211   20 Relapse Prevention Strategies
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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/CounselorToolbox. I’d like to welcome everybody to today’s
presentation on relapse prevention techniques. We’re going to define relapse
and really talk about it in terms of a return to prior functioning not
necessarily focusing on addiction because too often we forget I guess to
really address relapse prevention planning in our mental health clients
we’ll examine some relapse prevention techniques learn how to help clients
identify relapse warning signs and examine what needs to be included in a
relapse prevention plan and yes even for mental health clients it’s ideal if we
can let them walk out the door with a relapse prevention plan kind of in hand
that way they can identify those relapse warning signs and hopefully they won’t
have another episode as bad as the episode that brought them into
counseling so relapse is a return to addictive
behaviors or the recurrence of mood symptoms you know when somebody starts
having another major depressive episode or starts feeling that anxiety in their
chest again you know then they’re having some level of a relapse relapse often
starts long before the person uses or experience the symptoms again they get
caught up in the day in day out now think about some of our clients and
we’ll focus on anxiety today because we usually talk about depression clients
who develop really good mindfulness skills to address their anxiety and you
know really good coping tools and all that kind of stuff and you find that
some of their anxiety was brought on by poor time management being pulled in too
many different directions not enough self-care yadda-yadda well
they’re doing fine they feel great they start taking on a little bit more and
their feel still feeling good and they start taking on a little bit more and
before they know it they’re not practicing their mindfulness they’re not
getting the rest they need they’re not taking care of themselves anymore so
they start feeling rundown and they start feeling anxious and symptomatic
again and this can also be referred to or whatever you want to call it as
starting to act mindlessly they’re on autopilot they’re used to saying yes
they’re used to doing you know what they always did and they want to be
able to go back to doing what they always did and one of the things
sometimes we need to help people address in counseling is the fact that maybe
what you always did wasn’t a good fit for you and yeah you may want to go back
to doing what you always did but it may not be in your best interest when you’re
looking at those things that are important and meaningful in your life
you know do you really want to risk having another symptom exacerbation they
may start stopped going to meetings counseling Church or whatever their
lifeline is you know whatever their social support is whatever their
activities are whatever helps them stay grounded and feel connected and develop
that social support if they start neglecting those and you
know I always think of the the movie Oh golly The Shining when he starts typing
all work and no play makes Jack a dull boy and has his psychotic break but I
digress hopefully our clients aren’t going to get that to that state of
problem and problems but the same sort of thing can be true for all of us not
just our clients if we start start working and you know even if you love
your work and that’s awesome but you still need downtime you still need
recovery time you still need to do some things in your life that bring joy
because work by virtue of what it is has a certain element of stress associated
with it now if all your social supports are there you know you may be able to
finagle a few more hours at work than some other people who may not have a
great working environment but it’s important to feel balanced in your life
and you know when we stop having balance we start having problems if you think
again back to some of those things that we talked about when we were doing
multicultural responsive services look at the connection even if you tend to be
an individually focused person look at the connection between what you do and
your moods so people start you know burnin the
handle it both ends they stop doing things that bring them joy they begin
running out of energy to do new behaviors because they’re getting worn
down they’re getting tired and frustration irritability and exhaustion
can set in so it’s generally this kind of slow gradual taper as they regress or
revert to their to their old behaviors which often times are what brought them
to counseling so we want to help them see that what parts of those can you
incorporate you know maybe you loved working out and you want to work out
again great well instead of doing three hours a day let’s talk about an hour a
day maybe you love your work and you know because there are some of us who
really love what we do but maybe instead of working 12 hours a day you need to
set limits and work you know six or eight hours a day and some of you
working six hours a day whoo-hoo but you know it depends on the person whether
they do it like a straight-6 and you know work that hard I know I cannot see
you know when I’m working with clients and in clinic I cannot see more than
four clients in a day because then I’ve got paperwork and other things to do but
after four clients I start feeling like I’m not making the connection and being
with them a hundred percent and yeah I could probably work up to it when I was
in community mental health we had to have 30 billable hours a week so that’s
a minimum of six client contact hours a day but you know that was a struggle to
get through and you know by the time I got to my fourth intake of the day I was
having difficulty remembering you know have I already asked you this and that’s
not good for clients and that’s not good for us you know we start feeling kind of
like cogs in a machine instead of the helpers that we are so we want to look
at the behaviors that triggered the depression or the anxiety or the
addictive behaviors and the things that they do in recovery that support their
recovery so we’re aware of you know when we see these old behaviors or thoughts
or feelings start creeping in that might be a you know big red old
flag saying you you got to stop step back and take a look there is one caveat
for relapse and that’s that an extreme stressor comprar mediate relapse if
there’s a death in the family if there’s a divorce if you lose your job there are
things that can cause you know that sock in the gut that may cause depression or
anxiety symptoms to just like go through the roof in and okay you know so have it
helping the person develop a relapse prevention plan they’ll have some tools
that they can look at right away even if they can’t get in to see you
they’ll have tools they can look at right away and go okay I know this is
gonna really suck for the next two weeks or whatever it is but here are some
tools I can use to kind of take the edge off so relapse is the return to
something that’s been previously stopped and it’s multi-dimensional we have
emotional relapse people get sad people get anxious you know their feelings
return to what they were prior to recovery mental relapse they may start
becoming more negative may start holding on to grudges they may start having more
difficulty making decisions you know think about the mental symptoms in
depression and anxiety diagnosis they may have difficulty concentrating their
memory may kind of get dicey physical relapse symptoms you know if they’re
they’ve got an addiction there may be some cravings there may be some craving
different food cravings but they generally tend to start to feel rundown
and fatigued and exhausted and if they’ve got some anxiety going with it
they may start feeling panic attacks sort of symptoms and you know all the
other associated stuff the upset stomach the migraines the stress and the muscles
social relapse is when they start hanging out with people that either
cosign on their BS and say yeah you’re right
you know everybody’s against you and you know compound that feeling and or you
know sometimes this is the same group they hang out with people who have
similar diagnoses so they’re kind of feeding on each other and yeah the world
is against you or yes the guy is gonna fall and everybody gets
anxious and is like stressed out all the time
because in a social relapse so to speak you’re gonna withdraw from those people
or you often withdrawn from those people who kind of moderate you and say you
know let’s stop and think about that for a second
is it how likely is it that the sky is gonna fall tomorrow yes it could you
know no doubt it is possible and but how likely is it and those are the people
that you know you may have backed away from unintentionally and you don’t have
their good presence kind of balancing you out so relaxes multi-dimensional
it’s not just one thing those things that overwhelm your ability to cope are
what I to as extreme stressors they thrust you into the fight-or-flight mode
new coping skills and support resources may not even be considered or they may
only be considered half-heartedly the person is you know they feel like they
got sucked in the gut they’re kind of you know dizzy and wobbly think about a
boxer that just got his bell rung so we want to have clients identify things
that may be extreme stressors for them that they could anticipate coming up and
even just do some you know role plays if nobody has anything they can anticipate
one thing in Florida you know where I came from we regularly have hurricanes
and hurricanes can be really stressful because people start worrying about
their house and their loved ones and their this and that okay so let’s have a
hurricane you know um rehearsal if a hurricane comes what are you gonna do
how are you gonna plan for it up here in Tennessee we don’t have hurricanes we
have tornadoes so helping people figure out you know when you start hearing the
tornado sirens what do you do how do you cope with it
yada-yada but and that’s especially true if people have been in a tornado or a
hurricane and had significant losses so it may sit trigger some post-traumatic
stress type of stuff other things that could be an extreme stressor included
job law us or the diagnosis of a terminal or
chronic illness such as cancer ALS HIV any of those that they’re going to have
to be dealing with and you know when that happens we don’t expect their
coping skills to be able to keep up because that is a very unusual situation
so we need to have a plan for when your coping skills are overwhelmed what can
you do beginner tools for extreme stress
I tell people get support they’re outnumbered they have the positive voice
in their head that’s going you got this it’s going to be okay let’s be rational
let’s use the tools we learned in counseling and then they have the other
voice that has been in their head for much longer going this guy is going to
follow the world is going to end there’s no way you can handle this you’re a
loser whatever it says that critical voice that one that’s always you know
calling doom so get support get somebody else who can be a good sounding board
and moderate and say you know what let’s think about how likely that is you know
you’ve got these two different messages going on you’re not sure what’s going on
what’s the worst that’s gonna happen so support is good practice self soothing
and de-escalation techniques what can you do to help yourself calm down in the
midst of extreme stress part of that is getting your heart rate to calm down
some people will practice combat breathing when you breathe in for three
hold for three breed out for three just slow their heart rate down some people
find it helpful to move around using the big muscles of your legs tends to bring
the energy so it doesn’t feel like it’s going to come up and make your head
explode brings the energy down to your feet when your heart is racing when
you’re stressed out another way to look at it your body’s going oh we need to
move a fight-or-flight we need to go so in a way walking even if you’re walking
around in circles can help your body go okay we’re doing something we’re moving
that that’s a step in the right direction so encourage clients to walk
whenever we would have a incident if you will on the on one of the residential
units that was one of the first things that we would do we would have staff
member you know go in talk to the people that
were involved and we would separate them and we would go out and walk around the
property we used to call it the compound but that doesn’t sound very nice we’d
walk around the property and just talk you know tell me what happened and
generally we weren’t making direct eye contact and we were just we were looking
forward so there wasn’t a stress on the person we could listen to them they were
moving so they weren’t feeling like they were a caged cat and that’s helpful
systematic desensitization can help if there are things that periodically come
up that are extremely stressful encourage the person to practice
systematic desensitization you know get to the point where they can think about
doing this public speech without getting totally freaked out get to the point
where they can walk into the place where they do the speech and think about
giving the speech without getting totally freaked out you know how all
that goes but that can help people start practicing and this is especially useful
for people who’ve experienced some sort of traumatic stress and obviously it
needs to be used with care but there was a police officer I worked with who had a
traumatic incident on the interstate so the smell of fumes whenever he would
smell those even being in traffic not on the interstate getting on the interstate
those would all trigger sort of extreme stress reactions so we worked with
systematic desensitization their cognitive behavioral therapy can also be
helpful I’m big into note cards and now that we have mobile devices you know you
can use that instead because it’s more eco friendly but have a note card that
people can look at that says I feel whatever the feeling is I feel anxious
because and whatever it is so to get them to identify what’s going on and
then the next question is I feel this I’m upset about this because and what
are the facts for and against this belief that you know the world is going
to end or I’m going to die or whatever they’re feeling right now
am I using all-or-nothing thinking or jumping to conclusions and then the last
one is I need to call and they put a person’s name in there to get an
objective perspective or if they can’t reach that person what would this other
seemingly objective person do in this situation so I have them keep that on a
note card so when they get stressed they can look at it and they can go through
these questions even if it doesn’t provide great answers to them it gives
them time for that adrenaline rush to go away and then to get more in their wise
mind and be able to make better decisions the four DS of relapse
prevention delay most urges feelings and cravings rise and fall like waves in
about 20 minutes if you don’t feed them so if you start thinking about it and
thinking about how awful it’s going to be and worrying about it and then
thinking about all the permutations you’re feeding it if you can change
direction of your thoughts for a few minutes then urges and feelings will go
away oftentimes and I liken it to having a bee landing on your arm if a bumble
bee lands on your arm you’re gonna look down at it and your first reaction your
first urge is probably to swipe it off you don’t want it on there but if you do
that what’s gonna happen you’re gonna get stung most likely so probably not
the best idea if you can delay that urge eventually the bee is going to fly off
the same thing with our other urges you know we don’t want to necessarily act on
our impulsive urges right away because it might bite us in the butt so we want
to try to delay our reaction until that urge goes away and we can think about it
more clearly and this can be stress eating this can be you know calling an
ex after a breakup there are a lot of different urges we have that can be
destructive so encouraging people to when they have an urge to do something
that may not be in their best interest to think about it first and just give it
20 minutes let the bumblebee set distract you know during this time
you’re not just gonna sit there and look at the walls and there’s no way to clear
your mind doing that for most people so distract
the craving time passes more quickly when engaged in a distracting activity
for a few minutes now I’m not saying just stuff that stuff down and never
come back to it that’s not what I want people to do but when they are in that
really wound up state when they’ve got that adrenaline going they’re in the
fight-or-flight they’re in their emotional mind they’re not making
necessarily the best decisions so let’s let all that energy and drama bleed off
for a little bit until we can get into our wise mind so use distress tolerance
skills the improve and accept acronyms you can google those we won’t go into
those right now or you can watch the DBT video on our YouTube channel give
different ideas for people to distract themselves and there are a lot of
mindfulness things in there you can even do different activities or practice the
opposite emotions so if you’re stressed out
well stressed out or depressed it doesn’t matter do something that’s gonna
make you happy these stress by reducing your stress and distress you’re allowing
your body to maintain higher levels of calming and happy chemicals so in the
moment it may not be possible to do this you’re distracting and delaying right
now but leading up to it if you can make it a practice in your life to regularly
de-stress you’re gonna have more serotonin you’re gonna have more
dopamine in your system so you’re going to be you’re not going to be like
teetering right on the edge of freaking out you’re going to be calm you’re going
to be able to handle what comes your way because think about it when you’re
having a regular month you know we’ll go with a month because things can add up
and nothing majors happened and then all of a sudden something big happens you
know it feels like a little bit of a punch in the gut but you catch your
breath and you move on if all month you know every time you turn around
something happens then whatever that incident is that happens at the end of
the month may just kind of push you to the point where you have a relapse of
the anxiety or the depression because you’re your add energy your skills are
done you are worn down so distressing you can
also work on preventing vulnerabilities and helping clients remember how
important it is to eat well sleep well and recharge their batteries by you know
doing things that make them happy yes it’s important remember when we talked
about culturally responsive cows counseling with Asian persons there’s
that yin and yang you know you can have somebody who’s depressed because they’ve
got too much yen too much depressive stuff going on or you can have somebody
who’s depressed because they don’t have enough yang they don’t have enough
happiness and the yen just kind of naturally curves over because it’s
always in a balance so the yang shrinks begin is gonna grow so you we want we
want to add happiness to balance out the stress that everybody has I mean we’ve
got bills we’ve got things adulting can be stressful and help people learn to D
catastrophize encourage them to challenge their thoughts and when
necessary reframe them into more accurate notions like yeah this is
really uncomfortable but I can manage and uncomfortable it’s not usually where
the word I use but it sounded better for the presentation there’s a video on
thinking errors also on our website that you can look at please feel free to use
it you know I’ve had people tell me they use some of the videos or parts of the
videos in counseling groups and that’s totally cool you know if you find
something that’s helpful more power to you relapse prevention card is another
thing that you can have fold a paper into four squares on the first square
right delay distract distress and D catastrophize on the second square write
out five personally relevant distraction ideas so going back to that DBT the
improve and accepts acronyms identify five things in there that you think you
might be able to do that sound workable for you on the third square write out
three of your most significant reasons for wanting to recover or to be happy
you know that will remind you that you know why you’re doing all this hard work
and on the fourth square write out some negative expectations or accurate
predictions for what will happen if you slip if you go back into a major
depressive episode what’s gonna happen you know you might be wanting to sleep
all day and you’re gonna start missing your kids ballgames and you know there
can be some you know obviously there are some negative consequences when we’re
not able to function the way we hoped or or prefer to so encourage people to you
know create a relapse prevention card so they’ve got a snapshot of what they need
to do why they want to do it and you know why they don’t want to go back to
being the old way relapse prevention plans triggers and vulnerabilities just
like relapses are multi-dimensional so I want people to go through and they can
do this as homework you know you don’t have to do it in the office because this
is kind of psycho ed stuff you can this is great to do in group if you’ve got
you know eight people or whatever who are working on this because they will
talk about triggers and each person may throw out triggers and other people may
go oh yeah you’re right I didn’t even think about that one so emotional
triggers what makes you sad y’all know that the ASPCA commercials oh my gosh
during the holidays they were on I swear they were on every channel
I was watching I’d be at the gym and I just have to like look down at the
monitor because I couldn’t watch the the TVs that were up there because I can’t
see those poor little suffering puppies kills me but I know that’s one of my
triggers so emotional triggers what things trigger you trigger your sadness
trigger your anxiety write those down mental triggers what triggers your
negativity what makes it harder for you to concentrate physical triggers what
triggers you know physiological reactions like your panic attacks you
know sometimes those are those are physical reaction and you’re like where
in the world that come from you can also look at other
physical triggers that may prevent you from sleeping well and may make you want
to crave unhealthy foods or foods they’re higher in sugar and fat which
tend to when you eat them make your brain excrete dopamine or see-cret
I never got the grammar on that one oh well so those are things if you start
craving those foods you may realize that you’re headed down a slippery slope
social triggers what things and it could be social things that you’ve got to do
like going to holiday parties or family reunions or mixers or whatever it is or
it could be the people you’re hanging around or you’re exposed to but what
social triggers are in the environment and what are your environmental triggers
and the people forget about this I mean it’s not just the billboards but it’s
what you watch on TV it is you know around the holidays whether it’s
Christmas or Valentine’s Day they’re all always these hallmark movies on and if
you have a crappy family situation at the moment you know watching those may
feel like somebody is stabbing in the gut and it may trigger more depression
so look at what you’re watching on TV the pictures that you have look around
your environment does it say I am happy and energized or does it say pull the
curtains I don’t want to see anybody I just want to bury my head and watch
Netflix whatever it is but encourage people to look at that vulnerabilities
are the same way and triggers and vulnerabilities can kind of be the same
but understanding vulnerabilities emotional vulnerabilities if you’re
starting to feel stressed or sad I know when I used to work in the clinic I had
an office right up front and most of the time I’d leave the door open so my staff
could come in the clients could come in I tend to be an extrovert so I like
having people drop in but if I was having a particularly stressed-out day
for some reason I’d closed my door because I knew that I was emotionally
vulnerable to being a little bit more snippy or less hospitable so you know
I was aware of that through mindfulness I was aware when I was having a day
where I needed to give myself a wider berth mentally your vulnerabilities
understand when you start thinking more negatively physically nutrition sleep
and you know ideally exercise also sunshine
you know remembering that there are oodles of vitamin D receptors in the
areas of the brain responsible for mood they don’t know how it works but they
know vitamin D is implicated in depression so make sure that you know
there’s been enough sunlight even if it’s not the winter and you can’t call
it technically seasonal affective disorder some people start to be very
affected after two or three days of just dreary rainy weather so if that’s the
case what can you do social vulnerabilities if you’re feeling
if you have social anxiety or if you don’t like going to these mixers or
whatever I don’t like going to mixers so I use that example whenever I have to go
to one of those for the chamber I take somebody with me because I just I don’t
walk up to people and go hey how you doing very well just not my thing so I
know that that’s the vulnerability I’m gonna be stressed out going in unless I
bring you know somebody to kind of be my wingman and what are your environmental
vulnerabilities for people with addictions that would be having the
stuff in the house for example if you have somebody who has you know binge
eating you know they probably don’t want to keep all kinds of high sugar high fat
foods easily accessible somebody who’s a smoker probably doesn’t want to be
around cigarettes or nicotine you know so you want to look at these things what
things do you need to prepare for when somebody has cravings and this goes in
the relapse prevention plan once they’ve identified their triggers and their
vulnerabilities and ways to deal with those then you move on to cravings
compile a list of who you can call and what you can do to distract yourself
from craving and how you could stop a craving altogether and this refers to
gambling smoking sex overeating or even self-injury you know when somebody gets
that urge to self injure you know that’s almost a craving so
you know think about it in terms of that and then healthy tools need to be in
there too not just all the doom and gloom and this is how we intervene but
we want to be proactive not just reactive think about what new and old
behaviors you can use to keep you on the right track so what do you need to do
every day set an alarm in your on your smartphone that reminds you to do your
mindfulness activities if you need to some examples include writing a list of
consequences should you relapse attending support meetings exercising
journaling writing a gratitude list for some of my clients like if they have
anxiety disorder for example and they’re they’re worried about everything at the
end of the day I have them write down you know what they were worried about
and whether it came true and so they can see you know yeah I probably was
worrying about that for too much maybe not for no reason but but too much and
then what they can do to control that worry emotional relapse an emotional
relapse your emotions and behaviors become negative and unpleasant you find
it difficult to experience pleasure so encourage people to think and we’re
going to go through each of these and yes it can get granular it can get kind
of tedious especially if you do it all at once but it’s important to think
about what triggers their negative emotions and this is another one of
those we talked about station learning you know you can put flipchart paper or
whiteboards up around the room and have each emotion listed and then have the
group go around break them into groups of like three or four have them go
around and list on the papers what triggers their anxiety what triggers
their anger resentment jealousy yada yada so you can get a whole list of what
may trigger it for people and what they can do about it encourage them to think
about things the media people places and events that may trigger those feelings
negative emotions make us uncomfortable so encourage people when they start to
feel uncomfortable not to just stuff it or avoid it
but to identify the emotion and explore why they’re feeling that way and take
steps to fix the problem not to fight it I feel angry I feel depressed I feel
however I feel right now okay I don’t want to continue feeling this way
instead of fighting it what can I do to improve the next moment people can
sometimes become stuck in their emotions nurturing it and blowing it out of
proportion if you think about something long enough you can you know get that
snowball it’s kind of like telling fish stories and each time you tell it that
fish gets a little bit longer you can compound it with other emotions
like anger and guilt so somebody who’s depressed and not able to do the things
that they were able to do six months ago they just have no energy can’t get out
of bed may feel angry that they’re in that state they may feel angry at
themselves for not being able to do what they used to or what they think they
should be doing you know and guilt for the same reasons so you know you’re
getting this anger onion or this emotional onion so to speak and there’s
layer upon layer think about the bloomin onions at Outback Steakhouse so you have
the center core emotion and then all these surrounding things you can also
get stuck in the emotion and start personalizing it you know this is
happening because I am yada ya okay and you might get stuck trying to escape
from it so instead of dealing with it head-on you start fighting with it and
we know that telling yourself you shouldn’t feel depressed or you
shouldn’t feel anxious doesn’t work if you feel that way for a reason so you
need to figure out how to fix it how to address it instead of trying to run away
from it stuff it or compartmentalize it remember that emotions are just cues
like a stoplight or you know I make the analogy of the smoke detectors in my
house every once in a while you know I will be cooking and then I will get
sidetracked to to something else and and I’ll forget what I have cooking and the
smoke detector will go off does that mean the house is on fire
no does that mean there’s a big problem well not yet
but it’s telling me that there could be a problem so I need to pay attention our
smoke detectors were faulty for a little while I don’t know what was causing them
to do it and we would have the windows open and when the wind would blow really
strong through the house it would set them off you know there was no smoke at
all and you know the dogs would like freak out but that was just the smoke
alarm saying there might be something to be concerned about and we go around and
look and there was no problem emotions are the same way sometimes we
feel anger or we feel anxiety and we need to stop and look around and go is
this something that’s actually a threat to me right now
if so cool you know let’s figure out what to do about it how to fight flee
deal if it’s not then I need to figure out how to let it go because a lot of
times we get all riled up over things that really aren’t that big of a deal
there are obviously are times where there is a big deal so we don’t want to
just tell people you’re getting riled up over nothing we want to look at it we
want to examine it and then figure out how to deal with it negative emotions
you got to remember you feel how you feel in the moment so if somebody feels
angry they are angry don’t tell them you know there’s no point in being angry
well that’s how they are so we need to figure out how to deal with it and help
them figure out how to change or improve the next moment encourage people to
practice mindfulness increase positive experiences keep a gratitude journal add
one thing to it every day I am grateful today that and sometimes it can be
something like I’m grateful I didn’t get in a car wreck or I’m grateful that I’ve
got a job or or whatever it is it doesn’t have to be something
earth-shattering but encourage people to write in this gratitude list each day so
they remember that things aren’t all bad encourage them to increase positive
experiences avoid personalizing something that may not be about them I
always tell them to identify three other reasons that this might have happened
that have nothing to do with them and then evaluate you know where they’re at
remember that negative emotions are the minds way of telling us to get off our
butts and do something like my father used to call it the idiot
light the light that turns on when it says you’re about to run out of gas yeah
you need to get to the gas station or hunger pangs that tell us mmm blood
Sugar’s fixin to get low probably need to eat something it’s just your body
telling you pay attention you might need to do something dwelling on nurturing
avoiding or hiding from negative emotions generally doesn’t make them any
better you need to figure out what to do with them and you can choose to feel and
fix or relapse and repeat and feel and fix obviously you feel that
emotion you’re like okay you know I don’t like feeling this way how can I
approve the moment or relapse is doing what you used to do with emotions and
shoving them down avoiding them well they’re gonna come back up on you like
bad spaghetti so relapse and repeat one activity you can have clients do is to
list ten things that they chose to get anxious or angry about over the last
week identify why they got upset what their mind was telling them needed to be
fixed so that’s that cognitive behavioral stuff the B in the ABCs did
holding on to the upsetness do them any good and when I do the ABCs that’s the e
the evaluate was this an affective reaction and what was your initial
reaction and was it helpful and what could you do differently next time to
either change or fix the situation or improve the next moment change how you
feel about the situation which may mean walking the middle path accepting that
this sucks but I can get through it or let it go and that radical acceptance it
is what it is and with clients obviously we need to walk through these activities
in group to help them figure out what the difference is between all of these
things versus what they always used to do but help them get used to evaluating
their reactions in mental relapse there’s a war going on in your mind part
of you wants to stay positive but part of you struggling with tolerating the
distress the signs of mental ray apps are focusing on the negative and
tending to have a pessimistic helpless hopeless attitude if people have an
addiction they also maybe may start thinking about
people places and things that they used with glamorizing past use now you know
think about your overeating or binge eating they may start thinking about
that chocolate cake lying to yourself and others justifying behaviors
minimizing the impact of one drink hit that you know chocolate cake whatever it
is or just having a screw at attitude I don’t care nothing I do work so screw it
which kind of goes with the helpless hopeless attitude so encourage people to
think of what types of things trigger the negative thoughts things people
places and events and what thoughts do you have that make you feel angry
irritated resentful guilty envious scared anxious worried or stressed so
what thought and that’s you know one that takes some thinking about so it
could be thoughts like I’m not good enough or it could be thoughts like
everybody’s against me so encourage them and this is obviously you know if they
do some ABC worksheets throughout the week and they bring them in we can look
at some common themes in the thoughts in the B’s and see what types of thoughts
that may be triggering those dysphoric emotions so then we can address them
because they often relate to fears of rejection isolation and loss of control
or failure so connecting feelings and unpleasant thoughts you can have them do
this chart where they look and they say thoughts that make me feel angry
irritated or resentful what which of these thoughts relate to loss of control
or the unknown which of these thoughts relate to failure you know so you’re
grouping them by themes which of these thoughts relate to isolation or
rejection and which of these thoughts relate to death or significant loss and
death and loss of control or kind of end up getting wished sometimes you know
because you can have death of dreams or loss of dreams but help people kind
figure out how to categorize these and then they can see visually which types
of themes are keeping them stuck which can help them figure out what areas they
need to work on with us preventing mental relapse kiss keep it simple silly
trying to change too many things at once can lead to failure so encourage them to
do one thing at a time let’s develop self efficacy and confidence and like we
talked about with brief let’s focus on one thing that’s going to affect every
area of life prevent and address vulnerabilities that can make you focus
on negative or should have strong negative emotional reactions so if you
know that you’re one of those people who just doesn’t function well if you don’t
get enough sleep you know you see where we’re going and good orderly direction
include people encourage people to look at life like a road map the destination
is recovery or happiness or whatever they want to call it and encourage them
before they act think about whether what they’re getting ready to do keeps them
on the right path or is an unplanned detour and that’ll help them kind of
figure out is this helping me or is this kind of you know maybe even making me
spiral around and get lost in the process and encourage them to maintain
head heart and gut honesty because the head will tell us this is the logical
thing to do the heart will tell tell us what we want to do what’s going to make
us feel happy tend to be a more emotional and the gut is the one that is
kind of like the spidey senses the wise mind that says yeah let’s think about it
so you know your head and your heart may be going let’s go for it and your guts
going hold up here so encourage people to make sure that they’ve got head heart
and gut honesty social relapse you can return to the old people in places who
cosign on your BS so if you’re hanging out with those people that you were
hanging out with before may not be helpful you’ve withdrawn from your
social supports become self-centered or just withdrawn completely from
everything so again encourage people to look at
what triggers you to withdraw from people for some people holidays can be a
huge trigger so I encourage them to really look at holidays and see if that
may trigger some withdrawal because once you start withdrawing from your social
supports then you’re bearing the stress on yourself and you’re also eliminating
some of the positive some of some of the yang and and you know you could be
putting yourself in a position where you might be more vulnerable to relapse
preventing social relapse I encourage people to contact their healthy social
supports on a daily basis for the first three months it doesn’t have to be huge
I mean we all have Facebook or text messages or something just say hi how
you do and how was your day going get get involved know what’s going on so
you can ask them well you know did you get that promotion instead of calling
them up you haven’t talked to him for three months and go hey what’s been
going on with you by the way I need a shoulder keep a business card in your
wallet with the names and numbers of three social supports or keep it on your
mobile device change your phone number if you need to
and destroy contact information for people who might trigger a relapse
obviously this is critically important for people who are who are recovering
from addiction we would have clients in the residential facility they would have
been there for three weeks and their dealers would still be blowing up their
cell phones so a lot of times we recommended that they they change their
phone number but even for anxiety and depression you know sometimes people
have contacts that are draining and they can’t set affective boundaries with
because those people are just they’re constantly this isn’t so much for mental
health definitely more for addiction but sometimes you know getting a fresh start
sometimes I change my phone up my personal phone number periodically
because telemarketers will get it and I hate getting eight ten fifteen yes no
joke telemarketing calls per day it just it infuriates me well I don’t need that
kind of stress so you know that’s the good thing about
Google numbers you can change your number periodically and find at least
one pro-social activity to do each week volunteer go to church go to the gym
whatever it is where you can be around other people and feel like you’re
improving your health your wellness and/or the world that you live in
physical relapse is characterized by fatigue increased anxiety difficulty
sleeping neglecting physical health and if there was an addiction cravings and
maybe even dreams about the drug to prevent physical relapse we talked about
the acronym halt hungry nourish your body with proper nutrition so it can
make the neurotransmitters you need to be happy healthy and not anxious nourish
your mind with activities and things that increase those happy chemicals when
you do things that make you happy you’re getting the dopamine to flow you know
when you’re when you exercise you’re getting the serotonin increases your
dopamine can increase so those things are good hungry doesn’t necessarily just
mean food hungry can mean you’re hungry for companionship you’re hungry for you
know spiritual guidance you’re hungry for whatever
but hungry angry and anxious so encourage people to reduce chronic
stress what things can you eliminate what things don’t have to be draining on
you right now lonely encourage people to nurture their social supports to buffer
stress and be willing to ask for help and help them differentiate between
being lonely and being alone because people can be lonely in a group of 600
600 other people and they can also be alone and not be lonely so having them
look at the difference the semantics it’s sort of esoteric but there is a
concept here to help people realize that they can be alone without being lonely
and tired it’s important to encourage people to get sufficient quality sleep
and address issues such as sickness and pain that prevent quality sleep because
lack of quality sleep just does so much to keep our HPA axis or our threat
response system kind of on which keeps us from resting
and relaxing and it also prevents us from accessing as much serotonin and it
impacts all of our hormones so let’s make sure people are getting good sleep
for relapse prevention planning at the end of counseling or maybe even from the
beginning you start talking about this review people’s strengths ask them what
life is like when they’re happy what’s different and what’s the same because
what’s the same we obviously want to keep going and what’s different we want
to bring that back have them list three ways that they already cope with stress
what activities they like to do their positive qualities and strengths because
when relapse starts to come in when people start to feel depressed their
self-esteem may start going down too so having them have a written list of their
qualities and strengths and encouraged them or talk with them about how to use
this information to prevent relapse how can we use all this information to
create a recovery lifestyle for you encourage them to review prior relapses
and recoveries what was happening before this happened so before the relapse what
led up to it but when you were in recovery you
started and you’re feeling pretty bad and then what led up to you feeling good
again what did you start doing what changed
what triggered the relapse or the recovery you know what things did you
start doing that either made you relapse or helped you recover and encourage
people that to remember that change occurs when old behaviors are more
rewarding or stronger than new ones so things we’ve been doing for 20 years are
pretty darn strong these things we’ve been doing for 20 days we’re still
getting the hang of them so it’s going to be harder to use these new tools at
first so it’s important for them to you know have confidence and remember to use
them and practice and cut themselves a little slack if they relapse ask them
what became more rewarding than your recovery program you know what happened
what changed what made you want to slide back into those old behaviors and when
they recover ask them what made doing the hard work of
very so rewarding you’ve done great you know what kept you going even through
the tough things encourage people to look at their emotions thoughts
behaviors and interactions with others before relapses and in recovery so they
can see the difference they can see how they are different and how their
environment is different encourage them to identify relapse warning signs such
as feeling unable to cope and developing a strategy for that for example if
somebody has that feeling they may need to learn how to say no to taking on
extra projects limit work to 45 hours a week and learn how to use relaxation
exercises and meditation to unwind you know if they’re feeling like they’re out
of energy they need to figure out what they can do to help them get the energy
to cope again irrational thoughts somebody may have the thought that I
need to try harder in order to get things under control or else I’m gonna
be a failure and so encourage them to counter that with a more rational
thought such as looking at I’m burned out because I’m trying really hard I
need time to rest or I’m gonna start making more mistakes so taking out the
extreme notions looking at the cognitive distortions unmanageable feelings such
as humiliation embarrassment or this feeling of failure sometimes we get
these feelings and it’s hard to shake them and it they feel oppressive so what
can you do talk about your feelings with others remind yourself possibly and this
may or may not be true that there’s no reason to be embarrassed you may do
something that is embarrassing but who’s gonna remember it two weeks six months
from now and remind yourself that all human beings are fallible you know not
not just you so you know consider having counter statements that you tell
yourself when you start having catastrophic unmanageable feeling just
going through your head self-defeating behaviors such as driving yourself to
keep working even though you need to rest
the constructive behavior would be to take a break and relax ask someone to
review the project and see if they can help you to solve the problem
remembering from the seven habits sharpen the saw we need to take time to
do what’s right and and you can do it wrong I mean you can just pull through
and do it but let’s do it right the first time because do you really have
energy and time to do it the second time self-defeating behaviors kind of that
way if we feel like we just need to push through or suck it up or whatever you
want to say a lot of times that leads to errors and more problems so what can you
do that’s more helpful that’s probably going to take the same amount of time or
less time than having to redo or deal with all the problems when creating the
plan encourage people to identify why they want to change the most common
pitfalls for relapse for them what they can do to prevent that from those
pitfalls from happening again for me I’m big on you know alarms and
text messages to remind me to do stuff because otherwise I get a little
mindless and focus on what’s worked in the past encourage them to include in
their schedule recovery activities things that make them happy healthy
connected work obviously so you know you got to figure out how much time you got
and where your your allotting it reflection time so they can look back
and go you know what things are good this is their mindfulness time positive
health behaviors and nurturing positive relationships people’s self-esteem is
you know a sense of pride and who they are and acceptance of strengths and
weaknesses so we need to help clients work on their self-esteem as part of
their relapse prevention plan because if they feel good about themselves and they
feel confident they’re more likely to take on this challenge when they start
feeling anxious or depressed or craving again lack of self esteem can lead to a
need for external validation self-esteem workbooks abound out there to help
people develop positive self-esteem you can use them as an adjunct to group
therapy you can use them as an adjunct to individual or people can get them on
there but you know it’s not necessarily
something that you have to spend a lot of time on if you don’t have a whole lot
of sessions with somebody eradicating harsh self-critical self-talk is the
second part of working on self-esteem one book that I like is taming the
critical inner voice I do have a video review on that that you can look at
online but you know I like that book may not be for you and being aware of the
impostor phenomenon and that’s when somebody does something or makes
accomplishments and they’re like they should be just overjoyed that they did
it and but they feel like they’re an impostor they feel like they shouldn’t
have made that accomplishment or something and they’re just waiting for
somebody to find out so they’re always anxious they don’t feel like they
deserve the accomplishments that they’ve achieved relapse often begins when
mindfulness ends mindfulness is being aware of who you are how you feel and
what you want encourage clients to keep morning and evening journals to document
these sorts of things for themselves if they have to write it down or even spend
time thinking about it it can it can help them get grounded and encourage
them to develop behavior interruption activities so if they start feeling like
they’re getting into this anxiety spiral what can they do to interrupt that
behavior another thing that we can have clients do is the acceptance and
commitment therapy and just real briefly again there’s a video on our website on
our youtube channel about it but the mindfulness the act matrix and basically
you have four quadrants and over here is moving toward those things that are
important to you to give you a rich and meaningful life who and what is
important and what behaviors could you do to move you toward who’s who or
what’s important where you are right now you are angry you are anxious you’re
depressed you’re whatever you are okay it is what it is so what is the next
thing could you that would help move you
toward those things that are important so when he get angry sometimes you’re
getting angry about something that you just can’t control is holding on to it
and stewing about it gonna move you towards those things that are important
probably not it’s probably gonna move you away and drain your energy and then
on the away section what behaviors do you do like running away from stuff
stuffing it down drinking smoking sleeping eating whatever that move you
away from your goals stewing and what unwanted internal stuff shows up when
something happens that moves you away from those things that are important to
you like negativity and suspicion and all that stuff so you can walk clients
through completing these quadrants so they have an idea about the different
types of behaviors and thoughts that they can use you know even cognitive
restructuring to move them towards what’s important to them so relapse
prevention begins oh and Kevin Polk has several videos on YouTube walking you
through that as well his book is complicated if for
clinicians you know it might be a great resource for clients I don’t think it’s
super helpful but the videos are really helpful
mm-hmm relapse prevention begins when remaining aware of your wants and needs
it begins when the old behavior start to surface such as avoidance minimization
rationalization denial numbing anger resentment and regret people need to
learn how to self govern as part of their recovery you okay sorry yeah at least I made it
through the presentation this time without coughing um those are some tips
and tools for relapse prevention does anybody have any questions all right then everybody have an awesome
weekend and a wonderful new year and I will see you in 2018 if you enjoy this
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