Relapse prevention and management is the main goal when trying to reduce or eliminate drug use - the path through the stages of change is not smooth for a young person, or for anyone. However there are number of relapse-prevention and management strategies that can be used.
The term relapse is well established and is used in this module. However, the word 'lapse' is often used. Relapse implies a total reversion to heavy drug use and a sense of failure. Lapse has less negative connotations, and emphasises the everyday nature of slipping-up when trying to change behaviour. Lapses can be minor and temporary. Relapse management is the term used for working with a young person to prevent or reduce the impact of a 'lapse' before heavy drug use becomes re-established.
Even when a young person is extremely motivated to change their lifestyle and drug use, it is probable that they will encounter situations that encourage drug use. This may be due to the way they are feeling (low mood, anxiety, craving for the drug) and/or circumstances that are conducive to drug use (e.g. friends pressurising them into using, stress in relationships or at work).
What approaches do you take when working with a young person who is trying to change, but lapses?
Relapse (lapse) prevention and management
Motivational interviews and relapse drills
Relapse (lapse) prevention and managementThere are some essential ingredients of relapse (lapse) prevention and management. These include the following:
- Acknowledging that a lapse is a normal experience and should not be viewed negatively. Peers/friends are not likely to have any difficulty with this concept, but family members and workers often equate a lapse with the 'beginning of the end'. Both the young person and their families should be helped to adopt an attitude that lapses provide opportunities for learning how to avoid further lapses.
- Strengthening the motivation to change throughout the change process. Discuss with the young person (at a time that feels right for them) the need to revisit the pros and cons for maintaining change.
- Identifying high-risk situations (that include factors both internal and external to the young person). High risk factors for young people will not uncommonly include their friends and families under certain circumstances. It will help enormously if others can be aware which of their behaviours help protect against relapse and which serve as triggers. For example, a common trigger is monitoring the young person's every movement, so that they feel they are not trusted or sufficiently independent. This is a sure recipe for resentment and secretiveness, which is associated with relapse. Top of page
- Developing coping strategies and skills to avoid high-risk situations and to deal with them when they are unavoidable. One of the foremost strategies to cope with high-risk situations is to turn to prearranged supportive people such as friends and family members. Help the young person discover and participate in non-drug related alternative behaviours with friends and family to combat a possible lapse.
- Developing coping strategies and skills to deal with lapses. Again, if the worker, friends and family do not overreact, they can be invaluable in helping to terminate a lapse.
- Recognising and implementing changes to the young person's environment and lifestyle to minimise the frequency of high-risk situations and to strengthen their commitment to change.
- Positive self-talk: the young person can be helped to develop a phrase or two to repeat to themselves when tempted to use (or go beyond their limit). This phrase should be positive in tone so that it also helps to build their self-esteem (e.g. 'I've gone without before, so I can do it again'.). It would be useful for a friend or family member to help the young person develop their phrases, and could share in this process by occasionally repeating it aloud to the young person when they indicate they are feeling vulnerable.
- Problem-solving skills (see Topic 7). Enlisting family and friends in problem-solving will greatly increase the range of solutions to choose from.
- Relaxation skills. Change is stressful! Being able to relax will help to maintain change and face challenges. Craving for a drug is a very stressful experience. One of the ways of countering cravings is by relaxing and thereby reducing arousal levels. Some friends/peers, family members and situations will be an aid to relaxation, others definitely will not! There is no one way of achieving relaxation. Relaxation can also follow arousal associated with exciting risk-taking activities.
- Anger and depression management. Negative mood is associated with relapse, so mood needs to be monitored and dealt with before it builds up to a crisis. Anyone close to the young person (including the worker) can often detect the early stages of trouble brewing. They can also be the targets of anger, and so conflict resolution skills offer a huge advantage.
- Coping with craving. Young people and their supporters should be made aware that craving is normal and can be outlasted. Distraction is often useful, but the young person may also want a quiet space to retreat to until the craving subsides.
- Identify the build-up to relapse. Lapses usually occur at the end of a long chain of small decisions rather than happening 'out of the blue'. Marlatt & Gordon (1997) call them 'apparently irrelevant decisions' that result in a drift into a lapse. Identifying the early stages of the slide is very important.
A work situation
TaskSelect a young person you are working with and in point form jot down their issues and characteristics. Choose a particular situation or issue that they may have raised and, from the range of strategies above, draw up a plan to deal with it.
Motivational interviews and relapse drillsWhen you become aware that a young person has 'lapsed' a useful tool to revisit is Motivation Interviewing (Topic 4 and Topic 5). Informal discussion aimed at re-establishing the young person's motivation to maintain change may well help prevent relapse (as long as he or she welcomes the discussion - don't force it if you sense resistance).
Remember, this process is about developing a positive perspective and reinforcing the positives of maintaining change. Emphasise that a 'lapse' is not a failure.
After you have re-established a positive attitude in the young person emphasise again that a lapse is not a failure. Explain that they can use the experience to learn how to avoid further incidents.
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Ask them to recall the incidents that led up to their 'lapse'. Where were they? Who were they with? What were they doing? How were they feeling? Do they know what provoked those feelings?
The young person, with your help, can build up a picture of the situation, thoughts and feelings that preceded their 'lapse'. Think about other such situations. Were they similar? What do these situations have in common?
Consider each of these factors. Encourage and support the young person to devise strategies to deal with each of them. What can they do to avoid the situation developing? They should be specific: 'I will call this person'; 'I will go to that place'.
Remember the problem solving exercise in Topic 7. The solutions were definite and precise, not general – and possible actions were planned well in advance.
Maintaining changeLong-term maintenance of change often requires significant changes to a young person's lifestyle, such as:
- establishing social contacts that are not AOD centred (new friendships/peer group)
- establishing new leisure activities and hobbies that are not AOD centred
- living in a new place to avoid a familiar group of heavy users
- working in a new location to avoid heavy drug using scenes.