Chap 10 (Policy Approaches) Flashcards
failure to maintain behavioural change
Relapse
Majority of individuals eventually return to their 1. ________ patterns within 2. ________ after treatment
- pre-treatment behavior (relapse)
- the first year
Relapse prevention treatments can help individuals move towards change, rather than preventing _________
all recuring substance use episodes
- Binary versus C2. ontinuous Conceptualization
- Addiction & treatment outcomes have been conceptualized in a binary manner in the past (‘all-or-nothing’) i.e.; a person has alcoholism or doesn’t; Treatment outcome is either successful (abstinence) or unsuccessful (relapse)
Such binary conceptualization does not consider behavioral change following treatment
ALSO RELAPSES BELIEVED AS BINARY
**Addiction, treatment outcome & relapse are continuous processes , rather than discrete all-or-none events
**
The definition of relapse should consider multiple factors
- Threshold
- Reset
- Polydrugs
- Consequences
- Verification
amount of substance use in relapse
Threshold
period of abstinence required before one can be considered to have relapsed
Reset
the types of substance use that constitute a relapse
Polydrugs
behaviours & consequences required before one can be considered as having relapsed
Consequences
self-reports of relapse
Verification
an initial setback
Lapse
returning back to pre-treatment substance use
Relapse
recovering from a relapse by making positive behaviour change
Prolapse
Lapse & relapse can be differentiated by using
quantitative measures
(individual drinks 50% or more than pre-treatment = “relapse”, less than 50% of before treatment is a “lapse”)
In harm reduction lapse refers to
any harmful consequence related to substance use
The criteria for determining whether relapse has occurred may _____________
vary across different substances
Any use of cocaine relapse
Having a single cigarette lapse
A client-centered definition of relapse should consider 3 factors
- Individual’s progress towards treatment goals
- Personal & social consequences related to substance use
3.Individual’s return to the problematic behavior (ie; substance use)
Cognitive-behavioural model of relapse offering strategies for dealing with (& preventing) relapse
Relapse is conceptualized as a two-stage process the precipitants of substance use are distinct from the factors that prolong / sustain such use over time
Relapse occurs due to lack of coping skills to successfully avoid substance use in challenging situations
Marlatt’s 8 relapse determinants (aka ‘risk situations’)
Marlatt’s Relapse Prevention Model
Marlatt’s 8 relapse determinants (aka ‘risk situations’)
- Unpleasant emotions
- Physical discomfort
- Pleasant emotions
- Tests of personal control
- Urges & temptations
- Conflicts with others
- Social pressure to use
- Pleasant time with others
Marlatt’s Relapse Prevention Model: Limitations
- Relapse precipitants can be multidimensional & interact in complex ways
- Failure to cope is not necessarily due to deficit in coping skills, but may be due to other factors (ie; motivation, ambivalence, poor health care access, poverty, etc)
-Craving can have a substantial impact on relapse risk
Marlatt’s model has been extended to include
Both inter & intra-personal relapse determinants
Put more emphasis on cravings
Temporal relationships between cognitive, behavioural, affective & biological processes affecting relapse
Biological factors of Relapse
Repeated substance use can affect brain structure & function (ie; executive functioning and reward system)
i.e., individuals with CUD = effects on learning & memory function can influence treatment outcomes (i.e., lead to greater likelihood of relapse
Sex-related hormones may affect relapse risk
i.e., fluctuating hormone levels in women who are menstruating may contribute to intensity of cravings
Distal relapse risks may be influenced by
genetic factors & genetic variations = may influence cravings
(biological risks)
Psychological factors in relapse
Different personality variables have been associated with relapse risk
- Negative Cognitive Style ; feelings of inadequacy ; ineffective coping; rigid personality style; external locus of control
- Higher anxiety sensitivity
- Lower self-efficacy (Bandura)
both lead to relapse vunerability - Association between high levels of motivation & short- & long-term abstinence
- Continuous assessment of self-efficacy & motivation –> feedback about treatment effectiveness & relapse risk
- Assessing for personality factors –> helps with treatment planning & identifying supports during & after treatment
control over events (i.e., addiction) lies within oneself
High internal locus of control
control over events lies within the external world (i.e., fate)
High external locus of control
Social factors in relapse
Can increase the risk of relapse & protect one against it
Protective factors:
**Number of individuals in one’s social network & one’s attachment to one’s social support **(even if someone has only two people who they are very close with, the strength of the relationships help too)
Risk factors:
Living alone & being single
- Experience of chronic life stressors & drug availability = predict post-treatment substance use
- Levels of support within one’s network & specific behaviours of individuals in one’s network –> predict drinking outcome
- Important to help clients build strong social supports who are supportive of their goals during & after treatment
Social-Structural & Spiritual factors in relapse
Social-structural predictors of relapse: neighborhood factors (ie., crime rates), levels of education, living independently, lack of continuing substance use treatment & substance availability
Access to stable housing, high-quality health care & meaningful opportunities –> may sustain treatment progress & goals
There are associations between spirituality levels during treatment, & cravings & relapse (Less spirituality, higher chances of relapse, high = lower)
It is important to consider spirituality as engaging in prayer, relying on a higher power & finding a deeper meaning to life important complements to treatment interventions
A counselling approach for individuals with moderate to severe levels of addiction
Blends CBT with a motivational approach & is based on Marlatt’s relapse prevention model
Substance use triggers are addressed & structured coping skills training are provided
Includes a basic two-phase approach –> initiation-of-change strategies (i.e., avoidance & reliance on support) are complemented/replaced with more internalized coping strategies
All adaptations of ____ conform to this two-phase approach
Includes 5 components, which can be delivered to clients sequentially or in an “ad hoc” (as needed) fashion depending on client’s needs, motivation & readiness to change
Structured Relapse Prevention Treatment Intervention
5 components of Structured Relapse Prevention Treatment Intervention
Component 1: Assessment
Assessing: quantity & frequency of substance use, psychosocial resources & issues, co-occurring problems
Component 2: Motivational Interviewing (MI)
Component 3: Individual treatment planning
1. Goal setting & self-monitoring
- Identifying Problem Drinking & Other Drug Use Situations
Discussing IDTS & daily self-monitoring
Clients rank the 3 most problematic triggers & give examples of past substance use for each situation allows clients to identify what they might do differently in similar future situations - Identifying Coping Strengths
Component 4: Initiation Counselling
Component 5: Maintenance Counselling
ad hoc
as needed
- Successful coping responses in other areas may be effective for addressing problematic substance use situations
- Help clients focus on successes rather than failures
- Making use of client’s successful coping behaviours, personal strengths & environmental resources
- Providing coping skills training through different exercises & homework assignments
- Client selects priority areas for coping skills development
- Client is informed of program orientation, attendance requirement, limits of confidentiality , expectations for participation in planning & homework, other possible treatment options
- Client is asked whet
Identifying Coping Strengths (Component 3 of SRP)
- Focuses on counseling strategies suitable for clients who are still struggling to change their substance use (or those who are newly abstinent)
- Helps clients anticipate substance use triggers (& high-risk situations) for the coming week, then identify & commit to alternative coping strategies
- Clients are encouraged to use coping strategies effective in initiating short-term behavioural change: avoiding risky situations, taking medications to help with cravings, seeking social support
- Weekly Plan (Initiation Phase) form – helps clients anticipate substance use triggers & use safe initiation strategies
Component 4: Initiation Counselling
clients make note of: substance use goal, level of confidence in achieving goal, daily record of substance use & circumstances surrounding use (risky situations) & coping strategies used
- Goal setting & self-monitoring/ Component 3: Individual treatment planning
Clients are provided with individualized feedback of assessment results during MI sessions
MI will help engage clients who are reluctant to enter treatment
Component 2: Motivational Interviewing (MI)
quantity & frequency of substance use, psychosocial resources & issues, co-occurring problems
Assessing
Assessing: quantity & frequency of substance use, psychosocial resources & issues, co-occurring problems
Inventory of Drug-Taking Situations (IDTS)
Reveals specific risk areas to target in relapse prevention planning & coping skills training
The frequency of client’s past substance use is assessed across Marlatt’s eight risk areas
Component 1: Assessment
(SRP)
Discussing IDTS & daily self-monitoring
Clients rank the 3 most problematic triggers & give examples of past substance use for each situation –> allows clients to identify what they might do differently in similar future situations
Component 5: Maintenance Counselling Includes 4 steps
- Graduated real-life exposure to high-risk situations for substance use
- Homework tasks within each type of high-risk situation
- Assignments must be designed to help clients experience success & begin to build self-efficacy
-Multiple assignments must be agreed upon at each session to learn that high-risk situations don’t imply a relapse
- Assignments should draw on a wide variety of client’s coping strengths & resources
- As client’s confidence grows, they move up the hierarchy to more difficult situations
- A lapse in this stage of treatment is less likely to be a major setback – as it might have been earlier in treatment
- Slow reduction of reliance on initiation strategies
- Giving homework tasks that promote self-attribution of control
Client must take responsibility for designing their own homework assignments
Focuses on strategies suitable for clients who are in the maintenance stage of change
Have achieved relative stability regarding substance use goals (using initiation strategies) & now need skills to maintain change over the long term
Component 5: Maintenance Counselling
SRP: Summary
- In practice, a dynamic interplay occurs between counselling components & client’s readiness to change
- While some may proceed in a linear fashion through the counselling components & stages of change, others may not
- The purpose of treatment increase client’s self-efficacy across all areas of perceived risk
- Self-efficacy (confidence in oneself) has been associated with relapse onset
If a client fails to show improved Self-efficacy in a particular high-risk situation –> further work is required before client is discharged
Relaspe and Gender
- Women are less prone to relapse compared to Men
- Men tend to report more negative social influences, more exposure to substances & poorer coping skills
- Marriage affects relapse risk differently between the sexes:
Women with AUD more likely to have partners who are heavy drinkers (increasing risk of relapse) - Marriage seems to be a protective factor for Males with alcohol issues
- Women may be at higher risk for relapse after experiencing negative emotions/personal conflict
- Men may be at higher risk of relapse when experiencing positive experiences (i.e., pleasant time with others, experiencing pleasant emotions)
Youth relapse
- The rates of post-treatment relapse & time to relapse are similar for adults & youth
- Youth-specific treatment approaches different challenges youth experience
- Relapse prevention for youth must focus on youth-parent relationships & group membership
- Substance use by youth is associated with parental support , awareness & monitoring
- Avoid confrontation in counselling, as it may trigger rebellious responses & inhibit therapeutic alliance
-Help clients prepare for relapse in high-risk situations
Groups are the most widespread used modality with youth
Developing a relapse contract
Older adults in relapse
- High-risk situations among older adults more frequently involve intrapersonal issues
- Negative emotional states (anxiety, loneliness, social isolations, etc.)
Retirement, death of a partner / child, stressor of aging
Ethnocultural factors in relapse
Challenging for treatment programs to attract & retrain clients from diverse ethnocultural communities:
Differing languages, treatment philosophies & methods, norms & values regarding substance use, etc.
Clinicians must develop skills to work with diverse clients
“Ethnocultural competence” ability to function effectively in the context of ethnocultural differences
Clinicians must offer culture-appropriate therapy
ability to function effectively in the context of ethnocultural differences
Ethnocultural competence
Concurrent mental health disorder / Comorbidity on Relapse
Clinicians must routinely screen for presence of concurrent disorders
Not recognizing concurrent disorders can affect client’s recovery:
Premature dropout out of treatment
Higher risk of relapse
Risk of harmful interactions between drugs of abuse & Psychiatric medications
Individuals with severe psychiatric disorders:
More sensitive to effects of alcohol & drugs
May experience more negative consequences from smaller amounts of use
Quantity of use may be less important than the consequences of use
Effective modifications to relapse prevention groups:
Shorter group durations
Modifying clinical tools to incorporate disorder-specific treatment goals
Dedicating time to discuss access to services
Easier & simpler homework tools
