Relapse Prevention Basics | Counselor Toolbox Episode 240

[Music] This episode was pre-recorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through allCEUs. Register at allCEUs.com/counselor-toolbox.

I'd like to welcome everybody to today's presentation on relapse prevention for co-occurring disorders. So, we're going to go over a bunch of stuff over the next few weeks or a few minutes. Defining relapse, identifying triggers and warning signs, reviewing relapse syndrome and possible interventions. We'll explore the acronym DREAM and define and identify vulnerabilities, exceptions, and then we're going to end up by talking about how to develop a relapse prevention plan.

So, relapse indicates that the old behaviors have either returned, either because new skills were ineffective. So, sometimes we're working with a client and we give them tips for how to deal with depression or anxiety, and it sounds good in theory, but it's just not working. And a relapse may come come back and some of those old behaviors like sleeping a lot and overeating or undereating may come back. Or the old behaviors were more rewarding. I mean, they're trying to do what we asked them to do, like exercise and mindfulness, and it just all feels like drudgery and it's not giving them any sort of or much of a relief, whereas going to sleep at least they get some peace for a little while.

Recovery involves understanding what triggers each individual's person to relapse. So, we need to look at, you know, sort of a chronology of what was happening three, six months before the relapse. Because for a lot of people, relapse starts a couple months ahead of time. So, they not they stopped sleeping as much, or they're not eating as well, or they're taking on more tasks at work, or there's, you know, turmoil in their life and stress building up. So, these are all things that we want to take into consideration because one day the person may wake up and feel like the relapse came from out of the blue. And, you know, I was doing okay and then all of a sudden I'm not. And so we want to look back and see how long were they, I call it white-knuckling it, how long were they just kind of gritting their teeth and getting through, and they really weren't as quote fine as they thought they were.

So, relapse syndrome is what we call a fairly predictable pattern of behavior that leads to relapse. So, a lot of times it starts out with the person going, "I'm fine, I'm recovered," whatever. And they stop engaging in their preventative as well as their intervening behaviors. So, they start going back to the old ways of doing things, staying up late at night, not getting enough sleep, working too much, engaging in unhealthy relationships, whatever it was they were doing before. And they start neglecting their own mind/body/spirit wellness.

So, we want to teach them to consider what's going on. We want to teach them to be mindful. And this is, you know, step one is mindfulness. Be aware of their problems because life is rarely perfect. I mean, there are times when it's good, when you're content, you know, all those kinds of things, and that's wonderful. But we want people to regularly write down their problems or their hiccups and share this with someone. I also, instead of just focusing on the negative, I also encourage them to every day write down a list of their triumphs and things that went well that day or things that made them smile. So, they can remember that there are, you know, two sides to every coin. But it's important for them to be aware of the different stressors that build up.

So, if you ask a client, you know, you know, what kind of stressors do you have going on, they're gonna think of the proximal stressors, the things that are happening right now or have happened in the last week, probably. And they'll tell you about those. And then they may, may be like, "Oh, and then, you know, I had this death in the family like three months ago, and then my car broke down." And the further back they start going, they start seeing that there's been a litany of challenges that they've overcome, but that have worn them down a little bit to get to here. So, it's important that they stay cognizant of their stress levels. And that's really what we're wanting people to do. I'm not wanting them to get depressed and be like, "I've got so much to deal with," but to be cognizant because as the problems come up, if they're aware of them, they can deal with them. If they're not aware of them, then problems start to build up and then all of a sudden it's like, boom.

Think about spring cleaning. I don't know about you, but I know me, I kind of, you know, over the winter and stuff, I let things go a little bit more than I probably should in some areas. And then in the springtime, you know, when it's time to do spring cleaning, it's like this huge massive task of cleaning out closets and and doing all that stuff. Instead of, you know, when it's nasty outside and too cold, I could be whittling away and doing a closet today and, you know, the guest bedroom tomorrow and working on it and whittling those issues, so to speak, away and dusting and that sort of thing. So, not saying that, you know, housework is the only problem, but we can widdle things away and deal with them as they come up instead of letting them balloon into a huge task.

The next thing is the person actually starts avoiding defensive behavior because they start feeling focusing more energy on fixing others than on working on themselves and failing to do their relapse prevention exercises. They feel like, "Okay, I've got this, I'm fine, I don't have any problems," and la da da da da. So, they start surrounding themselves or they with people who need fixing. So, they're focusing all their attention out here. Well, what do we know when we do that? If we're focusing all of our attention out here, we lose attention to what's going on in here, which compounds the fact that they're not doing their mindfulness exercises and making sure that they're getting enough sleep and leaving or leading a relapse prevention type lifestyle or a recovery type lifestyle.

So, encouraging clients to surround themselves with people who will support and encourage them to continue working on their relapse prevention program. Their supporters that go, "You know what? You've always said you feel better if you get up and you go to the gym in the morning, and I haven't noticed you doing that lately. Or you seem to be drinking a whole lot of coffee lately. I'm wondering if you're getting enough sleep." So, people who can probe and just kind of point out things. But sometimes we don't notice. We don't realize that we've gone from drinking three cups of coffee to three pots. You know, I exaggerate, but you get my point. You know, it's just you're doing what you're doing and getting through the day on autopilot mindlessly. So, having people around that can point out, you know, "You might want to check this out. Not saying there's a problem, but you might want to check it."

Encourage people to maintain a negative image of what it was like when they're symptomatic. So, they remember, you know, I don't want them to dwell there, but with addiction, depression, anxiety, it's motivating if people look back and go, "Yeah, I don't want to go there again." So, I'm not feeling it going to the gym today. I'm not feeling it. I'd rather stay up late and watch another season of whatever. But I know if I do that, that I'm risking relapse. I'm risking setting myself back, and I really, really don't want to go back there.

And encourage them to develop and review a cost-benefit analysis of their current coping and lifestyle behaviors. You know, if they're not getting enough sleep, have them do a cost-benefit analysis. Obviously, they're getting something out of staying up. What is it? And, you know, what is the cost and benefit of getting adequate sleep? What do they feel like they're missing out on or or what's it not doing for them?

The next stage is crisis building. So, they're fine, they don't have any problems, they're helping everybody else, sometimes trying to make up for out of guilt or whatever the time that they were symptomatic and they weren't able to be there for everyone. But they're, you know, focusing outwards now. All that happens, they're operating often mindlessly. So, crisis begins to build. Problems begin to pile up, and it becomes more and more difficult to see options. The person develops tunnel vision and loses the ability to perform constructive planning. It's like they get up one morning, and this is where it starts to feel like it's coming from out of the blue. They're like, "Oh my gosh, I've got so much to do and, you know, this is going wrong and that's going wrong." And a lot of times they're that tunnel vision also tends to be negative tunnel vision. They start focusing on all the things that are going wrong and all the stuff they have to do.

So, encouraging them to take one day at a time. You know, "Yeah, you let some things pile up because you were focused over here. All right, you know, let's start whittling down that pile." When I used to have my kids, when I used to teach them to clean their room, you know, they would walk into their room and they wouldn't even know where to start. And they'd look at it and go, "It looks fine to me." I'm like, "Oh, it's not fine." So, I would take everything off the flat surfaces and that was on the floors and flat surface too, and we would take everything that needed to be put away and put it into one big pile. You know, that pile that we're talking about of stuff that just kind of piles up. And I'd say, "Okay, your room's clean when you get all this stuff put away." Same thing for our clients. You know, we say, "Okay, you let some things go while you were focusing over here. Let's make a list of everything that needs to be done, and then we'll start addressing it one at a time." And then when the pile is done, the pile is done.

Encourage them to take one day at a time and we'll look at that list of things that need to be addressed and prioritize based on what has to be done more urgently. Review coping behaviors. Encouraging them, "Okay, you let stuff build up. Now's not the time to say, 'Well, I need to work 16-hour days and I need to forego sleep in order to get caught up.'" You know, "You still need your rest. You still need to take care of yourself, or you're gonna end up symptomatic again, and that's not where you want to be. And you're definitely not going to get anything done back there." So, remember, you've still got to live a recovery-oriented lifestyle.

Encourage them to accept personal limits. What they can do, what they can't do, what they can take on, what they can't. You know, "I would love to, you know, be able to work full-time and, you know, school my kids and then on top of that also, I would love to coach my daughter's soccer team, and I would love to volunteer with doing something my son's interested in, and I would love to do pet rescue." There's a lot of things I'd love to do, but personal limitations. I need sleep, and I've got a lot on my plate, and there's only 24 hours in the day. That's not such a personal limitation, it's just a limitation. So, encouraging them to accept the fact that you can't do everything all the time and be everything to everybody, especially if you are crumbling. So, we need to make sure that you're doing what you need to do to be present for people and then figuring out what your limits are so you're setting good, healthy boundaries.

And remind them that it's the thoughts about an event and not the event itself that's necessarily bad or good. So, encouraging them when they start feeling like they're in crisis and this is the world is coming to an end. It's their thought about these events. "You know, I'm having the thought that I'm overwhelmed right now." Okay, well, that thought can come and go. So, let's figure out how to make that thought go away.

The next step is immobilization. And, you know, if you don't intervene up until now, so the person's been ignoring stuff, it built up, they wake up one morning, they see all this stuff that's gone on, and they start feeling crushed and trapped and oppressed by everything that's going on. And they're probably starting to not feel so well now to whatever their initial symptoms are. And they may have a sense that nothing can be solved. So, they're starting to feel hopeless and helpless on top of it. And they're just, they're stuck. They don't even know where to begin. And, you know, I think most of us have been there at one time or another when life has gotten chaotic and you're just like, "I don't even know what's the first step to take."

So, we want to look at helping them become mobile. Now, they're immobilized because they don't know which direction to turn. So, we're going to build on the stuff from back here, looking at taking one day at a time and making that list. Sometimes I have clients, depending on the client, they may make a list. Other times, I have them put it on index cards. And yeah, it's a waste, but we can recycle them. And they put one problem or issue on every single index card, and we put them all into a basket. And they start whittling away. They do one or two every single day until there are no more index cards left. And that helps them kind of keep perspective on what's going on. The list, they obviously cross things off. So, it depends on what your client wants to do. The index cards are nice because you can move them around and sort of organize them like a puzzle in order to prioritize and help people see, you know, out of this array of things, you know, which ones do you want to do right now? Or which ones are most important? Okay, let's pull those out and put those over here in a special pile. And then which ones are kind of secondary? Mowing the lawn, for example, paying the bills, keeping the electricity on, that's more crucial than necessarily mowing the lawn. So, start encouraging them to look at time management and plan and prioritizing what they need to get done. And then start setting SMART goals.

Encourage them to use the support people that they've developed again, acknowledging those personal limitations, reaching out to people, going, "Yo, you know what? I'm feeling overwhelmed right now. I could really use some help." Okay, that's fine. Generally, they've been reaching out and helping others, so there are others that are willing to help back at this point. Encourage them to review the concept of a lapse as opposed to relapse. Accepting the reality that they'll make some small mistakes, but this doesn't mean they failed. Obviously, you can see how this would be true in substance abuse where somebody takes a drink or, you know, gets drunk one night versus being drunk for three solid weeks. But the same is true in mental health issues. When they wake up and they have a depressed day, or they have a day where their anxiety is off the charts. Encourage them to look at that as a lapse, as an episode, as a learning opportunity, instead of a relapse. You know, they haven't lost all of the stuff that they've learned until now, and they aren't doomed to be back there and completely immersed in the old way of feeling, knowing, and being. So, it's important to encourage them to look at it as a moment in time, a snapshot. What can they do to improve the next moment?

So, they're immobilized. If they don't get any help here, then they start getting confused. You know, when you feel stuck, when you feel trapped, when you feel like that you're hopeless and helpless, then you can start getting confused about what's the right thing to do. And you're angry, and you're agitated, irritable, tense. So, when others try to help you out or ask you to do something, you tend to be overreact and get angry and frustrated, or downright just majorly depressed. So, when when people start feeling this way, when they're starting to feel these really powerful feelings, we want to have them identify the source of the feelings. "What is causing your sense of helplessness right now? What is causing your sense of hopelessness?" Or, you know, "What's the point?"

Encourage them to accept responsibility for the problems where credit is due. You know, some things they have no control over. Accept responsibility for their part, and then, you know, we can work on figuring out what they're going to do about that. And they need to consider at this point possible professional intervention. Up until now, they can rely on support group, social support systems, etc. But once they get to this point, they are really teetering on the verge of a full-blown relapse.

Depression comes next. You know, you feel confused, overreaction, your your threat warning signs are just our warning system is just going off like crazy, you're stressed out, then you just kind of hit that wall and it's like, "I give up." As the anger begins to build, so does a sense of hopelessness and begins to turn the anger inward in the form of depression. Or you can look at it in terms of your anger and frustration, you've been revved up for so long, and you just run out of gas. You're like, "I can't effect change. I can't seem to make myself calm down again."

Encouraging people to focus on the things that they can control. Identify their strengths. What things do you have going for you? What things can you do? What resources do you have? Let's look at all of these things so you don't feel like you are an island out there and you have to carry the right weight of the world all on your own. Encourage them to set SMART goals to develop self-efficacy. SMART: specific, something that can be accomplished in a day or a week, something that they can knock off and, you know, they're going to be able to accomplish it and it's defined. So, I can look at it and go, "Yes, you did," or "No, you didn't." So, cleaning your room, not real specific. Getting everything off the flat surfaces in your room, that's specific. So, give people specific goals. They need to be measurable, you know, again, so you can identify whether the person has or hasn't done them. Achievable. We want to make sure that the person has the capability to do it. If they want to lose weight, they're not going to lose 40 pounds in two weeks. It's just not, that's not achievable or realistic. So, what can they do? Is it achievable to lose weight? Sure. Is it achievable to lose 40 pounds? Certainly. Is it achievable to lose 40 pounds in, you know, three months? Maybe. So, we want to look at making sure we're setting goals that the person can attain so they develop that sense of, "Okay, if I break these goals down and start taking baby steps, you know, it's not gonna get finished tomorrow, but all these problems didn't develop in one day either." So, we need to just start whittling away at it.

And encourage them to seek social support from, you know, get support emotionally, get support and help doing things. If they're depressed for long enough, then they move into behavioral loss of control. The person is unable to control or regulate personal behavior in a daily schedule. They, they're just kind of out of control right now. They're trying to do anything to feel better. They may not be able to do anything at all. They may be sort of paralyzed and sleeping all the time and feel, you know, all those symptoms of clinical depression.

So, we want to encourage them to develop a routine. And it's not fun at first, necessarily, but encourage them to develop a routine so they can get their circadian rhythms reset so they know what they're doing because that'll eliminate some of the confusion. They don't have times when they're like, "I got three hours. I know I've got stuff I need to do, but I don't know where to begin or what to do." So, develop a routine. Regroup and redefine those people thinks and activities that are truly important to that person to have a meaningful life. Have them make a list so they remember what this destination is that they're working towards. Make a task basket or list like we talked about. You know, this is, these are all visual ways, concrete ways, because when somebody's in crisis, they're not thinking abstractly, and memory probably isn't the best because that's not where our neural chemicals are at that point. So, get it written down, get it so it's concrete, they can look at it, and they can order it, they can touch it, they can, you know, shred the card when it's done, whatever they want to do. And continue to set SMART goals to keep them moving forward.

So, these are things that we're going to see. You know, if you don't get intervention when the person is fine. And sometimes in substance abuse recovery, we call this the pink cloud. They think they're cured. They're kind of walking on cloud nine. They're feeling great, and they're not paying attention to the other stuff. And it's easy to fall into old habits and old routines.

So, the ten most common triggers for relapse: withdrawal symptoms, anxiety, nausea, physical weakness. So, if somebody is trying to quit smoking, if they are trying to quit stress eating, if they're trying to obviously quit other drugs, there are a lot of different things that will produce either physiological or psychological withdrawal symptoms. So, we want to pay attention to those psychological withdrawal symptoms. And anxiety is a big one. When someone has been using a specific thing to cope with with anxiety or stress, then they can't access it anymore. Post-acute withdrawal symptoms: anxiety, irritability, mood swings, poor sleep. This is more true for your compulsive behaviors, if you will, and any addictions. Substance addiction and gambling, compulsive sexual activity, anything that produces lots of dopamine rushes and tends to alter the brain chemicals can produce post-acute withdrawal symptoms. Poor self-care. And this is true for any of our diagnoses, and even things that aren't diagnoses. Stress management is so important. If clients are not managing their stress, then they're keeping themselves revved up. When they're revved, we know that it starts kind of wearing down on their energy levels. You've only got so much energy and and you've got to figure out how you're going to to spend that. My husband's a pilot, and the engine on airplanes has to go in, I think it's every 10,000 miles for a complete overhaul, not 10,000 miles, 10,000 hours, but it's important to remember that. And and we're kind of like that, you know, if we have 10,000 hours on our proverbial engine, and we need to figure out how we're going to spend it. And if we're flying or having a lot of stress in the first, you know, period, you know, you can burn through those 10,000 hours really fast to the point where you're gonna have to slow down and take a respite and relax and rebuild. So, it's important to take care of stress. Good nutrition. Gotta provide the body the building blocks to stay healthy and to develop the neurochemicals. And good sleep, so your body can rest and rebalance and set your circadian rhythms. And, you know, we've talked about how important that is. People going back to old friends who are unhelpful or critical, or getting in environments that are not supportive and nurturing can be a trigger for relapse. Old friends and, you know, other people like people you've broken up with in relationships that have the relationship, we're seeing that person triggers an anxiety or a depression or stress response can also be a trigger for relapse. Places where you used, where you used to use or buy drugs for people who are addicted. But for people who are depressed, for example, or grieving, people where places they used to go with their one. For people with anxiety, places that trigger their anxiety can trigger a full-blown relapse. If they're in going to those places enough times, or if they know they've got to go to that place, it may they may spiral. I know a friend of mine has an extreme terror of flying, and she starts getting stressed out about flying two months before she's even got to get on an airplane. And for someone who's in in recovery from generalized anxiety or depression or even substance abuse, that far, two months worth of dread can really put the person on edge, wear them down, put them at risk for relapse. Things that were part of your using remind you of using or remind you of things that make you depressed or anxious. Uncomfortable emotions. HALT: Hungry, Angry, Lonely, and Tired. An acronym we use in substance abuse recovery. Again, it's true for mental health. If you are not getting the nutritional building blocks you need, if your blood sugar is out of whack, or if you're hungry for other things, such as nurturance and love, then you you're at risk. If you're angry or anxious, you can be at risk because that can build on itself and and cause an emotional or substance relapse. Lonely, we all need support. And tired, get that sleep. Relationships and sex can also be triggers for relapse. If anything goes wrong, you know how devastating it can be when you break up with somebody. And sometimes it's devastating for a day, but sometimes it can be devastating for a longer period of time. And it can remind a person when they break up with this relationship, it can remind them of this really bad breakup they had five years ago that triggered a major depressive episode. So, it can, it can kind of reopen that own old wound and trigger a depressive relapse. Isolation gives you too much time to be with your own thoughts. And that's different than having time to yourself. It's withdrawing and being isolated, not reaching out for help, not getting other people's feedback. It can be a trigger for relapse because we can get too much into our own head and get too negative and and not have another perspective to say, "You know what? It could be true, but think about it this way." And pride and overconfidence, thinking that you don't have a problem, depression, anxiety, bipolar, schizophrenia, substance abuse, or that it's behind you. You know, "I'm I've got it cured right now." And we know that unfortunately for none of those things do can we say with any certainty that it's cured, that a person's never gonna have another episode. If a person goes two years without a major depressive episode, it's likely that they probably won't have another one, but we can't necessarily say that's true.

So, there are types of relapse we're going to be looking for as clinicians. You know, we're seeing people and we want to educate them of types of relapse for them to be looking for. So, they might need to, if they notice these, they can check themselves. Emotional relapse, mental relapse, and physical relapse. Emotional relapse is obviously when you start having more dysphoric emotions more often than not. Anger and anxiety eventually often leads to depression. People who are depressed tend to be more irritable. So, you know, if it starts becoming encompassing. Mental relapse, when your thoughts become more negative, when the cognitive distortions creep in. Those things are what we're going to be looking for. And physical relapse, when you start having the physiological symptoms, the fatigue, the pain, the cravings, if you're talking about substances, insomnia, either changes in eating habits. All those are physical relapse signs that are, you know, big warning signs to you that something's going south here. And it's kind of like when you're driving your car and all of a sudden these little lights start blinking on your dashboard. You may not know what they are, but you know it's something, and you probably need to pull over and figure out what it is.

So, emotional cues for relapse: If somebody's more angry, defensive, or frustrated than usual. If they have more anxiety or depression. If they're not asking for help when they need it. If they're hanging out with unhelpful friends. And for people who tend to be more anxious or angry, many times I find that they kind of gravitate towards other people who share their points of view. So, it's kind of this negative groupthink thing that goes on, and they can reinforce each other's negativity. Are you having more mood swings, or feeling restless and bored? So, these are all good questions to ask somebody like, "Before your last episode, did any of these apply? Do you, can you look back and see where any of these applied?" And the ones that did, write them down because these are questions that people need to ask themselves every day now, henceforth and forevermore, just to make sure that they are staying mindful of anything that might be going a little wonky.

Mental cues: Are they keeping secrets or isolating? Are they tending to see the worst in things and using cognitive distortions? So, in counseling, they've probably worked with you on identifying and addressing cognitive distortions. We can have them, you know, pay attention to whether they tend to be looking at things negatively or waiting for the other shoe to drop.

Physically, did they stop going to meetings, support group meetings, whether it's substances, depression, whatever, or whatever they were doing to get social support? This could, for some people, this is church. For other people, it's volunteer work. But it's somewhere where they're getting good, positive emotional support. I really encourage people to connect with some sort of diagnosis-specific support group, so to speak, so they're around other people who've been there. Not everybody's down for that. Did you stop going to counseling? You know, that can be a relapse warning sign. If somebody is in counseling and then they just drop out, or, you know, they're in the middle and, you know, "I don't have time for this right now, so I'm just gonna take a hiatus." That can be because they've got other stuff going on, or that can be because they're headed down a relapse trap. Are you having difficulty sleeping, taking medications as prescribed, and eating junk or not eating at all? Pretty simple question somebody can ask themselves. Not every question is going to apply to every person. So, we want to hit the highlights. What are the top ten relapse warning signs for you? What do you do? And again, look three or six months back to see if you can identify when it started. Are there other relapse warning signs that you see in your clients or that you encourage your clients to be aware of?

Okay, so we're going to move on to the acronym DARE to DREAM. DREAM stands for Determination, Resilience, Exceptions, Awareness of vulnerabilities, and Motivation. And this is a relapse strategy that I use in my practice.

So, the first thing is to help people develop determination and self-efficacy. Recovery's not easy. They need a high level of tenacity to get through the rough points. There are going to be times that they're just sitting there gritting their teeth going, "I don't know if I can do this." And their addicted selves or in their distressed selves, people tend to behave impulsively. A lot of times when people are really depressed, really anxious, they're gonna do anything. Well, not necessarily anything, but they're going to do things without thinking through the consequences as much, just to make the pain stop. Recovery involves being able to forego the easy or immediate reward to achieve longer-term goals.

Resilience is the ability to bounce back. We want to encourage them, "You know, get that determination going, increase that motivation, be ready, willing, and able to do it." All right, that's great. We got that. Now you've got to develop the skills to do it. And resilience means you're kind of like a Weeble wobble. You can wobble, but you won't fall down. You're going to bounce right back up. Part of resilience is hardiness. Commitment can be considered motivation. We want to help them figure out what they're committed to. And we want to help them look broadly across their lives. And we talk about this a lot, but I think it bears repeating. Something can go in going really wrong right here, wherever here is, their mood, their, you know, they may have a flare-up of their fibromyalgia, you know, whatever. All right, that really stinks. What else is going on in your life that you're committed to? So, helping them see that there are good things in their life that they're committed to and that are important that they want to focus on. And yes, they want this to go away too, but that commitment helps them balance the good with the bad.

Control. How much control is rewarding? You know, not you don't want to have too much control or think you have too much control because in reality, you don't. And that can be really disempowering if you think you can control everything and it turns out to not be so. But it is empowering to realize that you do have control over certain things, such as your reactions and what you do and your boundaries. Encourage them to identify of the things in their life that they're committed to, what parts of those things do they have control over? They have control over how much time they spend with their kids. They have control over what time they go to bed. They have, there are things they have control over. You know, when they spend time with their kids, they can't guarantee the kids are going to like it. We have mandatory family time at my house on Friday evenings, and it's not always the most looked forward to event, but they do it. And, you know, it's one of those things that's important to me to make sure we're all sitting down doing something. So, identifying what we have in terms of control. And, you know, for that mandatory family time, usually it's the boy who's not really on board with it. So, I will let him pick the movie that we watch, or at least have input into the movie if we have opinions. Having too much or too little control can be unmotivated because you want to feel like you can affect change. You don't want to feel like you're responsible for everything, and you also don't want to feel like, you know, fate or destiny is going to control everything. You want to feel like you can be an agent. And a person needs to feel challenged. Something is too easy, you're not really gonna do. I've been guilty of that. I'm like, "I can do that in 30 minutes." I'm gonna put it off. Something that seems like it's a challenge, you're like, "Okay, I can do this." Sometimes people who tend to be a little more competitive, if you tell them they can't do something, they're gonna do it. Challenging it means different things to different people. So, we need to help people figure out how they can develop an attitude where they want to embrace the challenge instead of looking at something as an obstacle, looking at it as a puzzle or a challenge to them.

Resilience also involves taking care of themselves. Self-awareness and self-care. If you're going to be resilient, if you're going to bounce back up, you have to be well nourished. You have to be well rested. You have to be, you know, feeling like you're somewhat connected. Not everybody has a hundred million friends, but somewhat connected. You have to have distress tolerance skills because life happens, and sometimes it doesn't just hand you lemons, it throws them directly at your head, and that's just reality. So, people in order to be resilient need to have distress tolerance skills so they can get through that period without making a choice in their emotional mind that's going to lead them down a path they don't want to go. And you have to have rational, accurate cognitive habits. So, checking those cognitive distortions regularly for all-or-nothing thinking, personalization, magnification, all those things in our daily journals. I have clients look through the cognitive distortions for the first 12 weeks that they're with me, if which is usually all that they're with me, but they check in with that every single day to identify any cognitive distortions they're using. They identify the ones they use the most, develop rebuttal statements for those, and identify the frequency of those statements. And hopefully, we're going to see those the frequency of those statements go down over the course of treatment. So, we want to have them start developing those rational, accurate cognitive habits. They need to be socially engaged. We've found that people who are resilient tend to be more generous with their, not necessarily money, not everybody has money, but with their time, with their compassion. They tend to live with integrity. So, they're aware of their values. You can't live with integrity unless you know what your values are. They live, they're true to themselves. They have humility and compassion. And they identify as a survivor, not a victim. So, these are all things that you can talk about in group or an individual. You know, "What does generosity look like and why is it important to be generous in order to help you be resilient?" And one of the theories is that generous people, when they're giving, they see other people being lifted up, and it helps them feel better. And when they're generous, and then when they need something, other people tend to be generous in return. But that resilience also develops compassion. And compassion for themselves helps people get through difficult situations. Meaning, people need to have a sense of purpose in life. You know, "Why am I getting out of bed in the morning?" That helps people be resilient, which goes back to that commitment part of commitment, control, and challenge. What am I committed to? Why am I getting up? They need to have a sense of gratitude. As any of us doing any good, encourage people to keep a gratitude list. Just write down all the things that they're grateful for. Encouraging them to focus on what they have, not what they are lacking or what they want. An attitude of hope. So, what brings them hope? And you can do, you know, groups on this, but first, they got to figure out what hope is. And that's one of those weird things to try to define. But having them define what it feels like to be hopeful, what they're hopeful about. And encourage them to start using that word in daily language. You know, "I hope this will happen. I hope you have a good day. I hope that it up." Because if you hope it, then you believe there's a possibility that it can happen. And optimism. Encouraging them to put on those obnoxious rose-colored glasses and try to see the silver lining in things that happen. Try to look at things optimistically. And it's challenging, don't get me wrong, but it does help if people force themselves to look at both sides. You know, they, they see the negative, but okay, let's look at, you know, "Could it have been worse?"

Attention and focus. People who are resilient tend to be more curious. That they don't feel like there's only one option. So, that Weeble wobble, you know, when when he goes down, he can bounce right back up like this, or but he might, you know, bounce all over the place. If you remember them, yeah, I'm dating myself, aren't I? Anyway, but we're curious about what's out there, and we're interested in exploring other options to solve problems. It's like, "Okay, that didn't work. Let's figure out a different way to approach it." They tend to be flexible. So, it's not my way or the highway. They recognize that, you know, different things, different times call for different interventions. They're persistent. So, think about solving a problem or maybe working with a client you've worked with, and they just seem to be, they have treatment-resistant depression. I love that phrase. It's just so disempowering sometimes because it makes the client sit there and look at you and go, "So, if it's treatment-resistant, why am I here?" But when those things happen, when clients seem to be stuck, for some reason, this is when my curiosity, flexibility, and persistence kicks in. I'm like, "Okay, what we've been doing ain't working. So, let's figure out when you haven't had these symptoms before, what's been different? All right, let's write those down. What do you think might work?" You know, because it's cognitive behavioral, doesn't always work. Neither does ACT. Persistence. So, let's keep trying. All right, this one thing didn't work. All right, I'm not giving up. Let's try another thing. Encouraging them to focus on any small progress they have. You know, even maybe they're not completely in symptom remission, but they had a morning that actually went okay. All right, so we're making progress. Now let's keep going with that. Encourage them to develop problem-solving skills. So, helping them use that curiosity and figure out how to find answers and solutions. And maintain a here-and-now focus. Resilient people are looking at, "How I improve the next moment? How can I improve right now?" As opposed to, "How can I improve next week?" or "Why did this happen to me?" They're focused on, "All right, it is what it is," as they would say.

So, exceptions. Determination, resilience, and exceptions. Nothing is done all the time. Exceptions are what people are doing when they're not engaging in the target behavior. And with depression, I look at target behaviors when you're not fatigued, when you are not wanting to sleep all the time, when you are not overeating or undereating. What's different? You know, let's look at some of those very specific behaviors that I can see so we can target some interventions there. Identify exceptions. Ask questions like, "Before this problem started, what was different?" And you can even do it just for the whole global depression thing. You could say, "What was different? How did you deal with stress before this happened?" In the past six months, when you were not depressed or sleeping all the time, what was different? How did you deal with stress? And, you know, generally, even if they've been in a persistent depressive episode, there have been days or parts of days where they haven't been depressed. You know, that even the DSM says most days for most of the time. So, on those exceptions, what was different? And let's do some more of that. Once you identify exceptions, help the clients strengthen those and do those things more. And that means scheduling it in. A lot of times clients aren't gonna think, "Well, you know, when I go outside and get some sunlight, it helps me feel a little bit more cheerful." Generally, if somebody's kind of in a funk, they're not gonna think that. Well, forward. So, have that as part of their relapse prevention plan. Do these things more. These are part of your recovery behaviors. Making sure that you get at least 30 minutes of bright light every day.

Awareness of vulnerabilities and relapse warning signs. So, strengths and vulnerabilities. We want to look at their sleep, not only their duration but their quality, and help them improve that. Their nutrition. If it's not great, I'm working with a client right now who's having real difficult time keeping anything down to the point where I referred her back to her physician so the medical doctor could work with helping her try to figure out ways to keep. And I know there are medications, anti-nausea medications and gastric medications that can help. I don't know what he's going to use, but it had been long enough where it was important for her to go, you know, get that looked at. Medication. It can be a strength. It can help people feel better, but it can also be a vulnerability. So, we want to make sure that any side effects of medication are attenuated the best as possible, and that people are able to afford and access their meds. Chronic pain. Always a vulnerability, but helping people figure out how to minimize that pain and live with that pain in a way that they have a meaningful quality of life is really important. Your sex hormones, estrogen and testosterone, affect the availability of a lot of your neurotransmitters, including serotonin. And they also impact your sleep quality. So, it's important to have that evaluated to see if that might be a vulnerability. Some people will find that they are more triggered, which is why we have premenstrual dysphoric disorder. They are more triggered when their hormones are at a certain level for a relapse. And social supports. What are your strengths in terms of social supports? And encourage them to look at of your social supports and those people that you interact with, who are the ones that are more your vulnerabilities? Who are the ones that you tend to feel more anxious or apprehensive around? And how can you deal with that? Relapse warning signs are the way people act when relapse is eminent. Have them describe their addicted and sober selves. If you are working with somebody who is addicted, obviously, so you can see how they act when they're in their addicted selves. And if you've worked with people with addictions, you know that there is a very different way of acting that tends to be more unhelpful and and borderline on symptoms of antisocial personality or borderline personality disorder. Not saying they have that, I'm just saying the symptoms overlap significantly. And then in their sober selves or their recovery selves, they may act very differently. They may be compassionate and giving and honest and loving and all that other stuff. So, you want to have them.

Reflect on those so when they see themselves becoming more manipulative or defensive, they they can check themselves. Same thing is true with mood disorders. You know, when you are in your episode, depressed and anxious, manic, what do you like? And what do you like when you're in remission? When the behaviors of the addicted self start to emerge, it's a warning sign that current strategies are not working. And the same thing is true for mood. When those relapse warning signs start to emerge, you know that whatever you're doing right now isn't working. So you need to look back and go, and what is, what I'm doing right now, my relapse lifestyle or recovery lifestyle, or my relapse lifestyle.

And N stands for motivation. People do what's most rewarding. So we want to help them identify the benefits to the target behavior. And you want to break this down in terms of behaviors, not just the benefits of being depressed. Well, there's really no benefits to being depressed that people are going to easily come up with. So break it down to what are the benefits to sleeping 14 hours a day? What are the drawbacks to sleeping 14 hours a day? What are the benefits to getting out of bed by 8 o'clock and not going back to bed until at least 7 o'clock? And what are the drawbacks to that? And start looking at enhancing their motivation.

Now, why are these different colors? Because we want to enhance the benefits of the new behavior and the drawbacks to the old behavior. We want to see what keeps sleep, for example. We want to help them see why it's so important and so helpful for them to get enough quality sleep, and why it's so unhelpful and potentially detrimental for them to be not getting enough sleep. Then, we in the red areas, we want to reduce these. The benefits to the target behavior, you know, it feels good to stay in bed and it's less overwhelming sometimes. That is totally true. But we want to eliminate some of those benefits. Help them figure out other ways they can deal with feeling kind of overwhelmed and overburdened besides staying in bed. And eliminate drawbacks to the new behavior. Some people will say, I don't think I can stay out of bed that long. I'm exhausted all the time. I hear you. Okay. So we're gonna look at the drawbacks and we might start instead of saying getting out of bed by 8:00 and staying out of bed until 7:00, we may say getting out of bed by 8:00 and staying out of bed the first week until five, and then six after that, and then kind of working our way back up. So they gradually increase the number of hours each day or each week that they are are staying awake until their staying awake for roughly 14 hours a day.

Motivation is multi-dimensional. So when we're helping them increase their motivation, you know, looking at the benefits and drawbacks, we want to look at the emotional, cognitive, physical, social, and environmental benefits and drawbacks of both what they're doing now and what we want them to start doing, or the new behavior. Does it make them happier? Does it make them, you know, elated? Emotions are pretty easy to deal with. Does it reduce their anxiety? Cognitively, does it help them think more clearly, improve their memory, help them think less negatively? Physically, does it reduce pain, help them feel more energized, improve their appetite, reduce their weight, whatever their goals are? Socially, how does it impact their relationships with themselves and with other people? And environmentally, if they start doing this, how's it going to affect their environment? And, you know, is it going to have a positive effect? It may be cleaner, they may be able to move to a new place. Is it going to encourage the other people in their environment to take on healthier behaviors? Those are all things that we kind of start brainstorming.

And one of the fun things to do with this is to make for flipchart sheets and put them around the room, which is nice because there's four corners in a room. And have people break up into groups, pick a target behavior, sleep, nutrition, whatever it is, and have them each of each group go to each station and identify all of these things. And where you have like the benefits of the target behavior, have emotional, mental, physical, social, cognitive, and environmental on that sheet as prompts for them to think about all the ways, all the benefits of the target behavior. And then as a group, you can start kind of addressing and whittling away. And motivation differs for each behavior. You may have somebody in your treatment, in your care, who has clinical depression, they're addicted to alcohol, and they're having relationship difficulties. Not an uncommon scenario. They may be really, really motivated to make their depression go away. And maybe pretty motivated to address their relationship, which they think is causing their depression. But they're not ready to give up that alcohol because that's the only thing that's helping them cope with living with this other person right now, or whatever the case may be. So motivation is going to differ. So our interventions are going to differ for, you know, each one of these things. So we want to look at what's their motivation here. And what motivation can also differ. Just even within within a goal for depression, maybe they're really motivated to work on nutrition and and sleeping. But exercise and medication, they're not real motivated to even look at those right now. Okay, let's work on the ones you're motivated on.

Stages of readiness for change. And y'all have heard this before. Pre contemplation. We're gonna imagine we're at the pool and it's a hot summer day. Pre contemplation, you're not feeling how hot it is yet. There's no problem. Not a problem. Nobody can tell you there is. Contemplation, at the pool, you're starting to sweat. You're contemplating getting into the pool, but you're like, yeah, it's really cold and I'm not hot enough to really move yet. I just put on my sunscreen. Preparation, you're starting to get hot. You walk over, you sit on the edge of the pool, you dip your toe in, and you're like, yeah, I'm probably gonna have to jump in pretty soon. But it's awful cold. I don't know if I want to do that. But you start making preparations to do it. You've moved over there. Action is when you take that plunge into the pool and you're getting cooled off. And you either stay there and swim around for a while, or if it's too painful, you right back out. Which is one of the reasons a lot of our clients will start treatment and then they may drop out of treatment. If things go too fast or it becomes too uncomfortable, they may not stick with it. They drop back to preparation and they're like, you know what, I just know that's, I'm not ready to deal with that yet. So action is when they stay in the pool and they get themselves all cooled off. And then maintenance is maintaining their temperature. Get out for a little while, get back in, get out for a little while, get back in. Relapse is basically when they get out and let themself get hot and uncomfortable again. They're doing that same thing going on. I don't want to move. I don't want to get into the pool. Relapse for our clients is going back to those old behaviors that's supported or triggered or caused contributed to, whatever you want to say, their distress.

Motivation is not linear. Mindfulness will help people identify when their motivation is waning. We all have things. We'll start on a task and we'll be gung-ho. And then a month into it, we're like, yeah, yeah. And I'm still doing it. And then three months into it, you're like, yeah, I don't know. Motivation wanes if there are not sufficient reinforcers in there. So we need to make sure that people stay mindful of their level of motivation. And when it starts to wane, they do something to improve it.

So what to include in a relapse prevention plan? We're going to run through these real quick. Triggers, they need to identify people, places, and things that trigger cravings or emotional distress. They need to include in their plan how to avoid triggers and how to manage high-risk situations that cannot be avoided, like holidays. They need to manage cravings, the emotional ones, mental ones, and physical ones. They need to identify any of those relapse warning signs. Manage any cravings for, you know, old behaviors. Useful tools, a gratitude list, relaxation techniques. And we want all these written down in the plan. So when somebody's in crisis, they're not having to go, what was that that I used to do? Stress management techniques, supportive people, mental and physical wellness activities. What can you do to get back on track? And problem-solving skills. So if somebody is stuck, they're like, oh yeah, I remember this mind mapping thing. Let me try that. Life improvement activities also need to be included. How are they going to improve their family relationships, however they define family? How are they going to address or improve their relationship with their significant others, with their supports and friends? What are they gonna do about any legal issues, school, work, work-life balance? They need to figure out how they're gonna work that out so they can stay balanced and harmonious and authentic. Finances, how are they going to address those finances? Finances are huge triggers for anxiety and relapse. Housing, basic needs, mental health, spirituality, and purpose. They need to have a life purpose in their recovery program. They need to include 12-step work or some alternative, something that they're going to do to remind them to maintain an optimistic, forward-looking attitude. Consider doing a moral inventory or identifying character defects. I do a self-esteem worksheet so they can identify anything about themself that they want to improve upon. Identify ways to make amends. So you know, they don't, even if somebody will stick with depression, they may feel guilty about not being able to go to their son's t-ball games for an entire season because they were just clinically depressed. And they, that guilt may be weighing on them. So how can they make amends for not being able to be there at that time? And they need to have identification of relapse warning signs for them. What are their relapse warning signs?

So recognize recovery. Give credit where credit is due. Even if it's just a morning or an afternoon, that's a respite. That's a period where you were not symptomatic. That's progress. And start building on that. Recognize what recovery looks like for you. So you're looking for the signs, but things are getting better. Just like you look for the signs of spring, look for the signs of recovery. Acknowledge that lapse is a normal experience and shouldn't be viewed negatively. It's not easy to, you know, all of a sudden start a recovery lifestyle. So you're gonna occasionally fall back into old habits. That's okay. Once you notice you're doing it, fix it. Strengthen the motivation to change throughout the change process. Identify high-risk situations. Encourage clients to develop coping strategies and skills to avoid high-risk situations, but to deal with them when they're unavoidable, like holidays, reunions, work. Develop coping strategies and skills to deal with lapses. And recognize and implement changes to the environment and lifestyle to minimize the frequency of high-risk situations and strengthen their commitment to change.

And in the discussion section of today's class, we're going to talk about different things that we might be able to do to minimize the frequency of high-risk situations and strengthen the commitment to change. People in recovery have determination, resilience, an understanding of exceptions, an awareness of their vulnerabilities and relapse warning signs, and they're motivated to live a recovery lifestyle. Relapse prevention planning helps them minimize vulnerabilities, incorporate mindfulness, and contains within it an emergency response plan.

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