AN OVERVIEW OF RELAPSE PREVENTION 1 LUIS LABOY, MPA, CASAC DEFINITIONS, PERSPECTIVES, AND THE PSYCHO EDUCATIONAL RELAPSE PREVENTION MODEL 2 GOAL: Participants will gain an understanding of historical perspectives of relapse definitions, the basic problems associated with reported relapse/recovery rates, a multi-perspective view of relapse prevention, and the psycho educational model of relapse prevention. OBJECTIVES: Upon completion of this section participants will be able to: 1. Describe the traditional definition of relapse. 2. Discuss definitions of relapse with a historical perspective. 3. Discuss at least two problems with relapse/statistics. 4. Identify at least three systems which have an impact on relapse. 5. Describe at least three variables associated with client relapse. 6. Discuss the Psycho educational model of relapse prevention. Goal of addiction treatment and relapse definitions 3 The primary goal of addictions treatment, as in other areas of medicine, is to help the patient to achieve and maintain long-term remission of disease. In the addictions field there has been continuing and growing concern among clinicians about the rates of relapse in the client population. For this reason, it is important to understand the issue of relapse and relapse prevention. WHAT STATISTICS DO YOU REPORT TO CLIENTS? STATISTICS 4 1980 classic AA survey (25,000 individuals) found relapse rate of 60% for those sober under one year, drops to 10% for those with 5 or more years of sobriety. 1980 AA-50% of newcomers to AA drop out within one month. Of the remaining 50%, 41% were attending a year later. 1982 Gorski reported that 60% of those clients treated privately relapsed. 1989 NIAAA reported 90% of alcoholics will have one relapse over the four year period following treatment. BE CAUTIOUS DUE TO POSSIBLE ERRORS IN VARIOUS STATISTICS REPORTED. 5 No standard measure Different treatment populations Cumulative effects of multiple treatments over time is difficult to measure. Individuals with dependence vary significantly in length and severity of dependence and related physical, psychological, social, familial, and spiritual problems. DEFINITION OF RELAPSE 6 To fall back or revert to a former state , regress after a period of recovery from illness, to slip back to bad ways. A tendency to revert back to criminal behavior. Relapse was initially viewed as use of alcohol, then expanded to include the use of any sedatives. In the 1960’s it was expanded to include use of any mind altering substances. In the 1980’s relapse started to be viewed as a process, not the event of drinking and drugging. FIVE PERSPECTIVES ON RELAPSE SEE HANDOUT PP 2-4 Perspective 1- The Chemically Dependent Person 7 This involves understanding relapse from the point of view of the client which involves: Gaining insight into the experience and impact of relapse (Learn from it). Identifying relapse triggers(internal and external). Knowing relapse prevention skills. (PP &T, saying no…) Relapse is confusing to the client and it does occur with those who are motivated to change. Twelve step programs like AA and NA address relapse in their literature. Relapse occurs due to the interaction of many variables including; affective; behavioral; cognitive; environmental; relationship; physiological; psychiatric; and spiritual. 8 AFFECTIVE VARIABLES: + and – mood states have an impact on relapse BEHAVIORAL VARIABLES: few effective ways to deal with situations that threaten sobriety. There is a positive correlation between abstinence and the acquisition of coping skills. Clients need to be taught alternative coping skills to increase ability to manage high risk situations. COGNITIVE VARIABLES: attitude towards addiction and recovery. Self-efficacy or the persons perception of his or her ability to cope with prospective high risk situation. Outcome expectancy or anticipated effects of picking-up. Attribution of casualty which determines whether a lapse will eventuate in a full blown relapse. Decision making. Level of cognitive functioning. Learning differences. Head Trauma. Relapse occurs due to the interaction of many variables including; affective; behavioral; cognitive; environmental; relationship; physiological; psychiatric; and spiritual. Cont. 9 ENVIRONMENTAL AND RELATIONSHIP VARIABLES: The lack of social and family stability. Primary relationships with people who are addicted. (partners) Social pressure to use. Major life changes. Lack of productive work, school roles, involvement in leisure or recreational activities. PHYSIOLOGICAL VARIABLES: craving and conditioned responses elicited by environmental cues. Brain chemistry. Diet, medications, illness or physical pain. Severity of dependence. H.A.L.T. Relapse occurs due to the interaction of many variables including; affective; behavioral; cognitive; environmental; relationship; physiological; psychiatric; and spiritual. (Cont.) 10 PSYCHIATRIC VARIABLES: Coexisting psychiatric disorder. A second compulsive DO. PTSD-combat, rape, child sexual abuse, parental violenece SPIRITUAL VARIABLES: Self-centeredness Guilt Shame lack of meaning for life Feeling empty. PERSPECTIVE 2- THE FAMILY 11 Family can provide an important and positive role in recovery or family can sabotage recovery. Relapse affects the family in several ways. The effects are mediated by: The nature of relapse (length, severity, medical/behavioral/legal and or economic problems it causes). Family members’ perception of recovery and relapse, and reason for relapse. PERSPECTIVE 3- THE ADDICTIONS PROFESSIONAL 12 The counselors knowledge of addiction, recovery and relapse are variables affecting the relapse process. Failure to thoroughly educate their patients about the relapse process and ways to avoid it. Poor therapeutic relationship-not engaging the client, canceling appointments. Negative feelings towards the client. Enabling-minimizing or bying into clients defenses. Failure to make an appropriate referral such as mental health,… PERSPECTIVE 4 – TREATMENT SYSTEM 13 Tx. Process-length of time in treatment , completion, number of episodes, modalities, individualized tx. Plan. Treatment system factors include: Length of waiting list. Lack of aftercare services. Lack of family services or failure to engage family. Limited availability of residential sources. Failure to address long term tx. Needs. PERSPECTIVE 5- OTHER SYSTEMS 14 VIRTUALLY ANY COMMUNITY SYSTEM CAN CONTRIBUTE TO CLIENT RELAPSE. Prescription medications Mental Health service provider ignoring addiction. Managed care provider denying payment or limiting services Relapse can best be understood by viewing it from a number of perspectives since it is a complex process. Exercise HOW DO YOU VIEW RELAPSE. 15 Who’s fault is it? Who needs treatment? Does Treatment work? What are the views of 12 step/Self Help Groups? DSM-IV TR SUBSTANCE DEPENDENCE COURSE SPECIFIERS 16 Substance dependence is conceptualized as having different degrees of remission. The remission specifiers can be applied only after one of the criteria for Substance Dependence have been present for at least one month. The specifiers do not apply to individuals “On Agonist Therapy or In A Controlled Environment. Early Full Remission. Used if for at least 1 month but less than 2 months, no criteria for dependence or abuse have been met. Early Partial Remission. Used if for at least 1 month, but less than 2 months, one or more criteria for dependence or abuse have been met. (but the full criteria for dependence have not been met) Sustained Full Remission. Used if none of the criteria for Dependence or Abuse have been met at any time during a period of 12 months or longer. Sustained Partial Remission. Used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met. RELAPSE PREVENTION TREATMENT MODELS Dennis Daley’s Psycho educational Model of Relapse Prevention 17 The goals for this model are : to provide information on topics relevant to relapse prevention and intervention to clients in early recovery. To help instill in clients the attitude that sobriety and relapse prevention are ongoing processes requiring long term commitment to working a program for change. To introduce clients to cognitive/behavioral coping strategies and assist them in dealing with high risk factors. To motivate clients into developing a relapse prevention plan based on their unique experiences. To help clients learn how to interrupt an actual relapse should one occur. Daley used developed this model in groups with a workbook in a residential setting. Dennis Daley’s Psycho educational Model of Relapse Prevention GROUP STRUCTURE AND CONTENT 18 Session 1: UNDERSTANDING THE RELAPSE PROCESS: Help clients understand relapse as a process and event. With use of actual relapse experience clients are taught cues and warning signs. Emphasis is on how clients set themselves up. Examine time frame from emergence of symptoms to alcohol/drug use. Also the when, where and who was involved. Devise positive coping strategies in small groups then share in the large community to teach new clients. This material is adaptable to individual and family sessions. Session 2 & 3: Identifying & handling High Risk Situations: Help clients anticipate potential problems or high risk factors and develop a strategy. Situations to be reviewed include: negative feelings and thoughts, social pressures, treatment related problems, urges, cravings, and other high risk situations. Dennis Daley’s Psycho educational Model of Relapse Prevention GROUP STRUCTURE AND CONTENT 19 Session 4: Identifying and Handling Urges or Cravings to use Alcohol or Drugs. Help client understand cravings is normal. Help recognize internal & external triggers. Establish craving management strategies to include: Labeling the craving and accepting it is normal. Putting conflicts with cravings into words and talking about them with others. Using self-talk procedures to change thoughts and talk oneself through the craving. Evaluating potential negative consequences of giving in to craving. Reminding oneself of the benefits of abstinence. Avoiding situations that would exacerbate the cravings. Maintaining a written craving journal. Dennis Daley’s Psycho educational Model of Relapse Prevention GROUP STRUCTURE AND CONTENT 20 Session 5: Identifying and Handling Social Pressure to Use Substances. Identify social pressures. Utilize role plays to practice skills. Evaluate for AOD dependence with significant others-utilize IC or other groups for additional support. Session 6: Anger Management: Help clients understand the connection between anger and relapse. The problem solving process can involve the following steps: Learn to recognize one’s anger Identify factors contributing to these feelings. Identify effects on self and others. Review alternative methods of handling anger. Anticipate positive outcomes of utilizing new responses. Dennis Daley’s Psycho educational Model of Relapse Prevention GROUP STRUCTURE AND CONTENT 21 Session 7: Handling Boredom and Using Leizure Time. Help clients understand how boredom can impact the relapse process, identify sources of boredom and the most difficult times of the week or day. Identify leisure interests. Session 8: Stopping Actual Relapse. (Learn from past relapses) Factors associated with relapse Warning signs Specific thoughts/feelings following the first use. SECTION II THE COGNITIVE BEHAVIORAL MODEL OF RELAPSE PREVENTION 22 Goal: Participants will gain a basic understanding of the cognitive behavioral model of relapse prevention. Objectives: upon completion of this section participants will be able to: Describe the cognitive behavioral definition of relapse. 2. Distinguish between a lapse and a relapse. 3. Describe at least 5 high risk situations. 4. Discuss the issue of a triple column technique. 1. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 23 This approach is a self-control program designed to teach individuals who are trying to change their addictive behavior, how to anticipate relapse, cope with it, and prevent it. This model is not based on the disease model. Theoretical assumptions: addictions are jointly caused by past learning, situational antecedents, rewards and punishments, beliefs and biological influences. The behavior exist in a continuim between social drinking and dependent drinking. Addiction is a maladaptive coping response to life stressors and problems. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) SEE HANDOUT 8-9 24 With addiction it is useful to view habit change as a multi stage process. The stages of change by Prochaska and DiClemente is a useful model in this regard. They studied 900 individuals who gave up smoking, in term of the process of change and the stages of change. They suggested that an individuals willingness or preparedness to change would be directly related to stages of change. And noticed relapse is common. The stages are as follows: 1. Precontemplation Stage: the individual may not be aware that their behavior is creating problems and it is not until acknowledgement of the link between behavior and the problem that they enter the next stage. The primary defense is denial. 2. Contemplation stage: at this point the individual begins to consider altering their behavior. Ambivalence is common, “yes but” syndrome. 3. Determination Stage: the individual now makes a serious commitment to action, this process may be gradual or sudden, but the individual will now move either on to action back to contemplation. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 25 Action Stage: in this stage the individual makes a choice of strategy for change and pursues treatment. This indicates a level of acceptance. 5. Maintenance Stage: this is the real challenge in all of the addictive/compulsive behaviors. This stage allows the individual to maintain gains, continue growth, and prevent relapse. 6. Relapse: a very common phenomena. It is important to intervene as early as possible to prevent further deterioration. The cognitive behavioral relapse prevention model defines: Relapse: a violation of a self-imposed rules towards maintaining recovery. Lapse as a single instance of violating the rule. Since lapse doesn’t always lead to relapse, it is viewed as a transitional state which can be valuable for learning. 4. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 26 THERE ARE TWO CONCEPTUAL COMPONENTS MATCHED BY TWO CORRESPONDING TREATMENT COMPONENTS. CONCEPTUAL COMPONENT 1: High Risk situation Begins with the assumption that the individual voluntary chooses to adapt a rule or set of rules for changing an addictive behavior. The person experiences perceived control over the behavior until a high risk situation (HRS) occurs. HRS is any situation which threatens perceived control and increases the possibility of lapse or relapse. 71% of relapses studied in 1980 were linked with one of three types of situations: 1. negative emotional states. 2. interpersonal conflict. 3. social pressure to violate the rule set. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 27 CONCEPTUAL COMPONENT 1: High Risk situation (continued). According to CRP, the likelihood of relapse depends on the person’s ability to cope with HRS. If the person does lapse, the abstinence (rule) Violation Effect (AVE) was postulated to depict how the person will react. AVE explains how a lapse escalates to a relapse. AVE has two elements: 1. The cognitive dissonence element- refers to the conflict ones prelapse self-image and self image post lapse. 2. Personal Atribution-describes the tendency to attribute the cause of the relapse to internal traits such as personal weakness or failure. It can become a self-fulfilling prophesy if the person has a negative belief system. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 28 Treatment Component1: Specific Intervention Techniques for HRSs. If past lapse physical and psychological reactions are perceived as positive relapse can result. (see handout p. 10). A combination of behavioral and cognitive skills are taught to help clients deal with HRS. Assessment: Remains on going during entire treatment process. Organized around HRS and skills assessment. Assessment of HRS: must first identify and anticipate the situations. Methods: A. Collect background information 1. Autobiography-rich source of information, paterns. 2. Structured interview.(handout p11-13) 3. Relapse fantasies-describe imaged situations, dreams (Reservations). 4. Glow Line-charting alcohol/drug history. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 29 Treatment Component1: Specific Intervention Techniques for HRSs. B. Self monitoring- keep records of amounts consumed, date, time, circumstances, rate moods. If abstinence-monitor cravings, circumstances, times, place, numerical rating for intensity, rate mood before, during and after the urge. Two weeks of data collection can quickly highlight influences and internal states. Assessment of preexisting coping abilities: Tools- 1. “situational competency Test”by Chaney, O’leary and Marlatt(1978). Client presented with a number of written or audio taped descriptions of potential relapse situations and then needs to respond. Response are then scored. (See handout P14) 2. Self-efficacy rating-also response to relapse situations. Results lead to focus of skills training. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 30 Alternative Skills Training (see page 15) CRP model now begins to teach that the client alternative ways to cope with HRSs. 1. Risk Recognition – recognition is an important step towards clients to developing a warning system. It is not always possible to avoid HRS, so learning coping skills enables the individual to get through difficult situations. 2. Remedial Skill Training- is the corner stone of the CRP treatment. It addresses the individuals deficiencies in coping skills. For instance, if the individual engages in addictive behavior after an argument with a significant other than remedial skill training could include: 1. COMMUNICATION SKILLS 2. ANGER MANAGEMENT SKILLS MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 31 Alternative Skills Training (see page 15) CONTINUED… 3. Urge Coping- clients must be prepared for the fact that urges will occasionally occur: A. one strategy is to let clients know that the urge does not indicate treatment failure, but instead represents a conditioned automatic reaction of either internal or external cues. B. Urges also vary in intensity and should not be viewed as a linear rise in discomfort. Urges are more curvilinear. A useful metaphor is “urge surfing” urges are like ocean waves, which: rise, crest and fall. Clients are encouraged to ride out the wave and maintain balance without wiping out. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 32 3. Urge Copingc. Another cognitive strategy instructs the client to view the urge with detachment as an external entity that can be defended off. A useful metaphor is that of a samurai warrior whose task is to become skilled at recognizing the urge and then fending off until it decreases. 4. Behavioral Urge Coping Skills are useful in preventing and managing urges. It may target an external cue such as a beer mug which can be removed. Remove all paraphernalia associated with use. Utilize avoidance strategies (People, places and things). Label the urge- “here it comes again” (awareness) Break the continuity of the urge by changing seats, going for a walk, calling a friend. It is not possible to think of two things at the same time. MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 33 5. Coping with Lapse- the clients reaction to having a lapse is pivotal intervention point in the CRP model because it can determine from a single lapse if the client moves to full blown relapse. To assist clients in this area: Set a therapeutic contract to limit use if it occurs. Use cognitive restructuring to help client view the lapse as a mistake, not as an irreversible failure. Utilize wallet cards for emergency plans- should include specific plans with names and telephone numbers. The text of the wallet card can include the following antidote: A single slip does not indicate full blown relapse. A single slip should be viewed as a reasonable mistake that can be evaluated and learn from. A single slip may create disappointment. Do not focus on guilt and conflict that can lead to further drinking. Blame should be placed on HRS and lack of coping skills, not personal weakness. Conceptual Component II: Covert antecedents of a relapse situation 34 An important question is: How does a person end up in a HRS? It may be unexpected or concocted “Set-up”. In covert antecedents analysis, lifestyle can lead to lapse. Daily routines and obligations (shoulds) can lead to feelings of stress. Shoulds can lead to feelings of deprivation. This in turn can lead to thoughts of “I owe myself a few drinks”. Lifestyle imbalance can lead to the desire for immediate gratification which can lead to urges/cravings. CRP conceptual components analyze: 1. How HRS lead to return to addictive behavior. 2. How people who set out to alter their behavior wind up in HRS. Based on these analysis the CRP treatment procedures stress two goals teaching people to: Cope effectively with HRS. Identify and respond to the early warning signals that steer them towards HRS MARLATT & GORDON’S RELAPSE PREVENTION MODEL GOGNITIVE BEHAVIORAL RELAPSE PREVENTION (CRP) 35 Treatment Component II-Global lifestyle intervention techniques An imbalance of lifestyle is characterized by more shoulds (obligations and duties) than wants (involvement in gratifying activities), which can lead to a sense of deprivation, which can in turn lead to a desire for immediate gratification (alcohol/drugs). The final thrust of the CRP model is teaching the client to achieve and maintain a balanced lifestyle that will promote mental and physical wellness (Inoculation against being set up for relapse). Recognition of lifestyle Balance. Use of self-monitoring techniques to inventory wants and shoulds. Daily inventories to record duties/obligations and fulfilling activities. Discrepancies can be measured. Treatment Component II-Global lifestyle intervention techniques 36 Restoring lifestyle balance 1. Involvement in regular exercise, yoga, messages, manicures, dance, etc. 2. Enjoy social activities. 3. Other activities to induce positive feelings such as movies, cooking, concerts, gardening, music, hobbies, drives. 4. Try new things clean. Recognition of urges and apparently irrelevant discussions. 1. Recognizes urges. 2. Utilize urge coping skills, 3. Assess “apparently irrelevant decisions”, such as keeping beer in the refrigerator in case a friend stops over. These are decisions that place a clients recovery at risk. Assist client in seeing distortions. 4. Clients can prepare a relapse road map that is metaphorically developing a map of the journey from initial cessation to prolonged abstinence. This will help him identify necessary adjustments needed. The CENAPS Model of Relapse Prevention Planning By Terrence Gorski (see handout p. 18) 37 The CENAPS relapse process begins when the individual begins to become dysfunctional in recovery and ends in chemical use. Assumption of the CENAPS Model of relapse: 7. Recovery is the process of learning how to live a meaningful and comfortable life without drugs. Abstinence is a prerequisite for recovery. Abstinence alone is insufficient for full recovery to occur. The relapse progression begins long before the person starts using. Relapse begins with internal and external dysfunction. The dysfunction causes such severe pain and life problems that selfmedication may seem like a positive option. The client perceives four options: insanity, suicide, physical collapse or self-medication. Use is the last stop on the relapse progression. 8. The client is usually out of control before drug use begins. 1. 2. 3. 4. 5. 6. The CENAPS Model of Relapse Prevention Planning By Terrence Gorski 38 Implications of the CENAPS Model 1. 2. 3. 4. 5. 6. Treatment must focus on more than simply teaching the client how not to use. The long term task of recovery needs to be explained to the client so that he has a road map to recovery. Treatments needs to follow client over a long term continuum of recovery, for a minimum of 3 to 5 years and it must be easily accessible to client who gets stuck at some point in the recovery process. People in recovery must learn to recognize and manage early warning signs. Relapse needs to be viewed as a normal and natural part of recovery. Specialized relapse prevention techniques needs to be developed for client rethreads that have been unable to maintain abstinence. SOBRIETY BASED SYMPTOMS OF ALCOHOLISM 39 Brain dysfunction occurs during periods of intoxication with both cellular death and withdrawal. As the addiction progresses the client can experience brain dysfunction that can create problems thinking clearly, managing feelings, memory problems, sleep problems, increased stress and problems related to psychomotor coordination. Sobriety based symptoms also present themselves in sobriety. There are six major sobriety based symptoms of alcoholism: 1. ACUTE ABSTINENCE SYNDROME Central nervous system agitation 1. Hangover 2. Tremors 3. Convulsions within 24 hours 4. Hallucinations within 48 hours 5. DTs- about 72 hours after last drink. Internal anguish SOBRIETY BASED SYMPTOMS OF ALCOHOLISM 40 Post-Acute withdrawal: is a bio-psycho-social syndrome. The term refers to the damage done to the brain central nervous system particularly the higher cortical regions of the brain. PAW is referred to as neurotoxicity, sub-organic clinical disorder, “stinking thinking” “dry drunk” prolonged abstinence syndrome, protracted withdrawal, and BUD (Build up to drink). Over time it can get better or worst. The symptoms may come during periods of high stress for the rest of the patients lives. Caused by chronic drug use. The symptoms include difficulty thinking clearly, difficulty managing emotions and feelings, difficulty in remembering things, difficulty sleeping restfully, difficulty in physical coordination, and managing stress. Treatment includes education to remove guilt, shame and fear. Symptom identification and management. Reversal of predisposing psychosocial stressors. 2. SOBRIETY BASED SYMPTOMS OF ALCOHOLISM 41 State dependent learning: that which was learned in one state is best recalled in that same state, and is difficult or impossible to perform in a new state until new learning takes place. 4. Adjustment reaction to abstinence: reactions to lifestyle changes needed in recovery, the changes in habits and daily routines to become recovery focused rather than alcohol focused. 5. Denial: sobriety based, acceptance of the disease does not necessarily interrupt all denial patterns, such as personal short comings or personal problems, denial of the possibility of relapse, denial of the need to change. 6. Cravings. 3. THE DEVELOPMENTAL MODEL OF RECOVERY (DMR) 42 The DMR is a roadmap to recovery. All humans pass through developmental stages from birth through infancy, childhood, adolescence and adulthood. At the early stages we develop basic skills and then move through more complicated tasks and skill building. The DMR is composed of six stages (phases): 1. Pre-treatment-may take a period of months to years. 2. Stabilization- four to eight months. 3. Early Recovery-6 to 18 months. 4. Middle recovery- 12-18 months. 5. Late recovery- 18-24 months. 6. Maintenance- lifetime. THE DEVELOPMENTAL MODEL OF RECOVERY (DMR) (handout 24-26) 43 Pre Treatment Phase- theme is giving up the need to control use. MAJOR TASKS 1. Recognition of addictive disease, need for abstinence and begin recovery process. Stabilization Phases- theme is learning how to abstain. MAJOR TASKS 1. RECOVERY FROM ACUTE WITHDRAWALS. 2. Stabilization of post acute withdrawals. 3. Resolution of drug related crisis. Early Recovery Phase- theme is learning to become comfortably clean. MAJOR TASKS 1. Compliance with externally regulated recovery program. 2. Recognition and acceptance of addictive disease. 3. Learning non-chemical coping skills. 4. Developing a recovery oriented value system. THE DEVELOPMENTAL MODEL OF RECOVERY (DMR) (handout 24-26) 44 Middle Recovery- theme is developing a lifestyle balance. Major Tasks 1. Establishing a self-regulated recovery program. 2. Re establishing major social structure: work, family, intimate, social. Late Recovery- theme is growing up beyond childhood limitations. Major Tasks 1. Identify and correct childhood mistaken beliefs. 2. Clarify adult value system. 3. Develop new life goals and plans. 4. Maintenance- Continued growth and development. Major Tasks 1. Continued personal growth. 2. Effective coping with day to day life problems and transitions. 3. Maintain a recovery program. CENAPS RELAPSE PREVENTION PLAN (SEE HANDOUT P. 27) 45 This model incorporates a nine step process. 1. Stabilization: bring relapser back to detox. Identify and manage PAW 2. Assessment: of the presenting problems, current relapse dynamic, relapse history, levels of treatment completed, unresolved DMR issues, factors effecting recovery and personalitystyle. 3. Relapse education: recovery process, warning signs and understand relapse patterns. 4. Warning sign identification: construct individualized list. 5. Warning sign management: teach client to interrupt the dynamic, develop three strategies for each warning sign. 6. Review recovery Program: address problems that surfaced during assessment, client may need more meetings, a sponsor or therapy. CENAPS RELAPSE PREVENTION PLAN (SEE HANDOUT P. 27) 46 7. 8. 9. Inventory training: Gorski recommends two daily inventory procedures. First establish a morning routine of outlining a plan for the day. Secondly, in the evening, review the tasks of the day to see what went well and what needs improvement. Involvement of significant others: assess key players.(Significant others) request what he would like from invited intervenors. Follow-up: up date relapse prevention plan as needed. Discuss counselor wellness, two hatters and causes of relapse.