1.RELAPSE PREVENTION & EARLY INTERVENTION STRATEGIES Windsor University School ofMedicinePsychiatry RotationConsultant Psychiatrist Dr. Sharon Halliday Presentation by:OLADAPO SAMSON OLUWABUKOLA RD

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. Definition of terms Relapse in a broader sense, is the return of signs andsymptoms of a disease after a remission. In the case of some psychiatric disorders, relapse is theworsening of symptoms or the reoccurrence of unhealthybehaviors, such as avoidance or substance use, after aperiod of improvement. Relapse Prevention A set of skills designed to reducethe likelihood that symptoms of the illness in question willworsen or that a person will return to an unhealthybehavior, such as substance use. Skills include, for example, identifying early warning signsthat symptoms may be worsening, recognizing high risksituations for relapse, and understanding how everyday,seemingly mundane decisions may put you on the road torelapse (for example, skipping lunch one day may make youmore vulnerable to get in a bad mood). Relapse can be prevented through the use of specificcoping strategies, such as identifying early warning signs. Early Intervention is simply bridging the gap between 4. Incidence According to recent statistics, relapse rates areapproximately 33% for people who gamblepathologically (within three months of treatment),90% for people who quit smoking, and 50% forpeople who abuse alcohol. Within one year oftreatment, people struggling with obesity typicallyregain 30% to 50% of the weight they lost. Relapse among people who commit sex offenses isa constant safety concern for those in thecommunity. However, some statistics show that thispopulation has a very low rate of relapse. A recentreport by Robin J. Wilson and colleagues indicatedrates as low as 3.7% to 6.3%. This same reportstated that, among various criminal offenses, thosewho commit sex offenses relapse at lower ratesthan those who commit general offenses. 5. An Overview of the Prevention,Treatment and Maintenance Triad! 6. An Overview of the Prevention,Treatment and MaintenanceProtractor! In 1994, the Institute of Medicine commissioned aninvestigation on Mental Health Interventions thatresulted in the development of the IOM Modelsummarized 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). Earlyinterventionis appropriate for indicated individuals. 7. An Overview of the Prevention,Treatment and MaintenanceProtractor! Prevention is a proactive process. This means that we anticipate aproblem and address it before it becomes a reality. We dont wait for aproblem to surface and then take action. Prevention also involves connecting people and resources withinnovative ideas, strategies, and programs. It is important to createpartnerships with all sectors of society to create a holistic preventionagenda. The goal is to promote the concept of no use of any illegaldrug and no high-risk use of alcohol or other legal drugs. The overall goal of preventing substance abuse problems can bereached by empowering individuals, families, and communities to takeaction. This means helping them develop problem-solving skills andthe ability to manage difficult situations. It also means helping themdevelop skills to cope with a situation while working to develop long-term solutions. Prevention is different from intervention and treatment in that it isaimed at general population groups with various levels of risk foralcohol and other drug-related problems. 8. Pathogenesis Reward Pathway A HEALTHY PATHWAY: The reward pathway produces feelings of pleasure in response to naturallyenjoyable stimuli, such as food and sex. Connected toother brain regions, including memory storage, thepathway motivates us to repeat activities thatperpetuate the species. AN ADDICTED PATHWAY: Drinking or doing drugshijacks the reward pathway. But in geneticallyvulnerable people, this altered state leads to anaddiction that they are, on their own, powerless toovercome. Someone with an addiction cant talkherself out of the compulsion any more than someonecan talk herself out of depression. 9. Pathogenesis Electrical and chemical signals pass between neurons in thereward 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 feelgood. For example, in a hungry person the release wouldstart with the anticipation of food and decline as desire issated. IN CONTRAST Psychoactive substances such as alcohol,methamphetamines and tobacco bypass the senses towork directly on brain circuitry, launching the pathway to asudden high. THE HIGH The result provokes an exaggerated release ofdopamine, leading to an over-accumulation of the pleasurechemical in the brain. This produces the feelings ofeuphoria, increased energy, confidence and relaxation. 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 becomesan addiction, driven more by fear of the negative emotional andphysical feelings associated with withdrawal than the desire tobe high. More and more experts agree addictions arethemselves a mental illness. Remi Quirion, professor ofpsychiatry at McGill University and scientific director of theInstitute of Neurosciences for the Canadian Institutes of HealthResearch 11. Pathophysiology 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. 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. Pathophysiology SUBSTANCE USEEFFECTCaffeine increase adrenaline and dopamine short term increase of dopamine, longNicotine term decrease of dopamine (desensitized receptors)Alcoholincrease GABA, increase DopamineMarajuanaTHC binds to cannabinoid receptors increase dopamine (blocks reuptake),Cocaine increase epinephrine, NE, and 5-HTAmphetamines Increase dopamine increases dopamine (blocks reuptake),Ecstasyinitially increases serotonin--2 days later--decreases serotoninOpiatesbind to opiate receptorsstimulants caffeine and cocaine/amphetamines 15. RELAPSE, RELAPSE PREVENTION & EARLY INTERVENTION INSUBSTANCE DEPENDENT PATIENTS 16. Relapse Asearlier mentioned, relapse is the worsening ofsymptoms or the reoccurrence of unhealthy behaviors,such as avoidance or substance use, after a period ofimprovement. Relapse is a process, its not an event. In order tounderstand relapse prevention you have to understand thestages of relapse. Relapse starts weeks or even monthsbefore the event of physical relapse. There are threestages of relapse. Emotional relapse Mental relapse Physical relapse 17. Emotional Relapse In emotional relapse, the patient is not thinking aboutusing the drug, but his emotions and behaviors aresetting up for a possible relapse in the future. The signs of emotional relapse are: Anxiety Intolerance Anger Defensiveness Mood swings 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 thesymptoms of post-acute withdrawal. Understanding the modalities of post-acute withdrawalmakes it easier to avoid relapse, this is because theearly stage of relapse is easiest to pull back from. Inthe later stages the pull of relapse gets stronger andthe sequence of events moves faster. 19. Emotional relapse Preventionstrategies Relapse prevention at this stage has to do more of thepatient recognizing that hes in emotional relapse andmaking conscious efforts to change behavior. Recognizing that hes isolating and remind himself toask for help. Recognizing sense of anxiety and practicing relaxationtechniques. Recognizing that sleeping and eating patterns areslipping and practice self-care. Staying too long enough in emotional relapse bringsexhaustion and trying to break loose fromexhaustion takes patient into mental relapse. 20. Emotional relapse Preventionstrategies Encourage patients about the following: Practice self-care. The most important thing you can do toprevent relapse at this stage is take better care of yourself.Think about why you use. You use drugs or alcohol toescape, relax, or reward yourself. Therefore you relapsewhen you dont take care of yourself and create situationsthat are mentally and emotionally draining that make youwant to escape. For example, if you dont take care of yourself and eat poorlyor have poor sleep habits, youll feel exhausted and want toescape. If you dont let go of your resentments and fearsthrough some form of relaxation, they will build to the pointwhere youll feel uncomfortable in your own skin. If you dontask for help, youll feel isolated. If any of those situationscontinues for too long, you will begin to think about using thesubstance again. But if you practice self-care, you can avoid 21. Mental relapse In mental relapse theres a war going on in your mind. Partof you wants to use, but part of you doesnt. In the earlyphase of mental relapse youre just idly thinking aboutusing. But in the later phase youre definitely thinking aboutusing. 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 ofaddiction gets stronger. 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. 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. 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 whats 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. 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. GOALS of Relapse Prevention The primary goals are to: Reduce use, limiting the number of users and thetypes of substances used and Delay use in those that will use. This means thatdelaying the start of use reduces harm during achilds development and reduces risk for developingaddiction and abusive patterns of use. Preventing the transition from use to abuse, and Diminishing harm resulting from use. This does notinclude only ways to make use safer (e.g., needleexchanges, safer-drinking strategies), but alsomovement into treatment and prevention of relapseonce treatment is completed. 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 lapsesafter a commitment to change has been madeandTo prevent any lapse that does occur fromescalating into a full-blow relapse 28. The 5 Ws (functional analysis)The 5 Ws of a persons drug use (also called a functional analysis) When? Where? Why? With / from whom? What happened? 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. 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 aboutusing? 31. Triggers & CravingsTrigger Thought Craving Use 32. Triggers & CravingsTriggerThoughtCravingUse 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 bydifferent clients.For some, the experience is primarily somatic. For example,I just get a feeling in my stomach, or My heart races, orI start smelling it.For others, craving is experienced more cognitively. For 34. Coping Strategies to CravingsCoping with Craving:1. Engage in non-drug-related activity2. Talk about craving3. Surf the craving4. Thought stopping5. Contact a drug-free friend or counsellor6. Pray 35. Levels of Prevention Levels of prevention refer to where in the issues 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. Relapse Prevention Strategies Learn to willingly accept your mind The first step to preventingrelapse is to understand and accept your mind. The presence ofwhatever your mind produces such asthoughts, beliefs, images, memories, feelings, or sensations istemporary. Even if you dont like them, if you understand that the ideasyour mind creates will change, you do not need to act on what yourmind is thinking. This goes for urges and cravings. Note how theysimply come and go. They may seem like a problem, but avoiding themthrough addictive behavior appears as the real problem in the long run.Consider learning and practicing Mindfulness to increase your ability tosit with or ride out urges without acting on them. Get psychological and medical help when needed Whenneeded, seek and get psychological and medical help for psychiatricillnesses and to learn better ways of coping with life events. Treatmentoptions 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 actionand never as a mark of failure or inadequacy. Take your medications as 37. Relapse Prevention Strategies Stimulus control Begin to understand and practice stimuluscontrol. Change the activating events, cues or triggers whichcan be changed. Accept those which cant be changed. They cancue you, but they dont rule you. PIG Awareness Live with awareness of the PIG (Problem ofImmediate Gratification). Learn about the PIG concept and ofnatural penalties for slips, lapses and relapses. Carry, review andupdate a Cost-Benefit Analysis or list of reasons for sticking toyour change plan. AIDs Awareness Beware of Apparently Irrelevant Decisions(AIDs) that lead to high risk situations and using. Recoveryrequires living with greater awareness or mindfulness. Beware of the Abstinence Violation Effect (the use of asmall slip as an excuse for a major relapse). Carry your how-to-cope reminder instructions. Remember: One swallow does notmake a summer, nor a relapse. 38. Relapse Prevention Strategies Find valued directions for your life Develop a balancedlife with healthy indulgences and activities that cansubstitute for unhealthy and undesirable addictive behaviorsis a good start. But in the long run we each need to decidewhat is really important to be doing and commit ourselves toacting on those values, taking us in our own valued lifedirections. Take better care of yourself TLC stands for TherapeuticLifestyle Change. Staying clean from drugs and alcohol orabstaining from unwanted behaviors is part of living abalanced life. Ample evidence exists that you can improveyour mental health through exercise, better diet andnutrition (including Omega-3 found in fish oils), getting outin nature, developing and maintaining good humanrelationships, engaging in recreation and vital absorbing 39. Relapse Prevention Strategies Learn and apply the SMART Recovery Four PointProgram and Recovery Tools Read, study, learnand apply what you learn. If you dont help yourself,who is going to help you? Self-help requiresdetermination and work on your part. Thats why itscalled self-help. Reward yourself - Be sure to celebrate successes andreward yourself for successful abstinence, compliancewith treatment and follow up. 40. Levels of Intervention Levels of Intervention are categorizedas Universal, Selective, or Indicated. Universal Intervention refer to efforts focused on every eligiblemember of a community. These are programs aimed at an entiregroup (rather than individuals) and include media campaigns,policies that affect all members of a community equally, such astaxes and laws, and educational programs provided to allstudents regardless their risk level. Potential benefits areexpected to outweigh costs for everyone. Selective Intervention are more focused at a more systemsdomain where higher-risk subgroups are targeted (e.g., childrenfrom homes where family members have a history of drug use orcollege students in general). Indicated intervention is individual-focused interventions andrepresents the most time and financially-intensive programs.These include prevention efforts targeted at individuals, forexample those who show signs of developing problems, e.g., 41. Early Intervention When a problem has been identified, early intervention isneeded to prevent it from getting worse. A key issue ismotivating change. Motivation is not just the responsibility ofthe problem drinker. Motivation is the result of an interactionbetween the drinker and others. A therapist can increasemotivation for change through his or her interactions with theperson experiencing or at risk for substance usage and itsabuse. Understanding the reasons people stop using drug can helpin motivating change. 42. RELAPSE, RELAPSEPREVENTION & EARLYINTERVENTION INMENTALLY ILLPATIENTS 43. Relapse, Relapse Prevention In the course of illness, relapse is a return of symptoms aftera period of time when no symptoms are present. Anystrategies or treatments applied in advance to prevent futuresymptoms are known as relapse prevention. When people seek help for mental disorders, they receivetreatment that, hopefully, reduces or eliminates symptoms.However, once they leave treatment, they may graduallyrevert to old habits and ways of living. This results in a returnof symptoms known as relapse. Relapse prevention aims toteach people strategies that will maintain the wellness skillsthey learned while in treatment. Prevention of relapse in mental disorders is crucialnot onlybecause symptoms are detrimental to quality of life but alsobecause the occurrence of relapse increases chances forfuture relapses. In addition, with each relapse, symptoms 44. Pathogenesis Relapse is a concern with any disorder, whetherphysical or psychological. Psychological disorders can follow a similarpattern, and certain psychological disorders tend tohave a higher rate of relapse than others. Addictive disorders, such as alcohol and drugabuse, smoking, overeating, and pathologicalgambling , are well known for high levels of relapse.Many addictions involve a lifestyle centered aroundthe addictive behavior. In such cases, individuals mustnot only discontinue the addictive habit, they mustalso restructure their entire lives in order for changesto last. Such vast changes are difficult atbest, approaching impossible in the worst scenarios.For example, an individual with a drug addiction maylive in a neighborhood where drugs are prevalent butmay lack the resources to move. 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,butonce themedication 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. Relapse Prevention Identifying high-risk situations: Symptoms are often initiatedby particular times, places, people, or events. For example, aperson with agoraphobia is more likely to experiencesymptoms of panic in a crowded building. An essential key topreventing relapse is to be aware of the specific situationswhere one feels vulnerable. These situations are called"triggers," because they trigger the onset of symptoms. Whilepeople with the same mental disorder may share similartriggers, triggers can also be highly individual. People tend toreactsometimes unknowinglyto negative experiences intheir past. For example, a woman who was sexually abused asa child may have negative emotions when in the presence ofmen who resemble her abuser. Because some triggers occurwithout conscious awareness, individuals may not know alltheir triggers. Many prevention programs encourageindividuals to monitor their behavior closely, reflecting onsituations where symptoms occurred and determining what 47. Relapse Prevention Learning alternate ways to respond to high-risk situations: Oncetriggers have been identified, one must find new ways of coping withthose situations. The easiest coping mechanism for high-risksituations is to avoid them altogether. This may include avoidingcertain people who have a negative influence or avoiding locations wherethe symptom is likely to occur. In some instances, avoidance is a goodstrategy. For example, individuals who abuse alcohol may successfullyreduce their risk by avoiding bars or parties. In other instances,avoidance is not possible or advisable. For example, individualsattempting to lose weight may notice that they are more likely to binge atcertain times during the day. One cannot avoid a time of day. Rather, bybeing aware of this trigger, one can purposely engage in alternateactivities during that time. Strategies for coping with unavoidable triggersare generally skills that need to be learned and practiced in order to beeffective. Strategies includebut are not limited todiscussion offeelings, 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 musclerelaxation (focusing on each muscle group separately, and routinelytensing then relaxing that muscle), prayer, or journaling; and cognitiverestructuring, such as positive affirmation statements (such as, "I amworthwhile"), active problem solving (defining the problem, generating 48. Relapse Prevention Creating a plan for healthy living: Besides being preparedfor high-risk situations, relapse prevention also focuses ongeneral principles of mental health that, if followed, greatlyreduce the likelihood of symptoms. These include factorssuch as balanced nutrition, regular exercise, sufficient sleep,health education, reciprocally caring relationships, productiveand recreational interests, and spiritual development. Developing a support system: Many research studies havedemonstrated the importance of social support in maintaininga healthy lifestyle. Individuals who are socially isolated tendto display more symptoms of mental disorders. Conversely,individuals with mental disorders tend to have more difficultlyinitiating and maintaining relationships due to inappropriatesocial behavior. 49. Relapse Prevention Preparing for possible relapse: Although the ultimate goal ofrelapse prevention is to avoid relapse altogether, statisticsdemonstrate that relapse potential is very real. Individuals needto be aware that, even when exerting their best efforts, theymay occasionally experience lapses (one occurrence of asymptom or behavior) or relapses (return to a previous,undesirable level of symptoms or behavior). Acknowledging thepotential for relapse is important, because many peopleconsider a lapse or relapse as evidence of personal failure andgive up completely. In their widely acclaimed book forprofessionals, Motivational Interviewing , William R. Miller andStephen Rollnick cite a study by Prochaska and DiClementethat found that smokers typically relapse between three andseven times before quitting for good. From the perspective ofMiller and Rollnick, each relapse can be a step closer to fullrecovery if relapse is used as a learning experience to improveprevention strategies. Although some argue that such a tolerantattitude invites relapse, general consensus is that individualsneed to forgive themselves if relapse occurs and then move on. 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 psychotherapybeforedeciding whether to enter a relapse prevention program. 51. PROCHASKA ANDDICLEMENTES STAGESOF CHANGE MODEL 52. Prochaska and DiClementes 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. Stages of Change Model 54. General Idea of the Model ofChange Behavioural change doesnt just happen in one step instead people tend to progress through a series ofsteps. Cessation is a dynamic process. The pace is individual. Some stay at one step for therest of their lives. The decision to change and to move through thesteps must come from within the individual himself to force people to change is naive and can becounterproductive. 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 peoples 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. Stage Two Contemplation In the contemplation stage people are more aware of thepersonal consequences of their bad habit and they spend timethinking about their problem. Although they are able to considerthe possibility of changing, they tend to be ambivalent about it.In this stage, people are on a teeter-totter, weighing the prosand cons of quitting or modifying their behavior. Although theythink about the negative aspects of their bad habit and thepositives associated with giving it up (or reducing), they maydoubt that the long-term benefits associated with quitting willoutweigh the short-term costs. It might take as little as a coupleweeks or as long as a lifetime to get through the contemplationstage. (In fact, some people think and think and think aboutgiving up their bad habit and may die never having gottenbeyond this stage) On the plus side, people are more open to receiving informationabout their bad habit, and more likely to actually use educationalinterventions and reflect on their own feelings and thoughts 57. Stage Three -Preparation/Determination In the preparation/determination stage, people have madea commitment to make a change. Their motivation forchanging is reflected by statements such as: Ive got to dosomething about this this is serious. Something has tochange. What can I do? This is sort of a research phase: people are now takingsmall steps toward cessation. They are trying to gatherinformation (sometimes by reading things like this) aboutwhat they will need to do to change their behavior. Or theywill call a lot of clinics, trying to find out what strategies andresources are available to help them in their attempt. Toooften, people skip this stage: they try to move directly fromcontemplation into action and fall flat on their facesbecause they havent adequately researched or acceptedwhat it is going to take to make this major lifestyle change. 58. Stage Four: Action/Willpower This is the stage where people believe they have the ability tochange their behavior and are actively involved in taking stepsto change their bad behavior by using a variety of differenttechniques. This is the shortest of all the stages. The amount oftime people spend in action varies. It generally lasts about 6months, but it can literally be as short as one hour! This is astage when people most depend on their own willpower. Theyare making overt efforts to quit or change the behavior and areat greatest risk for relapse. Mentally, they review their commitment to themselves anddevelop plans to deal with both personal and external pressuresthat may lead to slips. They may use short-term rewards tosustain their motivation, and analyze their behavior changeefforts in a way that enhances their self-confidence. People inthis stage also tend to be open to receiving help and are alsolikely to seek support from others (a very important element). Hopefully, people will then move to the fifth stage. 59. Stage Five: Maintenance Maintenance involves being able to successfully avoid anytemptations to return to the bad habit. The goal of themaintenance stage is to maintain the new status quo.People in this stage tend to remind themselves of howmuch progress they have made. People in maintenanceconstantly reformulate the rules of their lives and areacquiring new skills to deal with life and avoid relapse.They are able to anticipate the situations in which arelapse could occur and prepare coping strategies inadvance. They remain aware that what they are striving for ispersonally worthwhile and meaningful. They are patientwith themselves and recognize that it often takes a while tolet go of old behavior patterns and practice new ones untilthey are second nature to them. Even though they mayhave thoughts of returning to their old bad habits, they 60. References http://www.recoverymonth.gov/~/media/Images/Files/Webcast%20Transcript/2011_April_DiscussionGuide-508.ashx www.AddictionsAndRecovery.org http://facultypages.morris.umn.edu/~ratliffj/psy1081/Sec5_prevention.htm http://alcohol.addictionblog.org/relapse-prevention-strategies/ Freese CBT DMH Psychiatry 2009-04-09. Treatnet TrainingVolume 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