decades ago, a relapse was viewed as a “failure”. A person wasn’t trying hard enough nor doing what he or she could to work a program . </li></ul><ul><li>The full responsibility was placed on the patient, with the professionals often taking a position of blame. This negative response from caregivers can result in the patient giving way to feelings of hopelessness and despair . </li></ul>
  15. 15. Understanding Relapse <ul><li>It is often thought that most relapse-prone patients are not motivated to recover . Clinical experience , however, does not support this perception . </li></ul><ul><li>However, it is impossible to predict who will make it in recovery and who will not. </li></ul><ul><li>A relapse now can be approached as an indication that something within the total recovery system was not working. </li></ul>
  16. 16. Understanding Relapse <ul><li>Relapse does not occur in vacuum , so when a patient relapses there is frequently a collapse of the supportive systems, either from within or without. </li></ul><ul><li>Moreover, Saunders & Houghton (1996) suggested that relapse is probably better understood as a complex , generic , human behavior , undertaken at times by all of us . </li></ul><ul><li>Given this, it is possible that mainstream psychological theories, such as decision - making and attribution theory , are important in coming to any understanding. </li></ul>
  17. 17. Understanding Relapse <ul><li>Because relapse is a common occurrence during the process of substance abuse recovery, it is imperative that it be examined carefully. </li></ul><ul><li>It is important that we discuss the treatment with the patient to determine what effectively supported recovery and what was missing . In this manner we can join the patient in a problem-solving manner rather than only focus on the negative. </li></ul>
  18. 18. Understanding Relapse <ul><li>So, it is important that professionals work creatively with patients in recovery and tailor-make each person’s recovery plan . </li></ul><ul><li>It can be concluded that relapse is best understood as a complex process having multiple and interactive determinants that vary in their temporal proximity from and their relative influence on relapse. </li></ul><ul><li>An adequate assessment model must be sufficiently comprehensive to include theoretically relevant variables from each of the multiple domains and different levels of potential predictors (Donovan, 1996). </li></ul>
  19. 19. Situations that Lead to Relapse <ul><li>These are many high-risk situations that increase the likelihood of relapse to alcohol/substance abuse. </li></ul><ul><li>Studies have indicated that the highest proportion of high-risk situations for alcoholics involve negative emotional states (Marlatt & Gordon, 1985). </li></ul>
  20. 20. Situations that Lead to Relapse <ul><li>However, Rubin et al. (1996) were able to find a gender difference in relapse situations. They found that men relapsed alone more often than did women. </li></ul><ul><li>Men and women report relapsing frequently with same sex friends , and women showed a tendency to relapse in the presence of romantic partners as well. </li></ul>
  21. 21. Situations that Lead to Relapse <ul><li>Moreover, men also tend to report more positive mood states during relapse than women, which is congruent with the finding that women report more depression . </li></ul><ul><li>Also, severity of drinking pattern was found to be an important confounding variable in these analyses. </li></ul><ul><li>It was suggested that gender differences found in individuals in treatment for alcohol problems may reflect societal differences between men and women. </li></ul>
  22. 22. Situations that Lead to Relapse <ul><li>It is also worth mentioning that Kivlahan et al. (1983) found that among patients who attributed their drinking to negative emotional states , those who either relapsed or were lost to follow-up had significantly more external drinking - related locus of control scores as compared to patients who identified negative physical states (i.e., craving) as their primary reason for drinking, in whom relapse was associated with significantly more internal drinking-related locus of control scores. </li></ul><ul><li>On the other hand, the highest proportion of high-risk situations reported by heroin addicts involves social pressures (Marlatt & Gordon, 1985). </li></ul>
  23. 23. Situations that Lead to Relapse <ul><li>Understanding of some of the personal factors, which may contribute to substance abuse relapse, is useful in any discussion of relapse prevention. These may include: </li></ul><ul><li>Frequent exposure to “high-risk situations” that have led to drug or alcohol use in the past. </li></ul><ul><li>Physical or psychological reminders of past drug or alcohol use (e.g., drug paraphernalia, drug-using friends, and money). </li></ul><ul><li>Recurrent thoughts or physical desires to use drugs or alcohol. </li></ul><ul><li>Inadequate skills to deal with social pressure to use substances. </li></ul><ul><li>Inadequate skills to deal with interpersonal conflict or negative emotions . </li></ul><ul><li>Desires to test personal control over drugs. </li></ul>
  24. 24. How Do High Risk Situations Lead to Relapse? <ul><li>As long as the patient is abstinent , there is an increasing perception of self-control . </li></ul><ul><li>This will continue until the patient faces a high-risk situation , defined broadly as any situation that poses a threat to the patient’s sense of control and increases the risk of potential relapse. </li></ul>
  25. 25. How Do High Risk Situations Lead to Relapse? <ul><li>1) Negative emotional states </li></ul><ul><li>Situations in which the patient is experiencing a negative (or unpleasant) emotional states, mood, or feeling such as frustration, anger, anxiety, depression, boredom, etc., prior to or occurring simultaneously with the first lapse. </li></ul>
  26. 26. How Do High Risk Situations Lead to Relapse? <ul><li>2) Interpersonal conflicts </li></ul><ul><li>Situations involving an ongoing or relatively recent conflict associated with any interpersonal relationship such as marriage, friendship, family members, or employer-employee relations. </li></ul><ul><li>Arguments and interpersonal confrontations occur frequently in this category. </li></ul>
  27. 27. How Do High Risk Situations Lead to Relapse? <ul><li>3) Social Pressure </li></ul><ul><li>Situations in which the individual or group of individuals who exert pressure on the patient to engage in the proscribed behavior. </li></ul><ul><li>Social pressure may be either direct (e.g., interpersonal contact with verbal persuasion) or indirect (e.g., being in the presence of others who are engaging in the same target behavior, even though no direct pressure is involved). </li></ul>
  28. 28. How Do High Risk Situations Lead to Relapse? <ul><li>It is worth mentioning that some of the symptoms of withdrawal might even be experienced long after the expected withdrawal in what is known as post - acute withdrawal or protracted withdrawal that might lead to relapse. </li></ul><ul><li>If the patient is unable to cope with the high-risk situations because he/she had never acquired the coping skills necessary for these situations or because the appropriate response has been inhibited by fear or anxiety, he/she will relapse . </li></ul><ul><li>On the contrary, in patients with an effective coping response in a high-risk situation , the probability of relapse decreases . </li></ul>
  29. 29. How Do High Risk Situations Lead to Relapse? <ul><li>The Abstinence Violation Effect was described by Marlatt and Gordon (1985) and Curry et al. (1987). </li></ul><ul><li>Prior to the first lapse, the patient is personally committed to an extended or indefinite period of abstinence. </li></ul><ul><li>The intensity of the “Abstinence Violation Effect” varies as a function of several factors, including: </li></ul><ul><li>The degree of prior commitment or effort expended to maintain abstinence. </li></ul><ul><li>The duration of abstinence period (the longer the period, the greater the effect). </li></ul><ul><li>The subjective value or importance of prohibited behavior to the patient. </li></ul>
  30. 30. How Do High Risk Situations Lead to Relapse? <ul><li>It was hypothesized that “Abstinence Violation Effect” is characterized by the following key cognitive-affective elements : </li></ul><ul><li>Cognitive dissonance (conflict and guilt). </li></ul><ul><li>A personal attribution effect (blaming the self as the cause of the relapse). </li></ul><ul><li>Perceived positive effects of alcohol/substance. </li></ul>
  31. 31. How Do High Risk Situations Lead to Relapse? <ul><li>Patients who experience an intense “Abstinence Violation Effect” following a lapse often experience a motivation crisis (demoralization reaction) that undermines their commitment to abstinence goals . </li></ul><ul><li>On the other hand, some patients appear to set up their own relapse as the reward of instant gratification is seen to outweigh the cost of potential negative effects that may not occur sometimes in the distant future. </li></ul>
  32. 32. How Do High Risk Situations Lead to Relapse? <ul><li>Cognitive distortions such as denial and rationalization make it much easier to set up one’s own relapse episode ; one may deny both the intent to relapse and the importance of long-range negative consequences. </li></ul><ul><li>There are also many excuses one can use to rationalize the act of indulgence (Marlatt and Gordon, 1985). </li></ul>
  33. 33. How Do High Risk Situations Lead to Relapse? <ul><li>Addictive preoccupation seems to play an important role for some of the patients and forms a major area of abstinence-based symptoms . </li></ul><ul><li>It consists of the obsessive thought patterns , compulsive behaviors , and physical cravings caused or aggravated by the addiction. </li></ul>
  34. 34. How Do High Risk Situations Lead to Relapse? <ul><li>These behaviors become programmed into the patient’s psychological processes by the addiction. </li></ul><ul><li>They are automatic and can cause the recovering patient to return to use unless he or she has specific training to identify and interrupt them (Gorski & Kelley, 1996). </li></ul>
  35. 35. How Do High Risk Situations Lead to Relapse? <ul><li>Research findings suggest that the degree of life-style balance has a significant impact on the patient’s desire for indulgence or immediate gratification (Marlatt & Gordon, 1985). </li></ul><ul><li>It is worth mentioning that balance is the degree of equilibrium that exists in one’s daily life between those activities perceived as external demands (or “shoulds ”) and those perceived as activities engaged in for pleasure or self-fulfillment (the “wants”). </li></ul><ul><li>     </li></ul>
  36. 36. How Do High Risk Situations Lead to Relapse? <ul><li>Also, more recently, Walton et al. (1995) found that after controlling for confounding variables , aspects of the home settings significantly distinguished abstainers from reusers; perceived r i sk for relapse was the strongest predictor of reuse. </li></ul>
  37. 37. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase I: Internal Change </li></ul><ul><ul><li>Increased stress </li></ul></ul><ul><ul><li>Change in thinking </li></ul></ul><ul><ul><li>Change in feeling </li></ul></ul><ul><ul><li>Change in behavior </li></ul></ul>
  38. 38. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase II: Denial </li></ul><ul><li>Worrying about myself </li></ul><ul><li>Denying than I’m worried </li></ul>
  39. 39. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase III: Avoidance and Defensiveness </li></ul><ul><li>Believing I’ll never use alcohol or drugs </li></ul><ul><li>Worrying about others instead of self </li></ul><ul><li>Defensiveness </li></ul><ul><li>Compulsive behavior </li></ul><ul><li>Impulsive behavior </li></ul><ul><li>Tendencies toward loneliness </li></ul>
  40. 40. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase IV: Crisis Building </li></ul><ul><li>Tunnel vision </li></ul><ul><li>Minor depression </li></ul><ul><li>Loss of constructive planning </li></ul><ul><li>Plans begin to fall </li></ul>
  41. 41. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase V: Immobilization </li></ul><ul><li>Daydreaming and wishful thinking </li></ul><ul><li>Feeling that nothing can be solved </li></ul><ul><li>Immature wish to be happy </li></ul>
  42. 42. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VI: Confusion and Overreaction </li></ul><ul><li>Difficulty in thinking clearly </li></ul><ul><li>Difficulty in managing feelings and emotions </li></ul><ul><li>Difficulty in remembering things </li></ul><ul><li>Periods of confusion </li></ul><ul><li>Difficulty in managing stress </li></ul><ul><li>Irritation with friends </li></ul><ul><li>Easily angered </li></ul>
  43. 43. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VII: Depression </li></ul><ul><li>Irregular eating habits </li></ul><ul><li>Lack of desire to take action </li></ul><ul><li>Difficulty sleeping restfully </li></ul><ul><li>Loss of daily structure </li></ul><ul><li>Periods of deep depression </li></ul>
  44. 44. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase VIII: Behavioral Loss of Control </li></ul><ul><li>An “I don’t care” attitude </li></ul><ul><li>Open rejection of help </li></ul><ul><li>Dissatisfaction with life </li></ul><ul><li>Feelings of powerlessness and helplessness </li></ul>
  45. 45. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase IX: Recognition of Loss of Control </li></ul><ul><li>Difficulty with physical coordination and accidents </li></ul><ul><li>Self-pity </li></ul><ul><li>Thoughts of social use </li></ul><ul><li>Conscious lying </li></ul><ul><li>Complete loss of self-confidence </li></ul>
  46. 46. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase X: Option Reduction </li></ul><ul><li>Unreasonable resentment </li></ul><ul><li>Discontinues all treatment and AA (or NA) </li></ul><ul><li>Overwhelming loneliness, frustration, anger, and tension </li></ul><ul><li>Loss of behavioral control </li></ul>
  47. 47. THE PHASES AND WARNING SIGNS OF RELAPSE <ul><li>Phase XI: Alcohol and Drug Use </li></ul><ul><li>Attempting controlled use </li></ul><ul><li>Disappointment, shame, and guilt </li></ul><ul><li>Loss of control </li></ul><ul><li>Life and health problems </li></ul>
  48. 48. Categories of Patients <ul><li>According to Gorski & Miller (1986), chemically addicted patients can be categorized according to their recovery and relapse history into: </li></ul><ul><ul><ul><li>Prone to recovery. </li></ul></ul></ul><ul><ul><ul><li>Briefly prone to relapse. </li></ul></ul></ul><ul><ul><ul><li>Chronically prone to relapse. </li></ul></ul></ul>
  49. 49. Categories of Patients <ul><li>Patients who are relapse-prone can be further divided into three subgroups: </li></ul><ul><li>a) Transition patients </li></ul><ul><li>They do not accept or recognize that they are suffering from chemical dependence , even though their substance abuse may have created obvious adverse consequences. </li></ul><ul><li>This usually results from the patient’s inability to accurately perceive reality , due to chemical interference. </li></ul>
  50. 50. Categories of Patients <ul><li>b) Unstabilized relapse-prone patients </li></ul><ul><li>They have not been taught skills to identify their addiction . </li></ul><ul><li>In such cases, treatment fails to provide these patients with the necessary skills to interrupt the process and disease of addiction . </li></ul><ul><li>As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change. </li></ul>
  51. 51. Categories of Patients <ul><li>c) Stabilized relapse-prone patients </li></ul><ul><li>Recognize and are aware of their chemical addiction , that abstinence is necessary for recovery , and that an ongoing recovery program may be required to maintain sobriety. </li></ul><ul><li>Despite their efforts , however, these patients develop dysfunctional symptoms that ultimately lead them back to alcohol or drug abuse. </li></ul>
  52. 52. A Model of Change and Recovery <ul><li>Stage one: The Emergence of Addiction </li></ul><ul><li>Phase 1 : Initiation: Drug use begins. </li></ul><ul><li>Phase 2 : Substance use produces positive consequences. </li></ul><ul><li>Phase 3 :Adverse consequences develop but remain out of awareness. </li></ul>
  53. 53. A Model of Change and Recovery <ul><li>Stage two: The Evolution of Quitting </li></ul><ul><li>Phase 1 : Turning points. </li></ul><ul><li>Phase 2 : Active quitting begins. </li></ul><ul><li>Phase 3 : Relapse prevention. </li></ul>
  54. 54. Recovery in Substance Use Disorders <ul><li>Recovery is a structured plan for living that builds a foundation upon which the patient can function effectively and comfortably . This foundation creates the ability for the person in recovery to avoid circumstances in which they might be vulnerable . </li></ul><ul><li>Recovery requires change in attitudes , values , lifestyle , and behaviors . </li></ul>
  55. 55. Recovery in Substance Use Disorders <ul><li>It is not a static condition; it is an ongoing process . </li></ul><ul><li>Relapse occurs when attitudes and behaviors revert to ones similar to those exhibited when person was actively using drugs or alcohol. </li></ul>
  56. 56. Recovery in Substance Use Disorders <ul><li>Vital components of recovery include </li></ul><ul><li>Support of the family and friends. </li></ul><ul><li>Twelve-step meetings and sponsorship. </li></ul><ul><li>Individual, group and family therapy. </li></ul><ul><li>Proper rest. </li></ul><ul><li>Moderate exercise and nutrition. </li></ul><ul><li>Avoidance of “slippery” situations such as bars. </li></ul><ul><li>Medical supervision. </li></ul><ul><li>Psychiatric support. </li></ul>
  57. 57. Recovery in Substance Use Disorders <ul><li>Although relapse can occur at any time , it is more likely earlier in the recovery process (at this stage, habits and attitudes needed for continued sobriety, skills required to replace substance use, and relations with positive peers are not firmly entrenched). </li></ul>
  58. 58. The Developmental Model of Recovery <ul><li>Gorski & Kelley, 1996 Phases of recovery include: </li></ul><ul><li>1- Transition stage </li></ul><ul><li>2- Stabilization stage </li></ul><ul><li>3- Early recovery period </li></ul><ul><li>4- Middle recovery period </li></ul><ul><li>5- Late recovery period </li></ul><ul><li>6- Maintenance stage </li></ul>
  59. 59. The Developmental Model of Recovery <ul><li>1- Transition stage </li></ul><ul><li>The transition stage begins the first time a person experiences an alcohol or drug-related problem . </li></ul><ul><li>As a person’s addiction progresses , he or she tries a series of strategies to control use . This ends with recognition by the person that safe use of alcohol and/or drugs is no longer possible . </li></ul>
  60. 60. The Developmental Model of Recovery <ul><li>2- Stabilization stage </li></ul><ul><li>During the stabilization period, chemically dependent people experience physical withdrawal and other medical problems , learn how to break the psychological conditioning causing the urge to use, stabilize the crisis that motivated them to seek treatment, and learn to identify and manage symptoms of brain dysfunction. </li></ul><ul><li>This prepares them for the long - term processes of rehabilitation . </li></ul>
  61. 61. The Developmental Model of Recovery <ul><li>3- Early recovery period </li></ul><ul><li>Early recovery is marked by the need to establish a chemical-free lifestyle . The recovering person must learn about the addiction and recovery process. </li></ul><ul><li>He or she must separate from friends who use and build relationships that support long-term recovery. </li></ul><ul><li>This may be a very difficult time for criminal justice patients who have never associated with people with sobriety-based lifestyle. </li></ul>
  62. 62. The Developmental Model of Recovery <ul><li>4- Middle recovery period </li></ul><ul><li>Middle recovery period is marked by the development of a balanced lifestyle . During this stage, recovering people learn to repair past damage done to their lives. </li></ul>
  63. 63. The Developmental Model of Recovery <ul><li>5- Late recovery period </li></ul><ul><li>During late recovery, a person makes a change in ongoing personality issues that have continued to interfere with life satisfaction. </li></ul><ul><li>In traditional psychotherapy, this is referred to as self-actualization . </li></ul><ul><li>It is a process of examining the values and goals that one has adopted from family, peers, and culture. </li></ul><ul><li>Conscious choices are then made about keeping these values or discarding them and forming new ones . </li></ul>
  64. 64. The Developmental Model of Recovery <ul><li>5- Late recovery period </li></ul><ul><li>Development of health self-esteem, spiritual growth, healthy intimacy, and meaningful living. </li></ul>
  65. 65. The Developmental Model of Recovery <ul><li>6- Maintenance stage </li></ul><ul><li>The maintenance stage is the lifestyle process of continued growth and development , coping with adult life transitions , managing routine life problems , and guarding against relapse . </li></ul><ul><li>The physiology of addiction lasts for the rest of a person’s life. </li></ul><ul><li>Any use of alcohol or drugs will reactivate physiological , psychological , and social progression of the disease. </li></ul>
  66. 66. General Principles & Procedures of Relapse Prevention <ul><li>1)   Self-regulation and stabilization </li></ul><ul><li>As the patient’s capacity to self-regulate thinking , feeling , memory , judgment , and behavior increases , the risk of relapse will decrease . </li></ul><ul><li>Self-regulation can be achieved through stabilization . </li></ul>
  67. 67. General Principles & Procedures of Relapse Prevention <ul><li>1) Self-regulation and stabilization </li></ul><ul><li>Stabilization may include: </li></ul><ul><li>Detoxification . </li></ul><ul><li>Recuperation from the effects of stress that preceded the chemical use. </li></ul><ul><li>Resolution of immediate interpersonal and situational crises that threaten sobriety. </li></ul><ul><li>Establishment of a daily structure including proper diet, exercise, stress management, and regular contact with both treatment personnel and self-help groups. </li></ul><ul><li>It is worth mentioning that the risk of relapse is highest during this period of stabilization . </li></ul>
  68. 68. General Principles & Procedures of Relapse Prevention <ul><li>2) Integration and self- assessment </li></ul><ul><li>As understanding and acceptance increases , the risk of relapse will decrease . </li></ul><ul><li>During this phase it is important to explore the presenting problems which may have led to relapse in the past , and which might trigger future relapse. </li></ul>
  69. 69. General Principles & Procedures of Relapse Prevention <ul><li>3) Understanding and relapse education </li></ul><ul><li>Understanding the general factors that cause relapse will aid patients in relapse prevention. </li></ul><ul><li>Basic information provided in this phase should include, but not be limited to: </li></ul><ul><li>Medical , clinical , and social models in addictive disease . </li></ul><ul><li>Developmental model of recovery . </li></ul><ul><li>Common “ stuck points ” in recovery. </li></ul><ul><li>Identification of warning signs . </li></ul><ul><li>Management strategies for relapse warning signs. </li></ul><ul><li>Planning for effective recovery . </li></ul>
  70. 70. General Principles & Procedures of Relapse Prevention <ul><li>3) Understanding and relapse education </li></ul><ul><li>It should be noted that many relapse-prone patients may have memory problems associated with the chemical abuse, which may impede the learning process and retention of educational information . </li></ul>
  71. 71. General Principles & Procedures of Relapse Prevention <ul><li>4)Self-knowledge and identification of warning signs </li></ul><ul><li>This process teaches the patient to identify the sequence of problems that has led from stable recovery to chemical use in the past , and then synthesize those steps into future circumstances that could cause relapse . </li></ul><ul><li>This can be approached through the self-monitoring procedures by keeping a diary to identify high-risk situations. </li></ul>
  72. 72. General Principles & Procedures of Relapse Prevention <ul><li>5) Coping skills and warning signs management </li></ul><ul><li>This process involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur . </li></ul><ul><li>This also include relapse rehearsal methods , in this procedure, the patient is instructed to imagine being involved in a high risk situations and performing more adaptive coping behaviors and thoughts . </li></ul>
  73. 73. General Principles & Procedures of Relapse Prevention <ul><li>5) Coping skills and warning signs management </li></ul><ul><li>The emphasis here is on active coping rather than on resisting temptation . </li></ul><ul><li>To emphasize self-efficacy enhancement , the patient is instructed to imagine that the rehearsed experience is accompanied by mounting feelings of competence and confidence . </li></ul>
  74. 74. General Principles & Procedures of Relapse Prevention <ul><li>6) Change and recovery planning </li></ul><ul><li>Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they occur in sobriety. </li></ul>
  75. 75. General Principles & Procedures of Relapse Prevention <ul><li>7) Awareness and inventory training </li></ul><ul><li>Inventory training teaches relapse-prone patients to do daily inventories that monitor compliance with their recovery program and check for the development of relapse warning signs . </li></ul>
  76. 76. General Principles & Procedures of Relapse Prevention <ul><li>8) Significant others and involvement of others </li></ul><ul><li>Relapse-prone patients need the help of others during the process of recovery . </li></ul><ul><li>Treatment should ensure that others (e.g., family members , 12-step sponsors , supportive peers ) are involved in the recovery . </li></ul>
  77. 77. General Principles & Procedures of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></ul><ul><li>Ongoing outpatient treatment is necessary for effective relapse prevention. </li></ul><ul><li>Even highly effective short-term inpatient or primary outpatient program will be unable to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy. </li></ul>
  78. 78. General Principles & Procedures of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></ul><ul><li>A review of the original assessment , writing a sign list , management strategies , and recovery plan . </li></ul><ul><li>An update of the assessment by adding to an addendum any documents that are significant to the patient's progress problems since the previous update. </li></ul><ul><li>A revision of the relapse warning signs to incorporate new warning signs that have developed since the previous date. </li></ul>
  79. 79. General Principles & Procedures of Relapse Prevention <ul><li>9) Maintenance and relapse prevention plan updating </li></ul><ul><li>The development of management strategies for the newly identified warning signs . </li></ul><ul><li>A revision of the recovery program to add recovery activities , to address the new warning signs , and to eliminate activities that are no longer needed . </li></ul>
  80. 80. Challenges to Relapse Prevention in Many Developing Countries <ul><li>The most important problem we face in the area of relapse prevention in substance abusers in developing countries is that most of the personnel working in the field of psychiatry in general, of course including those working with substance abusers, have great difficulty accepting relapses . This is a reflection of the deep-seated attitude that these patients are not motivated . </li></ul>
  81. 81. Challenges to Relapse Prevention in Many Developing Countries <ul><li>However, this attitude is firmly held against substance abusers in particular and is not present to any extent on dealing with relapsing schizophrenics, depressives, or manics. </li></ul><ul><li>This attitude causes many personnel to refuse treating substance abusers with a resulting shortage in the number of personnel in the field. </li></ul><ul><li>Moreover, some of the treatment centers might refuse to admit patients after they exhaust a certain number of relapses (usually a small number as two or three times), which leaves the patient with no alternative except continuing in his/her addictive cycle. </li></ul>
  82. 82. Challenges to Relapse Prevention in Many Developing Countries <ul><li>Thus, we are badly in need for a change in attitude , which has to be started early in medical and paramedical education (i.e., on an undergraduate level). This process, of course, has to be continued on a postgraduate level as well as on continuing medical education level. </li></ul>
  83. 83. Challenges to Relapse Prevention in Many Developing Countries <ul><li>We are also in need for further research that addresses the benefit of relapse prevention techniques, as well as the tendency of patients (including the chronically relapsing ones) to benefit cumulatively from treatment over time. </li></ul><ul><li>On the other hand, there is a lack in evaluation of the ongoing service , as we do not have our own estimates of the cost/benefit of the ongoing services. </li></ul>
  84. 84. Challenges to Relapse Prevention in Many Developing Countries <ul><li>Last but not least, it has become a very well known and strongly agreed upon fact that addiction is a chronic relapsing disorder which makes relapse prevention one of the basic elements of its treatment. This is non-negotiable even though its benefits are commonly cumulative on the long run. </li></ul>
  85. 85. <ul><li>THANK YOU </li></ul>

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