Relapse Prevention Awareness: Addiction Recovery Counseling Tools

Foreign. I'd like to welcome everybody to today's presentation on relapse prevention, awareness and activities. I AM your host, Dr. Donnelly Snipes, and this is one of my very favorite topics. I really like talking about relapse prevention. And remember, relapse means a return to a prior state of being. So it can we relapse, relapse in terms of mental health disorders, we relapse in terms of attitude, we can relapse in terms of addiction. So we're. A lot of times when I use the word relapse, people automatically think addiction. But relapse can apply to just about anything. So we're going to define relapse, identify relapse warning signs, and identify strengths that can help people prevent relapse. And we'll talk about some fun ways to help people learn these in individual or group therapy. As I said, relapse is the return to something that has previously been stopped. If you were a messy person and you started being very tidy and then all of a sudden you just kind of let it all go, that's a relapse. That's a relapse in that habit. So we want to really think of relapse broadly. Relapse is multi dimensional too. Just like motivation is multi dimensional, relapse is motiv, multi dimensional, basically for the same sort of reasons. Emotional relapse is when we start feeling irritable about what's going on, we start resenting this new behavior that we're doing, or we start feeling like we're missing out on something. Mental relapse is when our thinking changes and we start justifying, denying, blaming, making excuses, anything like that. Physical relapse is, you know, as it sounds, when we start doing things physically that are akin to what we stopped doing before. And social relapse is when we go back to interacting with other people in a way that represents our old way to way of being. And I'm going to use depression and addiction as our main examples today just because those are really prominent. So let's talk real briefly about addiction relapse in these, just because that's the one everybody thinks of first. Emotional relapse in addiction. People start feeling frustrated and like they're not getting what they want, like they are missing out on something. Mental relapse goes back to that stinking thinking, the negativity, the expecting the worst, minimization, rationalization, denial. Physical relapse is when people stop taking care of themselves. It's not just going back to using, but it's going back to Doing those things that make them more vulnerable to distress, which makes them more vulnerable to use. So physical relapse is going back to those old behaviors like not eating well, not getting enough sleep, and obviously using substances. And social relapse is returning to those interactive behaviors with others where you're guarded, whether you're lying, where you're manipulating to get people to do what you want to do. In depression. You know, let's just kind of switch gears here. Emotional relapse is when you start feeling depressed again. Okay, hey, that's a shocker there. Mental relapse is when you start thinking in those through that depressive lens. You start seeing things as hopeless and helpless. You start telling yourself that you are useless and worthless, so your thoughts regress to those thoughts that support a. A feeling of hopelessness and helplessness. Physical relapse in depression is very similar to physical relapse and addiction. It's when you stop doing those things that you need to do to help maintain your neurotransmitters and the health of your body to support your mood. That can be stopping taking your medication, not getting enough sleep, not eating well, but it can also. It also can be sleeping too much. So there are a lot of things we want to look back and we want to say how, you know, when you were symptomatic, what were you like emotionally, mentally, physically, and socially? What were those relationships like when you are working on your recovery? Not necessarily that you've gotten there, because sometimes it's always a work in progress. A lot of times it's always a work in progress. But when you are in that good place for you, what is different emotionally, mentally, physically, and socially? How do you feel? We want to have people create a distress versus happiness worksheet. And this is one that I generally have people do when they are, you know, between sessions. If it's a group session, you know, that's fine. This is a homework assignment. They bring it back to the next group. But they basically do what I just said. I want them on a sheet of paper to identify what they're like emotionally when they're experiencing distress or they're experiencing symptoms and what they're like emotionally when they are experiencing happiness. A lot of people, for example, when they are happy or when they're in a good place or where. When they're in a recovery state, whatever you want to call it, emotionally, they're not just happy, they're also curious, they're also excitable. There are other emotions that, that happen, that when people are not Symptomatic. Remember that a relapse is when people start returning to any of the people, places, things, behaviors or feeling states that are characteristic of, of the problem. And, and I'm going to just generally call it the problem today because it can be so many different things. In emotional relapse, emotions and behaviors become negative and unpleasant. People may find it difficult to start experiencing pleasure. Just nothing does it for them. So we're noticing and think about different clients that you've had or maybe even yourself. It doesn't necessarily start with emotional or physical or social. You know, relapses can start in any of those different areas, and they generally kind of reverberate out and bring the other areas down with them. Likewise, recovery can start in one area and it reverberates out and can bring the other areas up. And that's what I want people to see, is to recognize that they need to be alert to all of these different dimensions in order to catch relapse early and in order to identify all the different tools they have to help them maintain recovery. It's important for people to identify what triggers their negative emotions such as anger, resentment, jealousy, guilt, anxiety, fear, stress, and depression. Now you notice anger, resentment, jealousy and guilt are all kind of smushed together with slashes. That's because they're all variations on the emotion anger. Resentment is anger at somebody else for something they should have done. Jealousy is anger at somebody else for having something that you want. Guilt is anger at yourself for something that you should have done. So it's anger. I'm kind of putting it in there. Anxiety, fear, and stress are all kind of different flavors, if you will, of fear. So I kind of smush those together. When people say that they are terrified, obviously that's on one end of the spectrum. When they say they are stressed out, that's kind of on the other end of the spectrum. And I tend to conceptualize anxiety is somewhere in the middle, but it's a continuum. And then depression. Some people say that depression could go in that anger area. I would argue it could go in anger or anxiety, but it could also be its own thing because when we are stressed out for too long, like we talked about on Tuesday, our body can go into a conservation state, which is hypocortisolism, which is causes us to have less fight orf flight activity because our brain doesn't want to become excitotoxic. Okay, that's cool. But unfortunately, when that happens, we tend to feel very, at the very least, Eeyore ish And, you know, poor Eeyore gets such a bad rap, at least in my classes, because, you know, nothing ever seemed to make him super happy. Nothing seemed to make him super depressed. He was just kind of there. He was just kind of blah a lot of the time. And, you know, that's something that we can see in people who are anxious for too long. When people are anxious or angry for too long, remember, those are both sides of fight or flee. Those are both indications that the body is experiencing a threat. The brain thinks that there's a threat. Well, when that threat persists for too long, eventually people are going to start feeling hopeless and hopeless. Now, I put depression in its own little category because depression can also mean we lose something that is important to us and that helps us know what's important to us. But it's important for people to know what triggers their three main categories of dysphoric emotions. Things and the media, people, places and events. And, you know, that I am fond of having flip chart paper around the room in the four corners, and that's what I generally do here. And, and I have people identify on the flip charts the things or, and. Or the media issues that trigger their anger, resentment and jealousy. And the people in their life. And they, they don't have to name particular people. They can say my cousin or, you know, whatever, or talk about different characteristics of relationships that trigger their anger. And they go around and do that for the anger cluster, and then we can go around and do it for the anxiety cluster and then the depression cluster. After each cluster, we, I have everybody sit down and we talk about the similarities between what triggers anger for the different people in the group so people can recognize that, you know, what this. A lot of people feel this way. It kind of normalizes their reaction. Then we talk about, okay, what do you do with it? We also talk about how anger, resentment and jealousy, you know, or some of these dysphoric emotions. We talk about how the dysphoric emotion can trigger or precipitate a relapse of the original problem, whether it's addiction or depression or, you know, some sort of mood issue and help them see why it's important to be aware of the things that trigger these emotions so they can mitigate them. They can eliminate as much as many potential sources of distress as possible. Negative emotions or unpleasant emotions make us uncomfortable. It's important to help people remember that they need to stop and that that's the hardest part, stopping, identifying the emotion, explore why they're feeling that way. And Then take steps to fix the problem. And there are a lot of things people can do to fix the problem, which is why I talk a lot about psychological flexibility, reminding them that, you know, feelings are natural. Feelings are our body's response based on our prior learning. When we have a feeling, just like when the smoke alarm goes off in the, in, in your house, when we have a feeling or the smoke alarm goes off, it tells us that there might emphasis on might be a problem. So we need to identify how we're feeling, explore why that we're feeling that way, and if there's really a threat, and if there is, figure out what we need to do. We can address the problem, we can address how we react to the problem. We can choose not to do anything. You know, inaction is also a viable choice, or we can really just stew on it and feed that emotion. So those are kind of your four options. And, and I encourage people to look at what their options are and choose which reaction is most helpful in that particular moment. If somebody cuts you off in traffic, it may make you angry for a minute, and then you can check, explore that you're feeling angry and realize, you know what, there's nothing I can do about this. And chasing after the person's probably just going to make the thing a lot worse. So what can I do to fix the problem in that particular case? A lot of times the recommendation is to let it go. When we're talking about, you know, there's a lot of stuff going on right now, unfortunately, politically, in the media, you know, yada yada, and it's making a lot of. It's triggering a lot of anger and feelings of hopelessness and helplessness and anxiety, and pretty much any dysphoric emotion you can name, it's triggering for somebody right now. Okay, so identifying that emotion, recognizing how they're feeling right now, exploring why they're feeling that way, and then taking steps to address the problem in a way that's meaningful for them. And, you know, that could mean staying home. For example. My children right now are not supposed to go out after dark just because there has been some less than peaceful gatherings in our proximity. Not in our town yet, thankfully. But one of the rules that, you know, my husband said, so we feel less anxious, is that they are not going to go out after dark during, during the day. There doesn't seem to be any problems in our, in our area in Nashville and, and the suburbs. So we haven't worried about that as much. But that was our response. We recognized that we were stressed about their safety and we took steps that were most meaningful. We're obviously not going to try to lock them down. They've already been locked down long enough. It's important to help people remember that they can be become stuck in emotions. Sometimes they can get stuck nurturing an emotion and blowing it out of proportion, thinking about if this happens or because this happened, what this means, and just stewing on it and burning up a lot of energy. It's, and I've used this analogy before, it's like getting your car stuck in the mud and sitting there and just pushing the gas and pushing the gas and going, I'm stuck and so I'm going to give it some more fuel and you just get more stuck deeper in that mud. You can be stuck, become stuck in emotions, compounding it with other emotions like anger and guilt. If you feel depressed, for example, then you may also feel angry at other people for not understanding. You may may feel angry at yourself, at your body, for not, you know, shaking it off or for having another depressive episode. You may feel guilty because you feel depressed and you don't have the energy to get up and go to your kids soccer game or whatever. And it's important to remember and recognize the totality of the emotions because the more secondary emotions you pile on, the more you've got a claw out of before you can see the light of happiness. People can get stuck in emotions when they personalize what's going on. If they feel angry, for example, they can personalize it and think, all of these people are trying to make me angry, they don't have any respect for me. And in reality, you know, a lot of people are so egocentric that they're real, not really not thinking about their impact on you. And people can get stuck in emotions trying to escape from it instead of accepting it is what it is right now. They try to escape, escape from it. And as soon as they quit running, as soon as they take a breath from trying to escape, that emotion is still there. And it's important to help them figure out how they're going to deal with it. There is definitely something to be said for radical acceptance and distress tolerance skills, but those are to be used to help people to get into their wise mind so they can figure out what to do to respond. Remember on Tuesday we talked about the fact that when people's HPA axis is activated, when their threat response system is in overdrive, there are a lot of things going on. They have high levels of glutamate and norepinephrine. That norepinephrine can cause tunnel vision. So we want to help them get back into their wise mind, turn down that HPA axis so they have less norepinephrine imbalance, and they can think more logically about what some of their options are. So instead of, you know, feeling like they're stuck and trying to escape from it and staying completely revved up, they can get into their wise mind again. Remember that emotions are just cues, like a stoplight. They are telling you, you know, stop, go, caution, but it's up to you to check and make sure what's going on. Negative emotions are how people feel in the moment. And I don't want my clients in recovery. I don't want anybody to ever think that they should be happy all the time, every day. That's unrealistic. I don't know a single person who is happy with all the time, every day. I. I think there are even, you know, examples of people who you might think of. They probably have bad moments, and it's important to recognize that that is an okay reaction. You know, we want to have sort of a range of emotions, and people have the ability to choose to change or improve the next moment. One of the things I like to do with people after we go through the emotional triggers, the distress triggers, activity that we talked about on the last slide, we talk about, what can you do to change or improve the next moment. When that happens, I want them to walk out of group that day having two or three ideas of different ways they may react instead of holding on to nurturing or getting stuck in that emotion. To prevent emotional relapse, people need to practice mindfulness. A lot of times, you know, sometimes you just get sucker punched and all of a sudden you are feeling really angry. Okay. You know, you couldn't have seen that one coming. But a lot of times, there's a gradual decline in our mood. People go from feeling, you know, great to okay to kind of flat, and it just works down from there. It's important for people to recognize how they feel emotionally each day and what's prompting that. It's important for them to increase positive experiences by doing things that are enjoyable. Go figure. Not just getting up, going to work, coming home, going to sleep, and repeating. That's not going to increase those positive experiences. On Tuesday, we talked about the bathwater, how our stress chemicals are like hot water and our calming chemicals are like cold water. Well, when we do positive experiences, we're increasing that cold water. We're helping Keep the bath water tepid instead of getting too hot. And people can also use guided imagery. You don't have to, you know, get out and do stuff all the time now. It's important to do things, you know, you can't use guided imagery for your only source of positive experiences. But guided imagery can be really helpful to help people get to a place where they're in their wise mind. Remember how I think it was a couple classes ago we talked about using guided imagery in order to help people. Tamping down that stress reaction. If they can go to their, and I don't know what else to call it, I call it their happy place. And just think about that for a few minutes and quit stewing on whatever is, you know, stressing them out at the moment. If they can get a second, then when they return to address that issue, they are often in a clearer frame of mind. Have people keep a gratitude journal. A lot of times we remember what happened most proximally or what happened most intensely. So if you get into a fight with somebody you know, you may be thinking that this relationship is always so stressful and this person is always getting on my nerves. Hear the always cognitive distortion in there. A gratitude journal you can look through and you can recognize that, you know what, all right, maybe we're in a fight right now. But overall, this relationship is good. A lot, a lot of people right now are feeling very stifled and very frustrated. And instead of focusing on what they do have, what they're grateful for, they're focusing on what they don't have. A gratitude journal helps people, you know, refocus. And I've talked before in other classes about creating a gratitude tree. And you can either do it with post it notes on a wall and have each post it note kind of represent leaves of a tree. If you have a classroom or a wall that you can do that on. My particular favorite way is to get a vase and get some sticks from outside. You know, long three, four, four foot sticks, something like that, in a big vase. And then get present tags, the ones that have the string and the little paper on them that you can write things on and write. Have people write down what they're grateful for on those tags. One thing they're grateful for every day. And if you do this as a family, it can be really cool because you can all of a sudden see that gratitude tree filling out. You can also do it if you're doing group therapy. I used to do it a lot in residential because we had 80 some odd people in house. So that tree got pretty full pretty quickly and it helped people recognize and they would read what other people were grateful for and go, hey, you know, that's something I'm grateful for too. Gratitude journals can really help us refocus and recognize accepting the good with the bad instead of focusing exclusively on the negative. Encourage people to check whether they're personalized something personalizing something that may not be about them. You know, I was talking to a person today who was really stressed because he had sent a text out to, you know, office mates about something and nobody responded. Nobody liked it. And this, this idea that people need to like things has, is something new to this generation. You know, we didn't have Facebook and stuff when I was younger, so Instagram and those sorts of things just, you know, aren't something that I'm quite used to. But it's very powerful when you send a message out to a group of co workers and not a single person responds. And this person felt very insulted that nobody liked his post that he sent out. And so we talked a lot today about what are some other reasons they may not have responded to that and you know, that that could have happened. And trying to fact check. Encourage people to remember that negative emotions are the mind's way of telling us to get off our butts and do something. My daddy always used to call it the idiot light in the car, which is not polite, I know, but I always remembered that. And that's the light that goes off when you've driven your car too long and you're almost out of gas and that little gas light comes on. It says, hey, get gas. I wish I could say mine didn't come on very often, but it does. But that's kind of like our emotions. It kind of flashes up and goes, oh, hey, pay attention, there's something going on here. Dwelling on, nurturing, avoiding or hiding from negative emotions almost never makes them better. And you know, maybe it does for some people sometimes somewhere, but it almost never works in the long haul. In the short haul it may, but in the long haul, when you sober up, when you wake up, when you pay attention to it again, it's probably still going to be a problem. So it's important to help people to feel empowered, to take steps to address the things that are triggering their negative emotions so it doesn't trigger a full out relapse. Another activity that you can do is to have people list 10 things that they choose to get anxious or angry about or they chose to get anxious or angry about over the last week. I like to use the last week because that's pretty proximal. People can usually remember 10 things that they got irritated about, and I have them write those down on a piece of paper, and then we go around and we talk about it. So that's kind of not super fun to do. Another thing I've done is collect those papers and write 15 or 20 of them on a beach ball. And, you know, not naming names, obviously, but some of the common things that triggered people's anxiety or anger over the past week. I write them on a beach ball, and we toss the ball around. People catch the ball. Whatever they see when they look down, they need to speculate why it might have caused somebody to get upset. What their mind might have been telling them needed to be fixed. And it's just a little bit more interactive than writing it down on making lists and discussing it. I like to do things that are a little bit more kinesthetic, partly because when people are moving, when people are having fun, their brain is more primed to remember things. Kind of an interesting little trick there. We talk about whoever's holding the ball. Also talks about how holding on to upsetness. I know it's not really a word about whatever it was. Would that have done any good? What was their initial reaction, and was it helpful? So whenever whatever this thing that happened happened, like getting cut off in traffic, what was your initial reaction? I got angry and, you know, I screamed expletives at the person. Okay. Was it helpful? You know, really? No, probably not. You know, the person couldn't hear you, and it probably just drained some of your energy. And then what could you do differently next time to either change or fix the situation? So in what we call in. In my practice, improving the next moment, change how you feel about the situation. Walking that middle path, recognizing, for example, that some people are crappy drivers and some people are really good drivers, and there's just nothing you can do to change them. All you can do is you, you know, be a defensive driver or let it go with radical acceptance. When people get their beach ball, they do. I do have them go through each one of these questions. You can do it where they only go through one or two, so it moves a little bit faster. There are a lot of different permutations that you can do. You can also do this with Jenga. You can have people. You can actually write the stressors on Jenga blocks. And when people pull a Jenga block, then they have to respond to whatever the stressor is. That's on that jenga block. In mental relapse, there's a war going on in your mind. Part of people's minds wants to stay positive, but part of it is struggling with tolerating the distress, the distress of life, the distress of recovery, some sort of distress. The signs of mental relapse, the main ones are focusing on the negative and having a pessimistic, helpless or hopeless attitude. When people notice that they're not looking through those obnoxious rose colored glasses anymore, it's important for them to check and say, am I seeing the big picture or am I only focusing on the threats and the negative things? For people who have addictions, specifically, they may be thinking about people, places and things that they used or used with. They may be glamorizing their past use, lying to themselves and others, justifying their behaviors, minimizing the impact of the addictive behavior. Or they may just have a screw it attitude like, you know, if life is like this when I'm not using, then I might as well just use. We want to recognize, recognize those signs. Obviously those behaviors are, or those thoughts are not going to be paralleled nearly as much, if at all in mood disorders. For, for example, you know, in depression, you're not going to glamorize your last depressive episode. So these are really unique to addiction in terms of mental relapse, but they are really important aspects to be aware of for people who do have a history of addiction. Just like with emotional relapse, in mental relapse, we want people to identify the people, places, things and events that trigger their negative thoughts. And the media right now, social media, mainstream media, media in general, even media like television shows, can trigger negative thoughts. And it's important for people to recognize the impact those things have on them and decide how to address them. If they want to expose themselves to them or not. Encourage them again to recognize the thought thoughts that they have that trigger them to feel angry, guilty, envious, or even scared. Now emotions, you know, kind of pop up. All of a sudden you notice you're feeling somehow some way. It's important to go through, you know, that old ABCs from cognitive behavioral therapy and identify those underlying cognitive beliefs, those underlying cogn cognitions that are, are triggering or are prompting the brain to feel or to, to activate that threat response system. So we do want people to recognize that there's a correlation when they're feeling a certain way. They're probably also having unhelpful thoughts. If they change their feelings, then their thoughts are probably going to change. If they change their thoughts, then their feelings are probably going to change that whole cognitive triad of thoughts, feelings and behaviors that we talk about in CBT when people are trying to identify unpleasant thoughts. Again, you can do the flip chart activity if you want to Loss of control, failure, isolation and rejection or death. Slash, you know, loss of something and have people identify the the thoughts that they have that make them feel angry, irritated or resentful. In what way do they represent a loss of control or the unknown? When you get cut off in traffic, for example, you know, you may get angry because you felt out of control for a minute because somebody got into your physical space. You may have also feared death. You know, I could have been killed. So examining which of the common threats to our self or to our self esteem are present when we start feeling certain emotions is also helpful preventing mental relapse. Kiss this is one that I I I learned in my internship. K Keep it simple. Silly. We'll say silly. I don't like the word stupid. Trying to change too many things at once can lead to failure. And often some of the simplest things can have the greatest impact, such as practicing mindfulness at each meal, keeping a gratitude journal, journaling for 20 minutes a day on the things that were going positive for you that day, just spending 20 minutes. Or maybe I've talked about this before at families making a particular meal time where all you're going to talk about at the meal is positive things. My recommendation to people is to pick one of those things, do it for a couple of weeks until it is, you know, kind of second nature, until it is integrated into their habits, and then add another one. Don't try to start doing three, four, five new things at one time because that sets you up to stumble. Help people prevent and address vulnerabilities that can make them focus on the negative or have a strong negative emotional reaction. Remember, vulnerabilities can include being overtired. When we're overtired, we have difficulty thinking clearly, concentrating, remembering those sorts of things. When we are not getting enough good nutrition, you know, it's more difficult to think clearly sometimes when our when we're dehydrated or our blood sugar is low, it's harder to have the range of cognitions that we normally would. So there's some really basic things. But also being around being in an environment for an example in which people are negative is going to be a vulnerability for negative thoughts yourself. You know, if you immerse yourself in negativity, some of it's going to rub off on you. Think about taking a. A white cloth or a paper towel and dunking it into coffee. When you pull it out of the coffee, what happens? It's coffee colored and saturated with coffee. Now, you could say that with appropriate boundaries and everything, you can prevent most of that. Well, maybe that's true, but do you really want to put yourself in a position where you're having to, you know, do like this to maintain your emotional boundaries if you don't have to? Sometimes you're going to be in a situation where people are negative and there's just nothing you can do about it. But if you, if you can prevent, you know, hanging around people or continuing to stay in a place where people are espousing negativity consistently, it can be helpful. Good, orderly direction. I talk to people and we think about life as a roadmap. The destination that most of my clients want to get to is happiness or recovery. What I want them to do is before they act, before they do anything, when they feel upset or even when they feel happy, think about whether that choice, that behavior, that thought keeps them on the right road, keeps them headed towards that destination, recovery, or is an unpleasant detour. We also talk about head, heart and gut honesty from mental relapse. Head honesty means it makes sense logically that this is going to help me. Heart honesty means it makes me happy. It makes my heart happy to do this. And gut honesty, that's those spidey senses. And when your gut is not. Is saying not so much, then there's a misalignment because the head and the heart can really try to bully the gut sometimes. But the gut is generally the. Generally the tiebreaker when we're getting ready to do something that is not helpful to our recovery. Head, heart and gut honesty, you know, we. We may be able to rationalize, may be something we really want. You know, thinking about, thinking about alcoholism, you know, maybe somebody is going to rationalize that. One drink. I really just want one drink, you know, so the heart may say, yeah, I want it. The head may say, ah, come on, you can do it. But the gut's probably down there saying, you've been down this road before, don't do that. Mental relapse can be prevented to a certain extent by making sure that our decisions all have head, heart and gut honesty. That'll help keep us out of some of our troubles. Social relapse is when people have returned to the old people places and other people who co sign on their bs. And yes, this is very prominent in addictions but it's also prominent to a certain extent in mood disorders because, you know, let's take depression for example. If somebody starts having a depressive episode, they may start acting and relying on others to caretake for them. They may start falling back into these social patterns that reinforce or reward their unhelpful behaviors, like staying in bed all day. So it's important to recognize that, you know, if somebody who is depressed wants to stay in bed all day, even though, you know, we know that that is going to mess up their circadian rhythms and all that other kind of stuff. They may gravitate to hang out with people who will cater to them, bring them their food in their room and not make them get out of bed, instead of people who would encourage them to, you know, at least get up and get a shower and then let's see where we go from there. Other symptoms of social relapse can be just completely withdrawing from social supports, becoming self centered or withdrawing completely, not just from social supports, but just kind of withdrawn into your own self. Just like the other forms of relapse. It's important for people to recognize the people, places, things and events that can trigger their social relapse. For example, if they notice they're starting to hang out with those people that support their unhelpful behaviors, you know, that's important to know if they notice, and this is a big one for mood disorders, that they've started to withdraw from their social supports or withdraw from everybody and kind of stay locked up in their house by themselves. That may be a very clear indication for some people that they are on the road to relapse, they're withdrawing. That means, for a lot of people, that means I just, I can't take any more input. It's just overwhelming. Preventing social relapse have people contact their social supports on a daily basis for the first, at least the first three months of recovery. It doesn't have to be a long talk, it can be a quick text, but encourage them to continue to start reaching out and getting in the habit of connecting with people. Keep a business card in your wallet with the names and numbers of three social supports. And yes, you can keep it on your mobile device too, but you know, change your phone number if possible and destroy contact information for people who might trigger a relapse. And this again can be mood disorders. There are some people who have associates, I won't, I'm not going to call them friends, associates who are manipulative and can actually make them feel bad about themselves and, and Harm their recovery process. And finally, find at least one pro social activity to do each week. Volunteer, go to church, go to the gym, go to the library. You, you know, I don't mean you have to be out with 15 other people if you're an introvert, but find something positive pro social to do where you're getting out of the house. Physical relapse is characterized by fatigue, increased anxiety, difficulty sleeping, neglecting physical health, sleep, exercise, nutrition, not taking your medication. And if there was also addiction, the person may start experiencing cravings or having dreams about the drug or using to prevent physical relapse. The old acronym, hungry, angry, lonely or tired or halt Hungry means part partly the body may need proper nutrition. And you know, that's the first thing we think of when we think of hungry. But hungry can also mean that the mind is needing happy chemicals. It's craving some positivity, and it's important to nourish. Encourage people to nourish their mind with activities and things that increase those happy chemicals that turn up that cold water. If they feel angry or anxious, we want to help them reduce chronic stress. When people are chronically stressed, they typically don't eat well and it impairs their sleep. When they are feeling lonely, encourage them to nurture social supports that can help them buffer their stress. Now, reaching out to people, texting, getting involved in support groups, volunteering at an animal shelter. If you know people are too much and you'd rather hang out with the dogs, you know, I get it. And encourage people to be willing to ask for help. And finally, tired. Ensure people are paying attention to getting enough quality sleep. And remember that issues such as sickness and pain also prevent quality sleep. We want people to review their strengths and you know, I like this activity we've been focusing on what triggers your anger, what triggers your anxiety, all the unpleasant stuff. I also want to talk about what is life like when you're happy with what's different when you're, when you are actually happy. Think back to the last time that you felt happy. What was different and what was the same? This is a question we don't often ask. But even when we're feeling unhappy, there are also times that we may feel. Even when we're feeling unhappy, there also may be things that are going on that make us happy. You know, even if I'm depressed, my kids being around makes me happy. You know, that is the same. When my kids are around, I tend to be happier. Have people identify ways they cope with stress, activities they like to do, and their positive Qualities and strengths. One of my favorite activities I like to do with strengths in group work is to give everybody an envelope, and they write their name on it, and they pass their envelope around everybody else in the group. And each person in the group adds something to their envelope identifying strengths that they've seen in that person. So Sally is going to get her envelope back at the end of group, and it's going to have 11 other things in that envelope, strengths that other people have seen in her. Because a lot of times clients don't see their own personal strengths. They see themselves as weak. They see their negatives, they see their drawbacks, and they have a hard time recognizing the positives and the strengths. So this is. That's one activity that I like to do, because then they have that to keep with them, and they recognize and they can see, see that other people see these strengths in them. Another activity that is super helpful is to have people review prior relapses. What was happening before the relapse? I like doing this in group because, you know, two heads are better than one, as they say. And so I can put up on the board and, you know, depression, relapse, what was happening before the relapse? And people identify the things that they can think about that they identify that they know that were happening right before that relapse happened. What were they doing differently physically, emotionally, cognitively? What was different? What triggered the relapse, if there was a particular trigger for it? Relapses occur, and this is a point that I repeat very often to, to my clients. Relapses occur when old behaviors are more rewarding or stronger than the new ones. What became more rewarding than your recovery program? So if somebody is starting to have a relapse, maybe they're depressed and they're starting to stay in bed all day, even though. Even though they know that is not helpful and they need to get out of bed, they just can't seem to force thems to do it. Well, that behavior is really, really strong. So we want to look at what's rewarding that. Well, it's keeping them from having any more input. Their. Their body's already saying, I'm overwhelmed. I feel hopeless and helpless and very vulnerable. So one of the benefits to staying in bed all day is you're not bombarded with any other negative information. You're kind of hiding from life and the world. So we want to recognize that at a certain point, you know, if somebody gets to that point where they're not wanting to get out of Bed that that is very rewarding to them right now because the tools that they have weren't getting the job done to help them deal with life on life's terms. And that's where we as clinicians can help them look and say, all right, what do we need to do? What needs to change? What supports can we provide to. To help you start, you know, be getting the energy back and feeling like you have the resources to deal with life on life's terms before you relapse? What changes in your emotions, your thoughts, behaviors, your interactions with others, and what have you learned? You know, for me, I noticed that, you know, before I have an episode, if I'm having a. A depressive episode, if I notice that I start sleeping a lot less, I get more stressed out, start worrying about things that, you know, are outside of my control. But the big warning sign for me personally is if my sleep starts getting disrupted, I know that that is really bad mojo for me. And it's important for people to recognize what their primary relapse warning signs are. There most people have a couple that are biggies for them. When we look back over prior relapses, you know, they say that hindsight is 20 20, the same thing with relapses. If we can look back over our relapses, we can identify warning signs, we can identify things that triggered those relapses so we can address them to prevent future relapses. And that's what we want to do. Reviewing prior relapses is not about saying, well, you should have known better. It's about learning from the past. It's about learning what we missed the last time. I use the acronym dream when I talk about relapse prevention just because it helps people kind of embrace the idea of dreaming that recovery is possible from whatever their problem is. But recovery takes determination, resilience, being willing to find exceptions instead of thinking that things are always bad or, you know, never going to be good again, an awareness of their vulnerabilities. Like I told you a minute ago, for me, poor sleep or, you know, even if it's not because I'm anxious. When my children were infants and I wasn't sleeping through the night because they weren't sleeping through the night, that was really, really tough on me and my mental health. So I'm aware that sleep is super important for me. But for other people, it may be food, it may be social support. Being aware of what your vulnerabilities are and motivation. So determination for recovery, resilience, the ability to bounce back up and problem solve. Finding exceptions to current problems, being aware of vulnerabilities and preventing them when possible, and maintaining motivation for recovery are all essential in order to prevent relapse. With relapse prevention planning, we want to make sure to include time in the morning and at night to use mindfulness skills to get grounded. I also like to say at lunchtime, so I usually typically have people do it at meal time. But at least twice a day in residential, I would have people fill out a check in sheet, a mindfulness sheet in the morning before we went to breakfast and in the evening before lights out, in order to, you know, get a sense of where they were, become mindful, get grounded, and then they would discuss those things with their, their therapist throughout the week. People need to identify and prevent or mitigate vulnerabilities each day. Some things can't be prevented. You know, for example, there's a lot of stuff going on in the world right now that is extremely stressful and extremely disheartening. I can't prevent that from happening, but I can mitigate it by limiting how much time I spend watching the news, reading the news, or on social media. Avoid alone or idle time. If your mind tends to wander to dark places. When you're in at the place where your mind wanders to dark places, you're already one step into that relapse. So it's important to find things to do when you're in that, when you're in that state of mind so you don't get sucked into that dark cavern. Mentally incorporate positive experiences each day. Set realistic daily goals and make sure to give yourself credit for positive accomplishments. Too often, people minimize their positive accomplishments and amplify their failures. Well, we really want to turn that the other way around. We want to minimize the negatives or learn, identify failures as learning experiences and really highlight those successes. Relapse triggers can be emotional, mental, physical, or social. For each trigger that people identify, have them describe at least one way they can deal with it. I really encourage my clients to keep sort of a list of their main relapse triggers with a line down the center and on the other half of the sheet, at least one way they can deal with that trigger. For example, if there's somebody in their life that is very pessimistic and that's a trigger for them, how can they deal with that person? Have people practice mindfulness each day in order to help them become aware of their personal daily vulnerabilities for relapse. Every day is a new day and every day there are going to be different things. Stressful meetings you've got to go to, bad traffic, bad weather, whatever it is. And for each general category of stressors, identify three things you can do to continue on your journey toward happiness. Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That's why I recommend Therapy Notes. Their easy to use platform lets you manage your practice securely and efficiently. 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