Refusal Skills:
How to Say ‘No’ Effectively
Louisiana Association of Drug Court Professionals
April 11-13, 2012
Jane E. Pfeifer, MPA
Addiction
• An addiction exists when a person
ceases to be able to make choices.
Peele, S. (1981). How Much is Too Much,
Englewood Cliffs, NJ: Prentice Hall
• Continued use despite adverse
consequences.
DSM-IV
How do you define relapse?
1. ________________
2. ________________
3. ________________
The Concept of Relapse
• The resumption of drug use after a period
of abstinence.
• A return to the previous level of use.
• Engagement in any unsafe behavior such
as breaking program, resuming contact
with using associates, self-harm, and noncompliance with medications.
Relapse
“An unfolding process in which the
resumption of substance abuse is
the last event in a long series of
maladaptive responses to internal
or external stressors or stimuli.”
Malhotra, Basu and Gupta, 2005
Degree of relapse?
Lapse/slip
vs.
Relapse
vs.
Full blown relapse
WHAT?
System Response to
Relapse
Is Crucial
• It should be SWIFT
• It should be CERTAIN
• It should be APPROPRIATE
Relapse responses
Lapse: continue treatment
Relapse: increase services
Full Blown: increase services, and control
the client’s environment
Good Intentions…
• “He just put the cocaine right out on my
coffee table and I couldn’t say ‘no’”.
• “They said we were just going to his
sister’s apartment to hang out. I had no
idea there would be drugs there.”
• “I didn’t think it would be a problem being
around my family, all they do is drink beer.”
What might lead to relapse?
•
•
•
•
•
•
Unresolved stress or trauma
Negative or positive emotions
Social pressure
Use of other substances
Presence of drug related cues
What else?
How can we tell if someone is
in a relapse mode?
• Return to old, unsafe behaviors (people,
places and things)
• Letting their guard down
• Reduced vigilance
• Increased demands
• What do you see?
Triggers
Cues & Triggers
•
Researchers observed that when
presented with stimuli, clients
consistently reported feelings of being:
1. “High”
2. “Withdrawal”
3. “Craving”
Refusal Skills
• Identify triggers/cues
• Make a plan to avoid triggers/cues
• Develop response strategies
Identify Triggers and Cues
• Discuss past use situations
– Who
– What
– When
– Where
• Discuss current challenges
• Make a list
• Offer insight [Last, because it’s last]
Make a Plan
• Most risk situations are avoidable, but
not all
• Review list of triggers/cues
• Discuss how to avoid each situation
• Write down specific ways to avoid
situations
• Help the client problem solve
Remember these?
• “He just put the cocaine right out on my
coffee table and I couldn’t say ‘no’”.
• “They said we were just going to his
sister’s apartment to hang out. I had no
idea there would be drugs there.”
• “I didn’t think it would be a problem being
around my family, all they do is drink beer.”
Develop Response
Strategies
• Review list of triggers and cues
• List individually the people who might offer
drugs or encourage drug use
• Prepare response to each person/situation
• Tips:
–
–
–
–
–
–
Say ‘no’ first
Make direct eye contact
Ask the person to stop offering
Don’t be afraid to set limits
Don’t leave the door open for future offers
Be assertive, not passive
Thought Stopping
•Visual Imagery
•Snapping
•Relaxation
•Call Someone
•Pray
Other Strategies
•
•
•
•
•
•
Delay
Ask questions
Name the trouble
Name the consequence
Suggest realistic alternatives
Move on
Added Challenges:
Dual Diagnosis
Patients with dual disorders often experience more
severe and chronic medical, social and
emotional problems.
They are vulnerable to both AOD relapse and a
worsening of the psychiatric disorder.
Patients with dual disorders often require longer
treatment, have more crises, and progress more
gradually in treatment. (See TIP 9).
Recap
• What is our role in reducing the likelihood
of a client relapsing?
• How is it different if we’re the judge? Or
the treatment provider? Or the case
manager? Or ?
• What are the strategies we can use to
assist clients before they use?
JanePfeifer@msn.com