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 Centre for Addictionand Mental Health |
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Publications
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SRP for Clients with CD - Adapting the SRP Approach - Other Issues with CD-Adapted SRPExcerpted from Structured Relapse Prevention: An Outpatient Counselling Approach.
Co-facilitationThere is no research examining whether or not CD-adapted SRP groups should be co-facilitated. In fact, the overall composition of CD-adapted SRP groups is an area we hope will be the focus of further research (e.g., should groups be composed of people with similar or with differing psychiatric diagnoses?). In our clinical practice, co-facilitation has been the model for several reasons, as discussed below. Safety It is not uncommon when working with people who have concurrent disorders for a group member to arrive acutely psychotic, acutely suicidal, intoxicated or acting out. When a situation like this occurs, one therapist is typically required, for safety reasons, to intervene directly with the person outside of the group. It is therefore helpful to have a second therapist who can be free to stay with the group and carry on with the session. Avoidance of Burnout One therapist “going it alone” in running a CD group can find the work to be emotionally draining. In a co-facilitation situation, the two therapists can support each other, plan for the group together and work together to manage challenging clinical group issues that inevitably arise. Within this model, therapists are less likely to feel isolated in this challenging clinical work, and to potentially burn out. Professional Development Co-facilitation allows the therapists to brief for the group before the group session, and to de-brief together after the session is over. This kind of clinical exchange stimulates analysis of the CD-adapted SRP approach and related group developments, and provides a forum for peer support. Also, exposure to a co-therapist’s insights can enhance professional development and skills. Opportunities for Training and Supervision We also believe there is value in having one seasoned, experienced therapist co-facilitating a CD-adapted SRP group along with a less experienced clinician or a student. This combination can provide a valuable real-life learning process and an ideal opportunity for close supervision. Opportunity for Mutual CD Capacity-Building A co-facilitation model comprised of one clinician with a substance use background and another with solid mental health preparation allows for mutual professional development, with a view toward building capacity in the area of concurrent disorders. Determining the Suitability of SRP for a Given ClientOnce the presence of concurrent substance use and mental health problems has been established, several factors contribute to determining whether SRP, among the range of other treatment options, would best fit a client’s needs. Although SRP employs written feedback, exercises and forms, the ability to complete written exercises is not essential. Where written exercises are not appropriate, we have substituted discussion and role-playing exercises (or individual therapy). If SRP is being delivered as part of an inpatient, hospital-based program, the major criteria for SRP treatment is the client’s ability to attend and participate in the group or individual sessions. However, before considering SRP on an outpatient basis, consider the factors listed in the table below. If any of the following are present, we suggest a more intensive treatment program (such as day or residential treatment), as SRP may not be the most appropriate treatment at that juncture.
If SRP is the best treatment option, it is important to give clients with concurrent disorders a thorough orientation to the format and content of the treatment sessions. In addition, for clients involved in the forensic system, there should be a discussion about how disclosures of substance use episodes, cravings and triggers, and exposure to risk situations, will be documented, as there may be legal implications for clients. The CD-adapted Therapist Checklist for the Assessment phase notes some of these group process issues, as well as listing relevant clinical tools. Handling RelapsesRelapse is often a part of recovery from mental health and substance use problems. Clients should be encouraged to view lapses and relapse as temporary setbacks. Relapse to Substance Use When clients relapse to substance use, we are careful to correct the interpretation that relapse means failure in recovery. On an emotional level, for some people, the perception that relapse equals failure often creates a significant experience of shame, pessimism about the ability to change and even self-loathing because they have continued to repeat old patterns. In settings where relapse is not normalized, clients have reported dropping out prematurely because they could not imagine returning to and facing the group. Within a CD-adapted SRP approach, we reframe experiences of relapse as an opportunity for learning and for problem solving. Relapse is also seen as an opportunity for clients to reaffirm their substance use goals and shore up their levels of motivation and commitment. The hope is that within a harm reduction approach, clients will feel comfortable disclosing relapses―should they occur―without fearing they will be asked to withdraw from the program. Permission to be honest about a relapse in the treatment process, especially if the relapse is already over, helps to normalize it as an occurrence, and helps to prevent the client feeling he or she cannot be genuine in therapy. It is also helpful for clients to explore the trigger(s) that led to the slip, and to discuss more adaptive coping responses that could prove useful for any similar situations in the future. Relapse of Mental Health Problems When working with a population that has concurrent disorders, it is also important to note clinically that relapse is a common occurrence with mental health problems such as depression and psychosis. However, in our experience, clients tend not to feel the same guilt and shame with a mental health relapse as they do with a relapse to substance use. The underlying belief for many clients seems to be that the use of substances is essentially their fault, but that a relapse to psychiatric symptoms is largely beyond their control. Nevertheless, relapsing mental health symptoms are associated with a feeling of disappointment and learned helplessness, and a profoundly demoralizing sense that the psychiatric condition will be a continuing struggle, possibly for a lifetime. This is a common reaction in clients with chronic depression or bipolar disorder. To foster a better, more helpful mindset for managing relapse, we normalize the idea that relapses occur in both domains, and then attempt to help clients identify personalized early warning signs that their mental health is deteriorating. Such signs in depression, for example, might include sensing a tendency to withdraw socially, beginning to lose interest in activities previously enjoyed and experiencing an increase in negative or pessimistic thinking. Once the client becomes aware of these early warning signs or “red flags,” he or she can develop strategies for coping and intervening early in the cycle. Such interventions might include relaying symptoms to a caregiver, implementing personal coping strategies such as good self-care and seeking social support, with the overall goal of circumventing a full relapse. The SRP approach helps a client to anticipate substance use triggers for the coming week and identify and commit to a plan of action. Within the CD-adapted SRP approach, relapse prevention goals include, but are not limited to:
The Supersensitivity HypothesisMueser and colleagues argue that people with severe mental illness are more sensitive to the effects of alcohol and other drugs, due to an increased biological vulnerability (Mueser et al., 1998). As a result, people with concurrent disorders may experience increased negative consequences from relatively small amounts of substance use. Thus, in someone with schizophrenia, relatively moderate use (e.g., two beers three times per week, or $20 worth of crack cocaine used once every few weeks) may result in negative consequences (such as increased psychotic symptoms), or may dramatically increase the risk of more severe substance use. A key message with respect to the supersensitivity hypothesis is that, when working with people with serious and persistent mental illness, the quantity of the substance use is less important than the consequences.
Return to the index of excerpts from Structured Relapse Prevention: An Outpatient Counselling Approach. |
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Last updated: Jan 03, 2007 5:51 PM Published: Oct 11, 2011 6:28 PM ID#P23565 |