Written plan helps clients note relapse triggers

By the Dartmouth Psychiatric Research Center

In the mental health field, recovery means progress toward managing symptoms in order to achieve personally meaningful goals. Today, with the implementation of integrated treatment, recovery for those with severe mental illness and substance abuse disorders is an achievable goal. A recently published 10-year study of adults with co-occurring severe mental illness and alcohol use disorders suggests that most of these clients will achieve at least one durable remission from alcohol use disorder. While lapses were common in the remission groups in the study, researchers found participants tended to continue to recover over time. Consistent with integrated, stagewise treatment, these study participants made a number of positive changes before achieving remission.

This fall marks the release of the second edition of the Integrated Dual Disorders Treatment manual - the manual addressing effective, evidence-based treatment for co-occurring disorders. To note the arrival of the new edition, we're featuring an excerpt from the manual. The excerpt's focus on relapse prevention we think is particularly appropriate to the manual's offer of practical guidance for clinicians and its message of hope for clients.

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Substance Use Counseling in the Relapse Prevention Stage of Treatment

The main cognitive behavioral treatment (CBT) strategy during the relapse prevention stage is the ongoing development of the relapse prevention plan that clients began to work on in the active treatment stage. Triggers and early warning signs were identified in active treatment, and connections were made about how substance use and mental illness triggers can mirror and feed each other.

During relapse prevention, we recommend that clinicians create a written plan for both disorders. Such a plan can be fairly simple by having clients note one or two early warning signs for each disorder and list two or three triggers for each disorder. After this is done, clinicians should have clients write down a plan for what they will do when they notice the early warning signs and triggers and list one or two supportive people they can contact. If possible, clinicians should include these support people in the development of the relapse prevention plan because they can offer their feedback to the plan and also be educated about the relapse process. Relapse plans are documents that are meant to be modified if new information arises following a relapse. Clinicians should remind clients that a relapse is not a failure but part of the recovery process. Clinicians can help clients understand how learning from a relapse and incorporating what was learned can strengthen their recovery. ...

Common Issues for Clients in the Relapse Prevention Stage of Treatment

Additional relapse prevention stage strategies include helping clients address some common issues, including employment, healthy lifestyle, leisure and recreation, and relationships.

Employment. Many clients will have been employed during all of the different stages of treatment. However, when they get to relapse prevention, they often take another look at work and begin to think if this is the kind of job they really want. They may decide to change jobs or go back to school.

Healthy Lifestyle. At this stage, many clients begin to focus on their physical health and begin exercising, eating healthier, or quitting smoking.

Leisure and Recreation. Up to this point, clients have usually tried few things for fun. Now they are ready to branch out and investigate a wide variety of activities with a well-established sober peer group.

Relationships. Many clients were cautious with relationships in their first year of recovery. Now, as they have a more stable sobriety, they are often ready to look for more meaningful relationships. As clients venture out into these different life arenas, the need for ongoing support from clinicians is increasingly important. Scheduling a regular time for checking in with clients is a respectful way to reinforce their ability to manage their lives and their recoveries.

The Importance of Twelve Step Programs

Helping clients join peer recovery support groups is a core part of substance use counseling. The well-established and widely available Twelve Step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are excellent resources. In the past, clients with co-occurring substance use and mental illness encountered problems with attending AA or NA groups, such as

• not feeling comfortable with talk about religion
• not feeling comfortable in a large group
• meeting people who told them to stop taking their medications
• being triggered to use by the stories
• feeling "different"

Because of these barriers, mental health clinicians were often reluctant to refer clients to Twelve Step programs. However, researchers have learned a great deal in the field of co-occurring disorders over the years and gained more experience with Twelve Step groups. As a result, mental health clinicians have generally come to understand the value of peer recovery support groups. Barriers encountered by clients are seen as the kinds of issues everyone might have to deal with when starting something new.

Clinicians can use a CBT strategy called cognitive restructuring to help clients deal with concerns about going to recovery group meetings. In cognitive restructuring, clinicians challenge thoughts that are producing negative feelings and try to replace them with thoughts that will produce more positive feelings. For example, clinicians would challenge the thought "no one here is like me" by reminding clients that several people from the mental health center go to groups. Clinicians would then work to plant a new thought like "maybe some people here also have a mental illness and a drug problem."

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