MANAGING RELAPSE AMONG OUR COLLEAGUES

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MANAGING RELAPSE AMONG OUR COLLEAGUES
THE IMPAIRED PROFESSIONAL
EUGENE P. SCHOENER, PH.D. Professor of
Pharmacology, Psychiatry Community Medicine
Wayne State University School of Medicine
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WHATS RELAPSE?
DEFINITION
Violation of rules governing behavior.
PRINCIPLES

• We set absolute limits of acceptable and
  unacceptable behavior
• Our commitment to the behavior waxes and wanes
• Internal external factors challenge our
  commitment
• Relapse is not an event, its a process

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WHATS RELAPSE?
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CBT MODEL OF RELAPSE
From Marlatt et al., 1999.
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RELAPSE RISK FACTORS

• Family history of substance use disorder
• Family history of mental illness
• Previous or current use of substances
• Stress! Causal link not established
• Intellectual arrogance
• Uncertainty Ambiguity about Role
• Inadequate supervision
• ACCESS, ACCESS, ACCESS

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RELAPSE TRIGGERS
DEFINITION
Unique internal and external cues that elicit
the motivational drive to use.
Triggers are numerous and truly individualized
High Risk conditions associated with relapse

• NEGATIVE EMOTIONAL STATES
• INTERPERSONAL CONFLICT
• SOCIAL PRESSURE

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DEFENSE MECHANISMS IN RELAPSE
Denial Unconscious mechanism to disavow
responsibility for intolerable thoughts or
acts Lying Assertion of something known/believed
to be untrue Avoidance Withdrawal from that which
is disagreeable/ undesirable Conflict Manifestatio
n of incompatible needs or desires Hostility Overt
antagonism
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DEFENSE MECHANISMS IN RELAPSE
Suppression Conscious inhibition of disagreeable
thoughts Repression Non-volitional unconscious
mechanism to inhibit unacceptable ideas or
perceptions Rationalization Conscious or
unconscious justification of unacceptable
thoughts, attitudes, or behavior Intellectualizati
on Reasoning used to justify feelings or behavior
in situations of conflict and stress Projection Re
pressed complex of feelings is regarded as
belonging to others
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SIGNS SYMPTOMS OF IMPAIRMENT
AT WORK

• Schedule disorganized, appointments missed
• Mistakes due to negligence or poor judgment
• Unexplained lateness, absence illness
• May become irritable, withdrawn or both
• Behavior toward staff clients is hostile
• Spends a lot of time behind locked doors
• Clients complain to other staff
• Quality of work deteriorates

From Talbott et al., 1998, ASAM.
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SIGNS SYMPTOMS OF IMPAIRMENT
AT HOME

• Unexplained absences
• Withdrawal from family activity
• Spouse and children assume family
  responsibilities
• Others isolate, become angry, hostile
• Emotional, verbal physical abuse occur
• Frequency of arguments/fights increases
• Spouse children disengage

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SIGNS SYMPTOMS OF IMPAIRMENT
IN THE PERSON

• Personal hygiene and grooming deteriorate
• Appears slovenly, unkempt and often ill
• Involved in accidents and traumatic events
• Visits doctor/dentist/hospital more often
• Unusual mood swings with deep depression
• Engages in unusual risky behavior
• Experiences legal problems

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OTHER CLUES TO RECOGNITION
PHYSICAL CHANGES etc.

• Eye signs
• Shaky hands (Tremors)
• Unsteady on feet
• Alcohol (or mints) on breath
• Long sleeves in warm weather
• Bad handwriting
• Broken beeper syndrome
• Self-medication

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IDENTIFYING RELAPSE IS DIFFICULT
Because of . . .

• Denial by the impaired professional
• Conspiracy of silence among others
• Degree of functionality
• Ability to conceal impairment
• Atypical presentation of the problem

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THE ULTIMATE RED FLAGS

• Pattern of behavior reflects progressive
  involvement
• Loss of control over behavior
• Continuation despite adverse consequences
• Preoccupation or obsession
  

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PATTERN OF DECLINE IN MEN
Community Involvement Family Life Employment
Pattern Physical Health Office Conduct
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If You Suspect Impairment

• Health care professionals have an ethical
  responsibility to protect patients and the public
  by identifying and assisting impaired colleagues.
• Intervention or Reporting?
• Obligation to report if imminent danger to
  patient exists
• Intervention is key to rehabilitation

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Why should I get involved?
Pragmatic answer is Protection for ...

• CLIENTS
• THE PUBLIC
• COLLEAGUES
• AGENCY
• SELF

But let us not forget ...

• ETHICS and ALTRUISM

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INTERVENTION!
DEFINITION
A deliberate procedure that helps one appreciate
the impact of their addiction and take the first
steps toward recovery.
REQUISITES

• Planning Investigation Goalsetting
• Identification of Intervenor(s)
• Orchestration

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Where do I get help?
EMPLOYEE ASSISTANCE PROGRAM Agency
retained Independent Professionals PEER SUPPORT
PROGRAM Michigan Health Professionals Recovery
Program
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Michigan Health Professionals Recovery Program
The State of Michigan's Health Professionals
Recovery Program (HPRP) was established in 1994
by legislation. This program is administered
through a contract with the Department of
Consumer Industry Services, Bureau of Health
Services, and is supported by various health
professional licensing boards and the
associations and societies of the health
professions in the State. The HPRP supports the
recovery of its participants who suffer from the
diseases which may bring about impairment. HPRP
is administered by a non-profit group, the
Michigan Health Professional Recovery Corporation.
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Contacting the MHPRP
Address MHPRC PO Box 989 Brighton, MI 48116
Phone [phone]
(Fax)810-225-1358
EMail hprp_at_mich.com
Website http//mondodyne.com/1mhprc/hprp.html
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Public Policy of ASAM The Impaired Health
Professional Whereas, alcoholism and other
chemical dependence are chronic, progressive and
often fatal diseases if untreated Whereas,
effective treatment is available for these
diseases Whereas, if effectively treated,
impaired health professionals are able to return
to and resume functioning as valuable members of
the health care community, ASAM supports the
following 1. Recognition of their impairment
caused by these diseases 2. Early referral
into appropriate treatment 3. Effective
monitoring long term 4. Sharing among health
disciplines of effective intervention,
rehabilitation and monitoring approaches.
Adopted By ASAM Board of Directors 4/12/84
Updated September 29, 2001
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Components of a Good Peer Assistance Program

• Discretion, Compassion, Confidentiality
• Coordination of the Intervention
• Referral for assessment and treatment
• Return-to-practice assistance
• Sustained monitoring of recovery
• Advocacy for participants

From a Project MAINSTREAM presentation by V
Waters, 2003
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SUCCESSFUL TREATMENT
Depends upon

• Understanding and acceptance of the disease
• Identification of individual triggers
• Development of healthy coping strategies
• Family involvement
• Peer-based therapy
• Involvement in mutual help groups
• Monitoring

From Talbott et al., 1998, ASAM.
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Recovery is Likely
Studies of health professionals have shown that

• 70 to 85 achieve sustained recovery
• 70 are successful with 1st attempt
• 2/3 of all relapsers achieve recovery

However, we must remember that

• addiction is a chronic, relapsing disease
• recovery is lifelong

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Prevention is Better
Relapse Prevention

• A Cognitive-Behavioral approach to maintaining
  desired behavioral changes (sustained sobriety
  and well-being.)
• Psychoeducational self-management
• Change thoughts and beliefs
• Skills training resist social pressure
• Anticipate and prevent lapse behavior