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substance misuse treatment:relapse prevention

substance misuse treatment:relapse prevention

In this stage it is assumed that change has been achieved and the aim is to ensure that gains which have been made are maintained. For people with mental health problems the notion of relapse is broader than a return to problematic substance misuse. They may also experience a relapse of their mental illness. For some people the two will be interrelated. A specific approach for working with clients to prevent relapse has been developed by Marlatt and Gordon. It uses cognitive behavioural strategies and the development of lifestyle change as its bases. The aim is to identify high-risk situations or triggers and develop strategies for coping with them without using substances. Effective coping enhances the person’s sense of self-control. If substance use does occur this is seen as a lapse or slip-up which can be overcome, and from which learning can take place. In terms of Prochaska and DiClemente’s  model, the person returns to the active treatment stage rather than precontemplation, or contemplation. Such a perspective contrasts with the sense of failure and hopelessness which can be engendered if the client sees drinking or using drugs as a relapse which has put them ‘back to square one’. Situations/triggers for relapse are likely to be many and varied. These include: negative emotional states (for example, anger, anxiety, depression, boredom), positive emotional states (for example, celebrations), interpersonal conflicts (for example, with partner, family members, employer), social pressures (for example, at a party) and associations with particular places, people, times/dates or situations. Tools such as diaries and decision matrices can help clients identify their triggers. With the information gained strategies can be developed for dealing with these. In conjunction with this approach to relapse prevention pharmacological interventions may be beneficial. For people with opiate problems naltrexone can be helpful as it blocks the effects of opiates. Naltrexone has also been shown to reduce craving in drinkers. However, acamprosate is more commonly used for this purpose.

Disulfiram (antabuse) acts as a deterrent to drinking as adverse consequences are experienced if alcohol is consumed (flushing, headache, palpitations, nausea and vomiting – in large amounts cardiac arrhythmias, hypotension and collapse may occur). While preventing relapse is at the heart of a person’s recovery or rehabilitation new skills and lifestyle changes will also be needed. A range of agencies may play a part in the person’s rehabilitation and within them various methods might be used (for example, individual counselling, group work, skills training, recreational activities). Some people will choose community options, for example, a structured day programme or self-help group (such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)). Others may decide that a residential project would better meet their needs. These range from supported hostel accommodation to more intensive therapeutic programmes. Within these there will be a variety of care philosophies – some have a religious basis, some are run on therapeutic community lines and some follow the ‘12 steps’ of AA/NA. Alongside a focus on substance misuse, clients may engage in new activities (for example, going to a gym or attending an art class) and develop vocational skills (for example, computing). Clients may also benefit from services which address more specific problems (for example, childhood sexual abuse, bereavement issues). A social services community care assessor/care manager may work with the client to develop an ongoing treatment package. They have access to the finances required for some services. With the increased emphasis on provision for drug users being made through the criminal justice system treatment can be accessed in prison through CARAT – counselling, assessment, referral, advice and throughcare– schemes. These provide interventions pertinent to each treatment stage.

Each client is different and a service which is helpful for one person may not be for the next. Some clients will attend several projects, others may not need further specialist input at all. At present, few projects are specifically set up for people with a dual diagnosis. While some mainstream substance misuse services are willing to work with this group their programme(s) may not be flexible enough to meet clients’ needs. Some services, particularly residential projects, exclude people who have a severe mental health problem; and people with a history of self-harm, suicide attempts or violence are also likely to be excluded. Throughout the treatment process clients may be involved with several different agencies. Services need to work together to find ways of sharing information so that clients can access help without having to negotiate unnecessary barriers. While there is an increasing recognition of this, the reality is often far from it, as Ken’s experience illustrates.

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