Foundation of Addiction Medicine 2019

Change talk

601

●Change/Sustain Talk

Why is ●Change talk predicts
Change behavioral change
Talk
important ●Mostly sustain talk or equal
? parts of change talk and
sustain talk= maintenance of
status quo

602

Evoking ● “What makes you think you need to
change change?” “What will happen if you don’t
talk change?” (Open ended questions)

● “Suppose you don’t change, what is the
WORST thing that might happen?”
(Provoking Extremes)

● “If you make changes, how would your
life be different from what it is today?”
(Looking Forward)

603

Evoking ● “On the following scale from 1 to 10,
change where 1 is definitely not ready to change
talk and 10 is definitely ready to change,
what number best reflects how ready
you are at the present time to change
your drinking?” (Readiness to change)

604

● “What are some of the good things
about your alcohol use? [Client answers]
Okay, on the flipside, what are some of
the less good things about your Alcohol
use?”(Pros and Cons)

605

Responding ● Reflections
to
Sustain ● Running Head Start: “It sounds like
Talk there are some benefits to this behavior.
I’m really curious to hear about more of
them.”

● Coming Alongside: “Perhaps drinking is
so important to you that you won’t give
it up, no matter what.”

● Emphasizing autonomy: “It is really up
to you with what you decide…?”

606

Take ● MI facilitates change by 3 conditions
home (Moyer, Miller and Hendrickson, 2005 )
message!
1. It reduces resistance
2. It raises discrepancy
3. It elicits change talk

607

Key
Readings

608

Course by
Stephen
Rollnick

https://learning.bmj.com/learning/mod6u09le

THANK YOU!

610

RELAPSE PREVENTION

Dr. E.Sinu, PhD, PDF
Associate Professor,

Post-Doctoral Fellow in Non-Communicable Disorders Across Life Span

Psychiatric Social Work Consultant – Centre for Addiction Medicine

Department of Psychiatric Social Work
NIMHANS, Bangalore

611

Learning Objectives

• To impart skills on relapse prevention
counselling

• To educate us on relapse prevention
strategies

• To know how to do relapse assessment and
manage relapse effectively

612

Relapse

Returning to heavy or problematic
substance use following an extended

or brief period of abstinence or
moderate use

613

Introduction

LAPSE - RELAPSE
'Lapse' - a shortcoming, just a 'slip',
‘Relapse’ - Returning to dependent pattern of use after a period

of abstinence.
a state in which an individual returns to a continuous
pattern of using substances, after a period of abstinence.
RELAPSE – is a part of recovery Process

614

Relapse is not all or .nothing

● A transitional process

● A series of events that unfold over time

Abstinent Modern Old View of Abstinent
View of Relapse Time
Relapse

Negative Emotion or
Experience

Cravings
Start Using
Stop Using
Source: Daniel Duhigg, D.O., M.B.A.
Medical Director – Behavioral Health
Presbyterian Healthcare Services,USA

Miller W, Ed., Treating Addictive Beha6v1iors: Processes of Change, 1986

RECOVERY PROCESS

Recovery does not progress like this

It progresses like this

616

Stages of Relapse

Emotional relapse Psychological relapse Physical relapse

Terence Gorski & Miller, 1986

617

Marlatt GA, Addiction, 1996;91(s):s37-s49

618

Marlatt's Determinants of Relapse

● Intrapersonal/Environmental: Source: Daniel Duhigg, D.O., M.B.A.
Medical Director – Behavioral Health
○ Negative Emotions: anger, PPrreessbbyytteerriaiannHHeeaaltlthhccaarreeSSeerrvviciceess,,UUSSAAc

frustration, anxiety, depression, boredom,
loneliness, etc.

○ Negative Physical/Physiological
States: withdrawal, physical cravings,

pain, illness, fatigue, etc.

○ Enhancement of positive
emotional state (positive outcomes

expectancies)

○ Testing personal control

○ Giving in to temptations or
urges

Marlatt GA, Addiction, 1996;91(s):s37-s49 61

Marlatt's Determinants of
Relapse

● Interpersonal:

○ Arguments, jealousy, discord, guilt,
anger, etc.

○ Worry, concern, apprehension, etc.

○ Social Pressures

■ Peer pressure

■ Enhancing sex, celebration, Source: Daniel Duhigg, D.O., M.B.A.
pleasure Medical Director – Behavioral Health
Presbyterian Healthcare Services,USA
Marlatt GA, Addiction, 1996;91(s):s37-s49 62

Covert Determinants of Relapse ● Lifestyle Imbalance

○ Balance between perceived external
demands (ie. Shoulds) and internally
fulfilling or enjoyable activities (ie. Wants)

Constant State of Generates negative Increases desire
Stress emotional states for please, and
rationalization for

indulgence

Marlatt GA, Addiction, 1996;91(s):s37-s49
621

Covert Determinants of Relapse Urges and Cravings

Source: Daniel Duhigg, D.O., M.B.A.
Medical Director – Behavioral Health
Presbyterian Healthcare Services,USA

622

ASSESSMENT OF RELAPSE

• Reason for relapse: • Remorse/ Guilt
• Duration of relapse: • Abstinence violation effect
• Avg intake during relapse: • Commitment towards
• Last intake:
abstinence
• Medication Compliance • Duration of last Abstinence
• Time taken to seek help • Status of Social Support:
• Relapse management: • Employment status:
• Response to relapse • Motivation :
• Recent Stressful life events
– Self and family • Ongoing stressors if any

623

Relapse Prevention Strategies

• Clarifications of Myths and Misconceptions
• Assessing High Risk Situations
• Craving Management
• Drink Refusal Skill Training
• Problem solving Skill training
• Coping Skills Training
• Anger Management
• Money Management
• Sleep Hygiene techniques
• Lifestyle Modifications

624

Key Questions

• Where and when did it occur?
• What were you thinking and feeling?
• What were your expectations?
• What will happen if you continue to use?
• What can you do between now and our next

session, so that lapses do not re-occur?
• What did you do on the days you did not use that

kept you from lapsing?
• Which of the coping skills you have been

practicing might be especially useful?

625

MYTHS AND MISCONCEPTIONS

MYTHS AND FACTS
MISCONCEPTIONS

626

Common Triggers of Relapse

• Post-Acute Withdrawal • Having a lot of cash
symptoms (irritability, mood • Testing personal control
swings, poor sleep).
• Feeling of emptiness
• Relationship issues • Places (B.A.R)
• Craving • People (who use drugs)
• Timing • Situations
• Boredom

627

High Risk Situations - HALT

HALT

• Help patients to list out their common causes
of relapse

628

CRAVING MANAGEMENT

• Drink Water 5D
• Deep Breathe
• Delay 629
• Discuss
• Divert/ Distract

Handling Peer Pressure

• Avoid them at First
Contact

• Be Firm & Assertive
• Repeatedly Say ‘No’
• No Temporary Excuses

• Go away from the place

• Recognize it is HRS
• Not To feel guilty

630

Problem Solving Steps

• Identification of Alternate Method
problems Break the problem into
small parts and solving
• Generation solutions one by one.
• Analysing pros and cons
• Choosing best solutions
• Implementation
• Evaluation and feedback

631

Coping Skills

• Emotion Focussed Coping

– Accepting responsibility
– Avoidance
– Distancing

• Problem focussed Coping

– Seeking social support
– Planful Problem solving
– Positive reappraisal
– Confrontive coping

632

Anger Management

• Talk it out
• Take time out, Go away from situation
• Express it what made you angry
• Punch a pillow
• Drink water, Calm yourself
• Avoid breaking things
• Avoid hitting people when you are angry

633

LIFESTYLE MODIFICATION /
Positive Addiction

RECREATION AND SPIRITUALITY
–Alternative activities to fill up spare time,
reviving old interests,
–cultivating new ones
–Spirituality
–Spend time with family members

634

Crisis Intervention

What If a lapse/ Relapse had occurred ?
• Take medications
• Inform your case manager
• Seek medical help within 24 hours

635

Warning signs of Relapse

❖ Making a list of warning signs
❖ Anticipate Craving, High Risk Situations
❖ Identifying methods to manage them
❖ Identifying list of people who can help you

…..

636

CORE ISSUES IN RELAPSE PREVENTION
• Motivation
• High Risk situations
• Handling Craving and Triggers
• Drink Refusal Skills
• Coping Skills
• Problem-solving Skills
• Stress Management/Time Management
• Sleep Hygiene Techniques
• Positive Addictions / Life Style Modifications
• Role of Family in Recovery

637

CONCLUSION

❑ Relapse Prevention (RP) - an evidence-based,
empirically supported practice for substance use
disorders. Has a well-documented track record of
producing positive outcomes.

638

Further Reading

1. Larimer ME, Palmer RS. Relapse prevention: An overview of
Marlatt's cognitive-behavioral model. Alcohol research and
Health. 1999 Jan 1;23(2):151-60.(Link to download)

2. Marlatt GA, Donovan DM, editors. Relapse prevention:
Maintenance strategies in the treatment of addictive behaviors.
Guilford press; 2005 May 20.

3. Chand PK, Preventing Relapse in Murthy P, Nikketha BS.
Psychosocial interventions for persons with substance abuse:
Theory and practice (page 41 to 49). National Institute of
Mental Health and Neuro Sciences (NIMHANS) De-addiction
Centre. NIMHANS Publication. 2007(64).(link to download)

639

COGNITIVE
BEHAVIOR THERAPY

FOR SUBSTANCE
DEPENDENCE

640

OVERVIEW

• Cognitive Therapy (CT) was developed by Beck (1967, 1976).
• Beck first developed a treatment manual for substance abuse in

1977 and elaborated it in 1993
Premise: The meaning that the individual attaches to the experience
is more important than the experience itself.

641

COGNITIVE BEHAVIOR THERAPY
(CBT)

• Collaborative: Both client and therapist are important and need
to share and agree on the aims of the treatment.

• Structure: In the ‘here and now’ (But also flexible)

• Brief: Specific number of sessions

• Focused: Treatment is focused and has a starting and a
pre-decided end point.

• The central concept: use of a substance in a involves an active

decision-making process-for which the individual has, or can,

regain control. 642

643 BELIEFS

Core beliefs Drug-related beliefs Automatic thoughts
(similar to expectancy (concerned with the
Basic beliefs that the current situation)
individual holds about beliefs)
Themselves,
Others, Anticipatory: the Usually short-term,
And the world expectation of a fleeting thoughts or
positive experience images
Formed as a result of Relief-oriented: the Short versions of
early experience expectation of basic beliefs
feeling or coping
better E.g., ‘this is bad’, ‘I
Facilitating: which can’t cope’, or mental
gives permission to images of drugs or
stop being alcohol
ambivalent

644 COGNITIVE DISTORTIONS

• When cognitive distortions are applied to information, the
individual is unable to appraise the information objectively.

• Distorted beliefs influences feelings and behavior.
• Can be present for a long time and can play a role in the

development of mental disorders.

645 SUBSTANCE ABUSE

Individuals are most likely to use a substance when they encounter
triggers

Internal emotional states (Depression, boredom, anger)
Physical states (withdrawal symptoms, pain)
External circumstances (Places or situations associated with drug use)
• Such triggers activate beliefs, which in turn trigger a process leading to
drug use
• These beliefs in turn activate drug beliefs (positive expectancies from
drug use), and both will activate automatic thoughts
• Automatic thoughts in turn activates craving and the urge to use

646 TRIGGER THOUGHT CRAVING
USE

• Experience of craving and urges and thoughts which prohibit
using creates dissonance or conflict between what the individual
needs and wants

• Dissonance is associated with the experience of anxiety and
ambivalence which the individual wants to exit/resolve

• Facilitating or permission-giving beliefs may follow from the
experience of craving or directly from automatic thoughts

• This resolves the dissonance

647 SUMMARY

• Use of the cognitive techniques in CBT is to identify and explore
substance-related beliefs

• A set of addictive beliefs appear to be derived from core beliefs
such as “I am helpless”, “I am unlovable”, or “I am vulnerable”

• These core beliefs interact with life stressors to produce
emotional states

• Activate drug related beliefs that may cause craving
• Opposing beliefs may exist- i.e., paradoxically, they may seek

drugs simply to relieve the tension generated by the conflict

648 FUNCTIONAL ANALYSIS

Identifying the client’s thoughts, feelings, and circumstances, before and after
substance use

The basic steps involved are:
• Antecedent (where, when, with whom)
• Behavior (what, how)
• Consequences (emotional, behavioral, and social)

• Using this structure of functional analysis, you can add other aspects such as
thoughts before use, craving experiences and positive and negative
consequences of use

649 QUESTIONING FOR FUNCTIONAL
ANALYSIS

Tell me all you can about the last time you used heroin..
• Where were you?
• What were you doing?
• What happened before?
• What thoughts came into your mind?
• How were you feeling?
• When was the first time you were aware of wanting to use?
• What was the high like at the beginning and what was it like later?

650 REASONS FOR SEEKING TREATMENT

Important because…
• Indicates the client’s motivational stage
• Provides insight into the client’s belief system (positive and

negative expectancies) in relation to substance use
• Encourages clients to take responsibility for their treatment, as

treatment is presented as a choice