Relapse Prevention G. Alan Marlatt, Ph.D. University of Washington Addictive Behaviors Research Center firstname.lastname@example.org http://depts.washington.edu/abrc Contemporary Approaches to Substance Abuse Treatment п‚Ў 12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA п‚Ў Traditional Minnesota Model Inpatient Treatment - Detox, medical supervision, disease model, AA, group, drug education п‚Ў Intensive Outpatient Minnesota Model Treatment - Medical supervision, individual sessions, disease model, AA, groups п‚Ў Therapeutic Communities for Substance Abuse - 24-hour residential setting, norms, responsibility, encounter groups п‚Ў Pharmacological Therapy вЂ“ Antabuse, methadone, LAMM, buprenorphine, naltrexone, etc п‚Ў Psychological Therapies вЂ“ Group, couple, and individual therapy п‚Ў Behavior Therapy вЂ“ Aversion therapy, cue exposure, skills training, contingency management, community reinforcerment п‚Ў Cognitive-Behavioral Therapy вЂ“ Relapse Prevention, coping skills training, cognitive therapy, lifestyle modification BrickmanвЂ™s Model of Helping & Coping Applied to Addictive Behaviors Is the person responsible for changing the addictive behavior? YES NO MORAL MODEL (War on Drugs) SPIRITUAL MODEL (AA & 12-Steps) Relapse = Mistake, Error, or Temporary Setback Relapse = Reactivation of the Progressive Disease Is the person YES Relapse = Crime or Lack of Relapse = Sin or Loss of responsible Willpower Contact with Higher Power for the development of the COMPENSATORY MODEL DISEASE MODEL addictive (Cognitive-Behavioral) (Heredity & Physiology) behavior? NO Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў BIOLOGICAL FACTORS Biological vulnerability and genetic predisposition in interaction with certain facilitating environments create problems and eventually disease. Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body. Tolerance вЂ“ Increased frequency of use and higher doses over time. Withdrawal вЂ“ Negative effects of cessation of addictive behaviors. Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў PSYCHOLOGICAL FACTORS Motivation вЂ“ Stages of habit initiation and stages of habit change. Expectancies вЂ“ Positive outcomes of drug use and self-efficacy. Attributions вЂ“ Effects of substance use and reasons for relapse. Sensation-Seeking вЂ“ Excessive need for stimulation Impulsivity вЂ“ Inability to effectively control or restrain behavior. Negative Affect вЂ“ Dysphoric moods such as anxiety & depression. Poor Coping вЂ“ Deficits in cognitive and behavioral skills or inhibitions in the ability to perform behaviors due to the effects of anxiety. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors п‚Ў п‚Ў п‚Ў п‚Ў SOCIOCULTURAL FACTORS Family History вЂ“ Dysfunctional family settings especially parental alcohol and drug problems and parental abuse or neglect of children. Peer Influences вЂ“ Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership. Culture and Ethnic Background вЂ“ Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the bodyвЂ™s rate and efficiency of metabolizing drugs and alcohol. Media/Advertising вЂ“ Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use. Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, and Heroin Addicts Alcoholics (N=70) Smokers (N=35) Heroin Addicts (N=32) TOTAL Sample (N=137) 38% 43% 28% 37% Negative Physical States 3% - 9% 4% Positive Emotional States - 8% 16% 6% Testing Personal Control 9% - - 4% Urges and Temptations 11% 6% - 8% TOTAL 61% 57% 53% 59% Interpersonal Conflict 18% 12% 13% 15% Social Pressure 18% 25% 34% 24% 3% 6% - 3% 39% 43% 47% 42% RELAPSE SITUATION (Risk Factor) INTRAPERSONAL DETERMINANTS Negative Emotional States INTERPERSONAL DETERMINANTS Positive Emotional States TOTAL вЂњLetвЂ™s just go in and see what happens.вЂќ Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and Overeaters Alcoholics (N=70) Smokers (N=64) Heroin Addicts (N=129) Gamblers (N=29) Overeaters (N=29) TOTAL Sample (N=311) Negative Emotional States 38% 37% 19% 47% 33% 35% Negative Physical States 3% 2% 9% - - 3% Positive Emotional States - 6% 10% - 5% 4% Testing Personal Control 9% - 2% 16% - 5% Urges and Temptations 11% 5% 5% 16% 10% 9% TOTAL 61% 50% 45% 79% 48% 56% Interpersonal Conflict 18% 15% 14% 16% 14% 16% Social Pressure 18% 32% 36% 5% 10% 20% Positive Emotional States 3% 3% 5% - 28% 8% TOTAL 39% 50% 55% 21% 52% 44% RELAPSE SITUATION (Risk Factor) INTRAPERSONAL DETERMINANTS INTERPERSONAL DETERMINANTS A Cognitive Behavioral Model of the Relapse Process E ffe ctive cop in g re sp on se In cre a se d se lf-e ffica c y D e cre a se d p rob a bility o f re la p se H ig h-R isk S itu atio n In e ffe ctive cop in g re sp on se D e cre a se d S e lf-e ffica c y В¤ P ositi ve ou t co m e E xpe ct a n cie s (fo r i niti al e ffe ct s o f the s ub st an ce ) La p se (in itia l u se o f th e su bsta n c e ) In cre a se d p rob a bility o f re la p se A b stin en ce Viola tion E ffe ct В¤ P e rce ive d e ffe cts of th e su b stan ce Relapse Prevention: Specific Intervention Strategies S e lf-M o nitorin g В¤ Inv e ntor y o f D ru g -Ta k ing S itu a tion s В¤ D ru g Ta k ing C o n fide n c e Q u e stion na ir e H ig h-R is k S itu a tio n D escription of P ast R elap ses В¤ R elapse F an tasies M ediation , R elax ation Train in g, S tress M anagem en t В¤ E ffica cy-E n h an cin g Im ager y In effectiv e C op in g R esp o ns e D ecr ea sed S elf-E ffica c y В¤ P ositive O u tcom e E x p ectan cies S itu ation al C om p eten cy Test В¤ C op in g-S k ill Trainin g В¤ C on tract to lim it ex ten t of u se В¤ R em in der C ard (w h at to d o if you h ave slip ) L a p se E d u cation ab ou t im m ediate vs. d elayed effects В¤ D ecision M atrix A b stin en c e Vio la tion E ffect C o gn itive R estru cturin g (a lap se is a m istak e: cop in g vs. Skill-Training with Alcoholics: One- Year Follow-Up Results Days of Continuous Drinking 60 SD = 62.2 p < .05 40 20 0 SD = 6.9 Skill training (Mean = 5.1) Combined Controls (Mean = 44.0) Skill-Training with Alcoholics: One- Year Follow-Up Results Number of Drinks Consumed 2000 1500 1000 SD = 2218.4 p < .05 SD = 507.8 500 0 Skill training Combined Controls (Mean = 399.8) (Mean = 1592.8) Skill-Training with Alcoholics: One- Year Follow-Up Results Days Drunk 80 SD = 17.8 60 p < .05 40 SD = 17.8 20 0 Skill training (Mean = 11.1) Combined Controls (Mean = 64.0) Skill-Training with Alcoholics: One- Year Follow-Up Results Controlled Drinking 6 SD = 17.8 P = N.S. 4 SD = 2.6 2 0 Skill training Combined Controls (Mean = 4.9) (Mean = 1.2) Empirical Support: Review of 24 RCTs Kathleen M. Carroll (1996) Relapse Prevention: вЂў Does not usually prevent a lapse better than other active treatments, but is more effective at вЂњRelapse Management,вЂќ i.e. delaying first lapse and reducing duration and intensity of lapses вЂў Particularly effective at maintaining treatment effects over long term follow-up measurements of 1-2 years or more вЂў вЂњDelayed emergence effectsвЂќ in which greater improvement in coping occurs over time вЂў May be most effective for вЂњmore impaired substance abusers including those with more severe levels of substance abuse, greater levels of negative affect, and greater perceived deficits in coping skills.вЂќ (Carroll, 1996, p.52) Empirical Support: Meta-Analytic Review Irvin, Bowers, Dunn & Wang (1999) вЂў Reviewed 17 controlled studies to evaluate overall effectiveness of the RP model as a substance abuse treatment вЂў Statistically identified moderator variables that may reliably impact the outcome of RP treatment вЂў вЂњResults indicate that RP is highly effective for both alcohol-use and substance-use disordersвЂќ Empirical Support: Meta-Analytic Review Irvin, Bowers, Dunn & Wang (1999) Moderator Variables with Significant Impact on RP Effectiveness: п‚§ Group format more effective than individual therapy format п‚§ More effective as вЂњstand aloneвЂќ than as aftercare п‚§ Inpatient settings yielded better outcomes than outpatient п‚§ Stronger treatment effects on self-reported use than on physiological measures п‚§ While effective across all categories of substance use disorders, stronger treatment effects found for substance abuse than alcohol abuse Relapse Prevention Recognition The вЂњBlack and WhiteвЂќ Model of Relapse A bstinence R elapse T hin Line The Abstinence Violation Effect п‚Ў Emotional- guilt, blame, failure, etc. п‚Ў Cognitive- Internal, stable,global, uncontrollable п‚Ў Self-awareness increase п‚Ў Comparison to Internalized Standardsgreater difference, more guilt п‚Ў Behavioral Reaction- dominant habitual response п‚Ў Cognitive Reaction- resolve discrepancy Relapse Prevention Specific Intervention Strategies п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў п‚Ў What to do if a lapse occurs Stop, Look, and Listen Keep Calm Renew Your Commitment Implement your Relapse Prevention plan Ask For Help Review the situation leading-up to the lapse RELAPSE PREVENTION Specific Intervention Strategies Coping with Lapses (Initial Use of a Substance) п‚Ў Relapse Plan with Emergency Procedures п‚Ў Relapse Contract to limit extent of use п‚Ў Relapse Reminder Card вЂњWhat do I do in case of a lapse?вЂќ Decision Matrix A L C O H O L A B S T IN E N C E P O S IT IV E N E G AT IV E Im m ed iate C o n seq u ences Im pr oved s elf- effic ac y, c onfid enc e an d es teem ; fam ily ap pr ov al; b etter h ealth ; fin anc ial g ains ; c ontinu ed s uc c es s F rus tr ation ; d enial of pleas ur e; an g er at on es elf f or n ot d oing w h at on e w ants D ela yed C o n seq u ences E nh anc ed ab ility to c ontr ol on eвЂ™s lif e; m or e m on ey; m or e r es p ec t; gr eater p opu lar ity D en ial of im m ediate an d s eem in gly eas y gr atific ation A LC O HO L USE P O S IT IV E N E G AT IV E Im m ed iate C o n seq u ences Im m ediate r ed uc tion of an xiety; r ev en g e ag ains t on eвЂ™s s p ous e; b etter feeling ab ou t w or k; im m ediate gr atific ation F eeling th at on e h as los t c ontr ol; an g er at fam ily an d em ploy er; fin anc ial los s ; w eak n es s D ela yed C o n seq u ences F eeling as th oug h on e is c aug ht in a fog , s o on e d oes nвЂ™t h a ve to d eal w ith r eality C ontin u ed d eterior ation ; los s of on eвЂ™s fam ily; los s of on eвЂ™s em p loym en t; p oor h ealth; los s of frien ds ; gr eater s elf-h atr ed Stages of Change in Substance Abuse & Dependence: Intervention Strategies M a in ten an ce S ta g e P r econ tem p la tion S ta g e C on tem plation S ta g e P r ep ara tion S ta g e A ction S ta g e R ela p se S ta g e M otiva tion al E n h an cem en t S tra teg ies A sses sm en t & Tr eatm en t M a tch in g R ela p se P r even tion & R ela p se M an a g em en t Thank You.