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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 12: Relapse Prevention

INTRODUCTION
During the relapse prevention stage of treatment, clients are in stable remission (not abusing substances), but they are still vulnerable to returning to substance abuse. Avoiding or reducing the impact of relapse, returning to work, improving social relationships, and getting more involved in recreational activities are important goals for the client in this stage of treatment.

This chapter presents a client who has stopped using substances and how his clinician helped him to maintain abstinence. Relapse prevention fosters the development of skills and activities to avoid alcohol and drugs and also to enhance life, for example, in the social, leisure, and vocational arenas.

VIGNETTE
Mark is a 35-year-old single man diagnosed with schizophrenia and alcohol dependence who lives alone in an apartment. He occasionally sees his brother, who is a drug dealer, and his sister, who is a secretary and doesn't use substances. Mark has been coming to the mental health center for the past 15 years. Three years ago he was referred to an assertive community treatment team for his dual disorders. After progressing through the stages of treatment, he has been sober for the last six months.

Mark and his counselor had developed a relapse prevention plan based on watching for early warning signs for relapse of substance abuse or mental illness. Hanging out with his old drinking buddies, driving by the liquor store, or being anyplace where drinking occurred, including bars or bowling alleys, were external cues, or early warning signs for his alcohol use; and not sleeping and feeling paranoid about police were early warning signs for his schizophrenia. Once these were identified, Mark and his counselor wrote down a relapse prevention plan that specified steps to take if he experienced any of these cues or high-risk situations. The plan also addressed what to do if he did relapse in order to minimize the length and severity of relapse. In Mark's case, the plan included immediate calls to his sister and to his counselor.

Since it was clear that spending time with old drinking buddies wasn't a good idea, Mark wanted to find new friends. He first renewed relationships with family. Mark enjoyed being around his sister again, went fishing with his brother-in law, and had weekly dinners with his sister's family. His counselor helped him work on social skills to use in making new sober friends. He attended one meeting of Alcoholics Anonymous, but felt uncomfortable and didn't return. He did, however, join a local church and met several people by attending regularly.

In addition, Mark began to expand his recovery to other areas of his life. Although he had been working part-time as a janitor for the mental health center, he was dissatisfied with this job. An employment specialist helped him to find a new job working in the stock room of a local retail store, a job that he really enjoyed.

Two years later, Mark was still not drinking, though he had experienced one brief relapse after running into an old drinking buddy at the grocery store. He was able to call his sister the next day, and she helped him get back on track by calling his case manager, renewing his goal to be sober, and developing a plan for what to do if the old friend called him.. He was still working part-time, enjoying a positive relationship with his sister, and attending church. He said, "Some days I still wish I could drink, but I know I just can't go back." Despite encouragement and support, he did not return to Alcoholic's Anonymous. He did continue to meet with his case manager regularly to review his relapse prevention plan.

HOW TO HELP CLIENTS WHO ARE IN THE RELAPSE PREVENTION STAGE OF TREATMENT
Mark is in the early relapse prevention stage of treatment, where the main goal is to maintain his sobriety and expand his recovery to other areas of his life. His case management team, including his counselor, has taken five important steps to help him remain stable and sober, but also to help him expand his recovery. The first step is to make a relapse prevention plan that will enable Mark to prevent a relapse or to stop a relapse at the earliest possible point if it occurs. The next step is to develop better social skills to establish friendships with sober friends as well as to get along with family, roommates, and coworkers. A third important goal is to develop (or renew) social and leisure activities as alternative outlets from using alcohol and drugs. A fourth step is to explore new job possibilities that Mark finds more interesting than his current job. The last important step is to participate in self-help groups to maintain motivation and social support for sobriety.

These steps do not need to be accomplished in any particular order. Some clients will focus on a few but not all of the steps. Many clients will begin to work on some of these steps during earlier stages of treatment. Also notice that client preferences and choices are important. Mark did not want to use Alcoholics Anonymous but found that church was a consistent support system for him.

MAINTAINING AWARENESS
Many of the skills and techniques used during active substance abuse counseling are still relevant in the relapse prevention stage of treatment. The clinician and client need to remember the client's specific cues or triggers for substance use. Though high-risk situations will be unique to each client, there are some cues or triggers that are common to many people. Common external cues include being with people or in situations where the client previously used substances, experiencing interpersonal stress (such as a disagreement with a family member or a breakup with a girlfriend), experiencing loss (losing a job or a case manager), and experiencing a relapse of mental illness symptoms.

The client then needs to learn to use strategies to avoid substance use when faced with an external cue. This may involve working with his clinician, treatment group, or self-help group to develop specific skills to carry out these strategies. They will include refusing substance use, leaving a stressful situation, and using distractions or other alternative behaviors, such as listening to relaxing music, instead of using the substance. Finally, identifying a supportive contact person who can be called for direction and support when the client feels he is at risk for using substances is vital.

Mark's main cues to drink involved being around people who drink or in places where drinking occurs. To address the cue of people who drink, the clinician can help him come up with ideas. Possible plans could include: (1) how to avoid these people, (2) finding different people to be with, (3) refusing a drink if he is with those people and is offered one, (4) calling a support person before taking a drink, and (5) staying busy with a particular activity or job to help him stay away for the old drinking friends.

SOCIAL SKILLS
Mental illness often interferes with relationships, and people with severe mental illness often have problems communicating effectively. They may then use substances with others as a way of joining a social group and finding acceptance from others. That is, many dually diagnosed persons rely on substance use for social contact. With ineffective social skills, they are unable to refuse offers to use substances from old peers and are unable to develop new friendships with sober peers. Thus, developing good social skills is key to maintaining sobriety.

People use three types of skills to communicate with another person: social perception, problem solving, and behavioral skills. A person must be able to accurately perceive relevant social information in the situation, such as the other person's affect and whether the situation is public or private. After the person has sized up the situation, he needs to be able to decide on a communication goal, to identify options for achieving that goal, and to select one with a high chance of success. This involves solving problems. Once a response to the person has been selected, behavioral skills are needed to put it in action. These include non-verbal behaviors, such as how close to stand to another, and verbal behaviors, such as loudness and choice of words. Social skills training programs are available in user-friendly manuals (see Recommended Readings below).

Groups or individual counseling can be used to teach social skills. The five basic skills important as a foundation for more complex skills include: (1) listening to others, (2) making requests, (3) expressing positive feelings, (4) expressing unpleasant feelings, and (5) refusing an unreasonable request. Clinicians can explain the behavior and its specific components, show the client the specific skills, and help the client to practice the skills with the clinician or with other clients in a group. Clients need feedback and practice to be able to use these skills in real life.

RECREATION, WORK, AND FRIENDS
When a client has a substance use disorder, using substances typically becomes a preoccupation so that other enjoyable activities and relationships are given up. Often clients with dual disorders can't remember how they used to have fun. If the only rewarding activity in a person's life is using alcohol, he is unlikely to give it up unless he has learned other ways to have fun. People with dual disorders often need to relearn ways to relax and pursue enjoyment. Clinicians should ask clients what they enjoy doing. Sometimes you will have to help the client remember what he did as a child to help him remember what he used to like to do for fun. Ask about all kinds of recreation: hobbies, crafts, sports, social activities, clubs, classes, art, household activities, yardwork, and volunteer work.

In some cases, it is helpful to give clients a list of fun activities and ask them what they used to do for fun and what they'd like to do now for fun (see Table 4). The list reminds people about which activities can be fun. Help the client set a goal for specific activities they'd like to complete in the next week and help them fulfill the goal.

Table 4. Fun Activities

VOCATIONAL GOALS
Work is a critical part of recovery for many clients. Having a daily activity like work is a major predictor of staying sober. Aside from the financial rewards, work is reinforcing in many ways that help people stay sober. Going to work helps people feel normal. It gives people a sense of purpose in life and helps them feel they are contributing to the world. It provides a place to make friends with other sober people. It provides structure in the day.

Surprisingly, people with dual disorders can hold down jobs as well as people who have severe mental illness who don't have substance use problems. Furthermore, many report that working was a key step in the recovery process. Encourage your clients to work. The vocational services described in the vocational toolkit are effective for people with dual disorders.

SYMPTOMS OF MENTAL ILLNESS
Episodes of mental illness can lead to relapses in substance use. Thus, it's important to encourage your clients to use medications, manage stress management, get adequate sleep, use social support, engage in enjoyable activities, and use recovery strategies to avoid or minimize symptoms of mental illness as well as to avoid abusing substances. Rather than badgering your client to take medication, you can help the person to develop an overall plan for achieving and maintaining wellness. This plan usually involves learning how to use medications effectively as well as many other strategies.

Recommended reading
Social Skills Training for Schizophrenia: A Step-by-step Guide, by Bellack, Mueser, Gingerich and Agresta (Guilford, 1997).

Relapse Prevention, Maintainance Strategies in the Treatment of Addiction edited by Alan Marlatt.

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