Objectives A Fresh Look at RelapsePrevention

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Objectives A Fresh Look at RelapsePrevention

Transcript Of Objectives A Fresh Look at RelapsePrevention

A Fresh Look at
Relapse Prevention:
From Gorski to Behavioral Economics Erik Anderson, LMSW, CAADC [email protected]

2/24/18
Objectives
Participants will:
• Gain in-depth knowledge of relapse as a process and
identify stages of the process in returning to AOD use.
• Explore the research around willpower and identify the
strengths and weaknesses of willpower as a resource for maintaining recovery.
• Examine the role of habits in sustaining behavior change. • Examine a framework for understanding personal, social,
and structural influences on addiction/recovery and explore interventions in each domain.
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Short-term Relapse Rates
▪ 40% to 60% return to alcohol or drug use in the first year after treatment.
▪ 60% of those who return to use will have multiple periods of abstinence and use.

Long-term Relapse Rates
▪ Pathways to Long-Term Abstinence CSAT funded pilot study (n=354)
▪ Over 50% had sobriety periods of year or longer before relapse
▪ 29% relapsed after three years or longer

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“Addiction is a primary, chronic disease of brain reward, motivation, memory and
related circuitry…Like other chronic diseases, addiction often involves cycles of relapse and
remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or
premature death.” (ASAM, 2010)
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Treatment Outcomes for Chronic Diseases

Hypertension Treatment

Addiction Treatment

Severity of Condition

Stages of6Treatment

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Event-Based View of Relapse

Abstinent

Use

Relapse

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Relapse as Process
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Two Relapse Process Models

Gorski’s Early Warning Sign Approach
1. Stress 2. Denial

Marlatt’s Model 1. High Risk Situation 2. Ineffective Coping
Response

3. Internal Dysfunction
4. External Dysfunction
5. Option Reduction
6. Relapse

3. Decreased self-efficacy and increased positive outcome expectancies for effects of AOD
4. Lapse (Initial Use)
5. A.V.E and Belief in positive effects of use

6. Relapse

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RELAPSE'SITUATION'''''''''''''(Risk'Factor) Alcoholics'''(N=70) Smokers''(N=35)

''INTRAPERSONAL'DETERMINANTS' '''''''Negative'Emotional'States '''''''Negative'Physical'States '''''''Positive'Emotional'States '''''''Testing'Personal'Control '''''''Urges'and'Temptations '''''''TOTAL ''INTERPERSONAL'DETERMINANTS '''''''Interpersonal'Conflict '''''''Social'Pressure '''''''Positive'Emotional'States '''''''TOTAL

38%

43%

3%

M

M

8%

9%

M

11%

6%

61%

57%

18%

12%

18%

25%

3%

6%

39%

43%

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Heroin''''Addicts'' TOTAL'''Sample''

(N=32)

(N=137)

28%

37%

9%

4%

16%

6%

M

4%

M

8%

53%

59%

13%

15%

34%

24%

M

3%

47%

42%

STRESS:
MAJOR PLAYER
We all face stress, yes…but we don’t all:
▪ Face the same severity of stress ▪ Face the same pattern of stress ▪ Have the same functioning coping mechanisms ▪ Come to the table with the same brain

The Willpower Trap

Confessions from AA
▪ “I thought I should be able to do this on my own”
▪ “I just need to be strong”
▪ “I won’t let it happen”

What they mean
• These statements reflect cultural and social norms
• These statements attribute relapse to personal weakness
• These statements are over-simplified and incomplete.

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“We feel like we are ascending a summit when in fact we are simply walking a treadmill. That is the
willpower trap. Lots of effort, no progress.” Patterson
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What We Know About Willpower
• When people were asked to list personal strengths, self-control comes last
• When are asked which virtues they wish they had, self-control comes first
• Are we overestimating the effectiveness of sucking it up and pus14hing through?

Four Broad Categories
▪ Control of Thoughts ▪ Control of Emotions ▪ Impulse Control ▪ Performance Control
People in early recovery are likely using willpower in all categories at the same time.
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Research Shows Us
▪ Willpower is finite and becomes depleted as you use it.
▪ The same supply of willpower is used for everything.
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An Experiment in Willpower
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An Experiment in Willpower

The Cookie group spent: On average 19 minutes and making 34 attempts on the unsolvable problems

The Radish group spent: on average 8 minutes and making 19 attempts on the unsolvable problems

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In Early Recovery How Much Time is Spent: 1. Resisting Temptation? 2. Concealing Feelings? 3. Feeling Stressed? 4. Making Difficult Choices?
= Constant State of Willpower Depletion

The Good News:

Willpower is like a muscle: you can exhaust it, but you can also make it stronger.

Small things

▪ posture

▪ exercise

▪ one task at a time

AA things

▪ meditation

▪ faith

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▪ social support

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Final Willpower Fact
• Making Choices for
Yourself Depletes Willpower
• Making Choices for
Others Does Not Deplete Willpower


“Our whole trouble had been the misuse of willpower.”
-Bill Wilson, 1953

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Habit Loops

Left to its own devices, the brain will try to make almost any routine into a habit.

1. CUE

Craving

2. ROUTINE

3. REWARD
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The discovery of the habit loop is so important in that it reveals a basic truth: When a habit emerges, the
brain stops fully participating in decision making.
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If you use the same cue, and provide the same reward, you
can shift the routine and change the habit.
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Habit Change and AA

Habit Change and AA

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Tips for Finding New Routines

• Know when the bad habit occurs. 4th step
resentments and fears can be helpful.

• Think about what triggers the habit – such as
boredom or anxiety.

• Think about what you felt after you completed the
habit –such as calm or fulfilled. This is the reward

• Play around with different new routines. It may
take some work to find healthy routines that

satisfy the new reward. 12-step recovery can help

out here too.

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What makes habit change stick?
• Alcoholics Anonymous does not only work by
reprograming addicts’ habit loops
• Habit replacement worked pretty well for most people
until a major stressor occurred in their life (death, job loss, illness)
• Research showed difference between those who
relapsed and those who didn’t was Faith and Belief.
• People with faith in something larger than themselves,
God or the group are more likely to avoid this kind of breakdown in habit change.
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Relapse Myth: The individual will see a relapse coming and will be
able to stop it.

Relapse Fact
▪ Actually, individuals often describe a relapse as a “flash,” “shock,” or “surprise.”
▪ Why does this happen?

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We are blind, We are outnumbered

6 Sources of Influence

▪ We are blind because we are unable to see all the different forces acting on us - and what we can’t see is usually what is controlling us.
▪ We are outnumbered because forces working against recovery may be legion - and they work in combination.

Personal

Motivation Source 1

Ability Source 2

Social

Source 3

Source 4

Environmental

Source 5

Source 6

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6 Sources of Influence
Motivation

Source 1 Personal Whether you want to
do it

Social

Source 3 Whether other people encourage right behaviors

Source 5

Environmental Wenhceotuhreargeensvtihroenrmigehntt

behaviors

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Ability
Source 2 Whether you can do it
Source 4 Whether other people provide help, info, or resources
Source 6 Whether environment supports the right behaviors

▪ Love what you hate

Source 1: Personal Motivation
Personal Motivation Ability
Social
Environmental
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▪ Love what you hate
▪ Tell the whole vivid story

Source 1: Personal Motivation
Personal Motivation Ability
Social
Environmental 37

“Owning our story can be hard but not nearly as difficult as spending our lives running from it.
Embracing our vulnerabilities is risky but not nearly as dangerous as giving up on love and belonging and joy—the experiences that make us the most
vulnerable. Only when we are brave enough to explore the darkness will we discover the infinite power of our
light.” -Brene Brown
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▪ Love what you hate
▪ Tell the whole vivid story
▪ Visit your default future

Source 1: Personal Motivation
Personal Motivation Ability
Social
Environmental 39

▪ Love what you hate
▪ Tell the whole vivid story
▪ Visit your default future
▪ Use value words

Source 1: Personal Motivation
Personal Motivation Ability
Social
Environmental
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▪ Start with a skill scan

Source 2: Personal Ability
Personal Motivation Ability
Social
Environmental 41

▪ Start with a skill scan
▪ Employ deliberate practice

Source 2: Personal Ability
Personal Motivation Ability
Social
Environmental
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▪ Start with a skill scan
▪ Employ deliberate practice
▪ Develop willpower

Source 2: Personal Ability
Personal Motivation Ability
Social
Environmental 43

▪ Identify accomplices

Sources 3 & 4: Social Motivation & Ability
Personal Motivation Ability
Social
Environmental
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▪ Identify accomplices ▪ Redefine Normal

Sources 3 & 4: Social Motivation & Ability
Personal Motivation Ability
Social
Environmental 45

▪ Identify accomplices ▪ Redefine Normal ▪ Tell People

Sources 3 & 4: Social Motivation & Ability
Personal Motivation Ability
Social
Environmental
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▪ Identify accomplices ▪ Redefine Normal ▪ Tell People ▪ Add new friends

Sources 3 & 4: Social Motivation & Ability
Personal Motivation Ability
Social
Environmental 47

▪ Identify accomplices ▪ Redefine Normal ▪ Tell People ▪ Add new friends ▪ Distance from
unwilling

Sources 3 & 4: Social Motivation & Ability
Personal Motivation Ability
Social
Environmental
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▪ Build fences

Source 5 & 6: Environmental Motivation & Ability
Motivation Ability Personal
Social
Environmental 49

▪ Build fences ▪ Manage distance

Source 5 & 6: Environmental Motivation & Ability
Motivation Ability Personal
Social
Environmental
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▪ Build fences ▪ Manage distance ▪ Add cues

Source 5 & 6: Environmental Motivation & Ability
Motivation Ability Personal
Social
Environmental 51

▪ Build fences ▪ Manage distance ▪ Add cues ▪ Engage autopilot

Source 5 & 6: Environmental Motivation & Ability
Motivation Ability Personal
Social
Environmental
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▪ Build fences ▪ Manage distance ▪ Add cues ▪ Engage autopilot ▪ Use tools

Source 5 & 6: Environmental Motivation & Ability
Motivation Ability Personal
Social
Environmental 53

Spire Breath
Through monitoring breath rates, Spire claims to improve the user's mental and physical health

Place your screenshot here
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Lumo Lift
Through monitoring posture, linked to improved willpower, energy, stress reduction

Place your screenshot here

Sober Grid
Sober Grid is a Sober Social Network: for people that don't use drugs & alcohol.

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Place your screenshot here
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A-Chess Sober App

6 Sources of Influence

“A-CHESS (Addiction Comprehensive Health

Motivation

Ability

Enhancement Support System) helps to prevent and intervene when relapse

Place your screenshot here

• •
Personal •

Love what you hate Tell the whole vivid story Visit your default future

• Start with a skill scan • Employ deliberate
practice • Develop willpower

may occur using a series of

• Use value words

mobile supports by promoting coping competence, social relatedness, and autonomous motivation”

Social

• Identify accomplices • Redefine Normal

Environmental • Engage autopilot

• Tell People • Add new friends • Distance from
unwilling
• Build fences • Manage distance • Add cues • Use tools

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“ Theories that diseases are caused
by mental states and can be cured by willpower, are always an index of how much is not understood about
the physical terrain of a disease – Susan Sontag
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MotivationMotivation AbilityWillpowerAbilityAbility Motivation Ability