Relapse Prevention | Behavior Change Strategies for Addiction Counseling

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you 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 experiences 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 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, yada yada. Well, they're doing fine. They feel great. They start taking on a little bit more, they're 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 run down 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. 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 stop 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 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 to that state of problems. But the same sort of thing can be true for all of us, not just our clients, if we start working. And even if you love your work, and that's awesome, but you still need downtime, you still need recovery time, 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 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 balance in your life. And 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 burning the candle at 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 oftentimes 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 are going six hours a day. Woo hoo. But you know, it depends on the person whether they do it like a straight six 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 100%. 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 that was a struggle to get through and by the time I got to my fourth intake of the day, I was having difficulty remembering. Have I already asked you this? And that's not good for clients and that's not good for us. 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 that might be a, you know, big red ol flag saying, you got to step back and take a look. There is one caveat for relapse and that's that an extreme stressor can prompt an immediate 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 again and okay, you know, so 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 going to 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 health symptoms in depression and anxiety diagnoses. They may have difficulty concentrating, their memory may kind of get dicey. Physical relapse symptoms. If 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 run down 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 in the muscles. Social relapse is when they start hanging out with people that either co sign 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 sky is going to fall and everybody gets anxious and is like stressed out all the time because in a social relapse, so to speak, you're going to withdraw from those people or you've 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 going to fall tomorrow? Yes, it could. No doubt it is possible, but how likely is it? And those are the people that you may have backed away from unintentionally and you don't have their good presence kind of balancing you out. So relapse is multidimensional. It's not just one thing. Those things that overwhelm your ability to cope are what I refer 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 socked 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 their that. Okay, so let's have a hurricane, you know, rehearsal. If a hurricane comes, what are you going to do, how are you going to 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 trigger some post traumatic stress type of stuff. Other things that could be an extreme stressor include a job loss 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 fall. 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 going to 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, breathe 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. 1 When your heart is racing, when you're stressed out, another way to look at it, your body's going, we need to move. 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's a step in the right direction. So encourage clients to walk. Whenever we would have a incident, if you will, on one of the residential units, that was one of the first things that we would do. We would have staff members, 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 there. 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, 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 and 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 bumblebee lands on your arm, you're going to 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 going to happen? You're going to get stung, most likely. So probably not the best idea. If you can delay that urge, eventually the bee is going to fly off. 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 bumble be set, distract. You know, during this time, you're not just going to sit there and look at the walls. There's no way to clear your mind when you're 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 going to make you happy. De 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 going to have more serotonin, you're going to 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 the 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 major's 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 out of energy, your skills are done, you are worn down. So de stressing. 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 doing things that make them happy. Yes, it's important. Remember when we talked about culturally responsive counseling with Asian persons? There's that yin and yang. You can have somebody who's depressed because they've got too much yin, 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 yin just kind of naturally curves over because it's always in a balance. So if the Yang shrinks, the yin is going to grow. So 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 decatastrophize. 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 is not usually 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 video 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, write delay, distract, distress, and decatastrophize. On the second square, write out five personally relevant distraction ideas. So going back to that dbt, the improve and accept 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'll 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 going to happen? You know, you might be wanting to sleep all day and you're going to start missing your kids ball games. 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 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 multidimensional. 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 psychoed stuff. You could. 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 TVs that were up there because I can't see those poor little suffering puppies. Kills me. But I know that is 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 a physical reaction, and you're like, where in the world did 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 that are higher in sugar and fat, which tend to, when you eat them, make your brain excrete dopamine or secrete. 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 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, there are 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 close my door because I knew that I was emotionally vulnerable to being a little bit more snippy or less hospitable. So I was aware of that through mindfulness. I was aware when I was having a day where I needed to give myself a wider birth. Mentally. Your vulnerabilities understand when you start thinking more negatively physically. Nutrition, sleep, and ideally exercise. Also sunshine. 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 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 a vulnerability. I'm going to be stressed out going in unless I bring somebody to kind of being 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 binge eating, 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. When somebody gets that urge to self injure, that's almost a craving. So 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 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 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 too much. And then what they can do to control that worry. Emotional relapse. In 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 flip chart 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 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 yada, 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. 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 something else 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, free 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 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 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 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 mind's 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 blood sugar's fixing 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, I don't like feeling this way. How can I improve the moment? Or relapse is doing what you used to do with emotions and shoving them down, avoiding them. Well, they're going to come back up on you like bad spaghetti. So relapse and repeat. One activity you can have clients do is to list 10 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 and 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 effective 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 relapse are focusing on the negative and tending to have a pessimistic, helpless, hopeless attitude. If people have an addiction, they also may start thinking about people, places, and things that they used with glamorizing past use. Now, you know, think about 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 bet, you know, chocolate cake, whatever it is, or just having a screw it attitude, I don't care. Nothing I do works, 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 thoughts? 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 bees 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, 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? Which of these thoughts relate to loss of control or the unknown? Which of these thoughts relate to failure? 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 are kind of end up getting mushed sometimes, you know, because you can have death of dreams or loss of dreams. But help people kind of 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 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 roadmap. 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 that tell us what we want to do. What's going to make us feel happy Tend to be more emotional. And the gut, 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 and places who co sign 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 the yang. 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 doing? How was your day going? 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 hadn't talked to them 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 change their phone number. But even for anxiety and depression, you know, sometimes people have contacts that are draining and they can't set effective boundaries with because those people are just there 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, my personal phone number periodically because telemarketers will get it. And I hate getting 8, 10, 15, yes, no joke telemarketing calls per day. It just 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 talk 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. 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 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 encourage 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 were feeling pretty bad. 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 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 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? What happened? What changed? What made you want to slide back into those old behaviors when they recover? Ask them what made doing the hard work of recovery 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. 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 going to be a failure. 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 going to 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 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 going to remember it two weeks six months from now and remind yourself that all human beings are fallible, you know, not just you. So, you know, consider having counter statements that you tell yourself when you start having catastrophic unmanageable feeling 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 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 those pitfalls from happening again. For me, I'm big on 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 you're 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 in 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 their own, 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 imposter phenomenon. And that's when somebody does something or makes accomplishments, and they're like, they should be just overjoyed that they did it, but they feel like they're an imposter. 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 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. 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 or what's important, where you are right now? You are angry, you are anxious, you are depressed, you're. Whatever you are, okay? It is what it is. So what is the next thing you could do that would help move you toward those things that are important? So when you get angry, sometimes you're getting angry about something that you just can't control. Is holding onto 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, 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 Is Complicated for Clinicians. It might be a great resource for clients. I don't think it's super helpful, but the videos are really helpful. Relapse prevention begins when remaining aware of your wants and needs. It begins when the old behaviors 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. Okay, sorry y'. All. At least I made it through the presentation this time without coughing. 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 podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.