Relapse Prevention for Addiction & Mental Illness

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. Today we're going to be talking about relapse prevention for addiction and mental health issues. And one of the things I'm going to start out, and if you've been to my classes before, then this is going to be old hat for you. But for the new people I really look at when I talk about addiction or mental health, I'm really thinking co occurring because we know that they estimate 47% of people struggle with addictive behaviors. And we know that, you know, somewhere around 30% of people have some mental health issues going on. We also know that when people are in active addiction or recovering from active addiction, it's almost always true that they're going to have some sort of mental health stuff going on because their neurotransmitters are out of balance. And the reason for that could be different for, you know, other multitude of reasons. But we, we want to realize that if somebody is depressed and sober, they're not going to stay sober for very long if that depression is oppressive. Likewise, if they are feeling pretty good but they're using, then the using is probably going to muck up their neurotransmitters and they're going to have a relapse of their mental health issues. So when I talk about relapse, I talk about relapse in terms of the whole person, in terms of mood and behaviors and urges. So this is going to be a broader relapse prevention than maybe you might be used to. So we're going to define relapse, identify relapse warning signs, identify people's strengths. Because when people are in a place where they're getting ready to relapse, they've probably been walking down that path for a while and this is kind of their black swan. And we'll talk about that. But when people are in a place where they're getting ready to relapse, they're in a bit of a crisis. So having them start with a tool that they've never used before is going to be less effective than saying what's worked before, when you've been able to stay clean, when you've been able to be happy, when you've been able to not be anxious for an hour, for a day, what has worked. I'm not talking about two weeks, six Months, whatever. I'm talking about work, small goals. Let's not start setting goals that are too high right now. If somebody is really struggling just to get through this minute, let's figure out how to help them get through this hour and then maybe the rest of the day, and we'll learn about how the issues developed in the first place and what we can do to prevent walking down that relapse path again. So relapse is the return to something that's been previously stopped. And, you know, I put it really broadly because it's not just using addictive substances. That means the behaviors associated with depression, that means the symptoms associated with depression, the symptoms associated with anxiety, those come back up. Relapse, recurrence, whatever you want to call it. And it's multidimensional. There are emotional aspects to every relapse, and generally they're not pleasant. You're not going to relapse and just be elated about it. Most likely there was some sort of lack of pleasure, anxiety, stress, depression, grief, something unpleasant. Mental relapse is when that thinking starts to change. Physical relapse, we're talking really about the neurotransmitter starting to get wonky. Sleep starting to get wonky because. And wonky is one of my favorite clinical terms. I apologize if it bugs you, but when people are starting to feel stressed and depressed, their threat response system goes off, which means they're not going to get quality sleep, and they don't get quality sleep. That's going to have a negative cascade effect on the rest of their life. So physical relapse, a lot of people stop sleeping as well, stop eating as well. They may start engaging in some unhealthier behaviors. And then social relapse is. And remember, I talk about social in terms of self esteem, your relationship with yourself as well as your relationship with others. But in both of them, in many cases, there's a withdrawal. You just kind of numb out and you're not feeling or you're trying to withdraw from other people because you can't handle dealing with anything right now because you're barely dealing with your own life. So we're going to talk more about those. And relapse is a return to any of these people, places, things, behaviors, or feeling states. So that's a lot of stuff, which is why we're going to emphasize, or I'm going to emphasize mindfulness so much throughout this process. Over 20 years of working with people with mental health issues and addictions. One of the common threads that I've Seen with most relapses now, every once in a while somebody is doing really well, and then the rug gets pulled out from under them. They get diagnosed with terminal cancer or something, and you know, that's a whole different ball game. But in general, the majority of people who relapse, especially the ones that say it came from out of the blue, they quit being mindful. You know, six weeks, six months ago, they were feeling pretty good. They're like, I don't need these meetings anymore, or I don't need to go to these groups anymore, or I don't need to do this anymore, or other things just started taking priority. And they say, you know, I'm feeling pretty good. So you know what, the boss needs me to do this, you know, extra overtime, no problem. And they start going back into that autopilot mode, not keeping a priority on the recovery behaviors. One activity I have my clients do, and you can phrase it however you want, you can either do addicted versus sober, which is actually the clinic I came from that I learned this activity is where it started. And obviously 20 years ago, we didn't know as much about co occurring, so we didn't understand the interaction nearly as much. Now I present it in terms of unhappiness versus happiness, because in our unhappiness, in our addiction, in our whatever that state is for that person, how are you behaving, acting, feeling emotionally? How are you behaving, acting, feeling, thinking, mentally? You know, Are you negative? Are you optimistic, pessimistic? Are you worried physically? How do you treat yourself and what's going on in your body, even if you're not doing it? What's going on in your body when you're in your unhealthy, unhappy, addicted state versus when you're in your recovery state? And socially, how do you interact differently? How do you feel differently about yourself and other people when you're in that relapse state versus when you're in your recovery state? And you can choose whatever words fit your clients, whatever words seem to resonate with them most in order to make this happen. This makes for a great group activity if you want to put it up on the board and have different columns for emotional, mental, physical, and social on one board, and then do the same thing on the other board for the recovery and have them identify how they are different because this is what they're going to start looking for when they're doing their mindfulness, if they start noticing that their mood has turned a little bit more south or worried or however they want to put it. Or if they start notice they're being more negative or impatient or intolerant. These are early clues that something is amiss at the Circle K and they need to check in and figure out what's going on in their recovery plan. Now, they may just be stressed out and they need to tune up certain behaviors. Maybe they need to just call it at work for the day and, you know, after they get out of work, go hang out with friends, go to a meeting, go to a support group, go see their coach, whatever it is. But this is a clue. And I love when I hear clients and friends and anybody identifying when they are feeling vulnerable, when they are feeling like they're not in their happy mode, not in their recovery mode, go, you know what? I need to do something different because I'm in a bad space. And they do that before they get to a full blown relapse. And I'm just like, oh, score. I really love seeing, seeing that. So once we identify how you're different when you're in your relapse state versus your recovery state, we want to start talking about triggers. Okay. We know that you're feeling a little bit differently. We know that you may be starting to feel negative things like that, but what's triggering that? And we want to look at for stimuli that are setting off the event. It could be a phone call from somebody, it could be a bill you got in the mail. It could be maybe you have bad memories or memories that revolved around using where your parents live and you're having to go home for a family reunion or something. There are a variety of different triggers that can set off an event, and being aware of those things that trigger your unhappiness or your relapse sort of stuff, versus the things that trigger your happiness. And triggers work both ways. These are just stimuli. It's just a fancy word for stimuli. And it doesn't have to be bad. And we'll talk more about creating positive triggers in the environment later. But triggers can be visual. Anything you can see, you're driving down the interstate and you see a billboard that talks about something. You know, for me, if I saw a billboard that talked about how many animals were euthanized every year, I would just be like, okay, really? That's depressing now. Would it take me down this whole depressive road? Probably not. But being aware that there are triggers in the environment, there are triggers. On television shows I used to watch, there was a show called Wings on, you know, many, many years ago. And one of the Characters had an eating disorder, and they would kind of poke fun at that a lot. And as someone with an eating disorder myself, I took it a little bit personally. You know, that was one of those things that would. I would find myself getting wrapped up in. So being aware of what your triggers are, being aware of how to deal with them so they don't take you down a bad path. Just because it's a trigger doesn't mean you have to act on it. You can just let it pass. Auditory triggers, things you hear. If you hear something that reminds you of something else. We talked about PTSD in the last class, and for many people, there are auditory triggers to their trauma. They heard things leading up to the trauma, or they heard things during the trauma that now trigger traumatic memories. So being aware of auditory triggers, tactile things you can feel, and, you know, these are a little bit different. But for needle users, for example, the feeling of something tight around their arm can be a trigger. So just encourage people to think olfactory, which is smelling. Our sense of smell is one of our greatest triggers for memories. So what do these smells tell you? And if you start feeling negative, impulsive, feeling like you want to use whatever your relapse is, stop and think, am I smelling something that's triggering that memory? And if so, what could I smell differently? How could I get out of this situation? I always encourage people to keep something pleasant, whether it's an essential oil or just a smell that they like on a hanky in a plastic bag. Either, you know, if you're a female, in your purse, if you're a guy, you know, find somewhere you can stick it where it's easily accessible. Sometimes guys put it in their cars or their briefcase or something. That way, if you're having a moment and part of it is from smell, you can kind of jar yourself back into the present. Cognitive. Cognitive triggers or any kind of thought triggers. If you start getting negative, impulsive feeling like you can't do it. All those cognitive distortions that we talk about and temporal, and this is one that people forget about time or location. If you've done grief work, this is no surprise to you, because we know that it takes at least a year after a loss for somebody to really fully work through it. In many cases, because you have to go through those anniversaries, you have to go through those holidays, you have to go through certain things and accept at each one of those points in time that, you know that person or that thing is no longer there. And sometimes it takes longer than a Year. But there are a lot of time or location oriented things that can trigger relapses. It can also trigger happy things. You know, I think I gave the example the other day that when you wake up in the morning, if you realize it's your birthday and you like your birthday, then that is a temporal trigger for happiness. So what kinds of things can you look forward to? You want to put temporal triggers in your day, Something to look forward to each day or at least a couple times a week. So I said earlier that there are multiple kinds of relapse. In emotional relapses, your emotions and behaviors become negative and unpleasant. And those are really broad garbage terms. Obviously, we want to narrow it down a lot more with our clients when we're talking about what are the earliest signs of your relapse? I was talking earlier about how sometimes people are feeling good. And in substance abuse recovery, we talk about a pink cloud. This is when they think they've got it licked. They think they are, you know, they're recovered and they start getting overconfident. And overconfidence is one of the first signs of relapse for many people, because that's when they start losing their motivation to do the hard work of continuing the new recovery behaviors. And I do say that recovery is hard. It's hard work. It gets easier as those behaviors become more second nature. It becomes a lot easier to do the next right thing and be great with it. But that first year, and maybe for some people, even that first two years, it's work to remember to do the next right thing, to use the distress tolerance skills, to call a friend, to do whatever you're supposed to do. So we know that when people are feeling good, and sometimes it's because life is going well, and life will go well sometimes, and that's awesome. But you don't necessarily know. At some point, you may be thrown a lemon or two. You've got to be prepared to handle that. And if you're not on your A game, it may catch you upside the head. And nobody likes getting hit upside the head by a lemon. So. I told you I was goofy today. Sorry. Anyhow, we want to make sure that people are aware of what their personal emotional states are. That and emotional and mental kind of get mishmashed for a lot of clients. And that's okay. I'm not real particular. But what's changing that leads you to start being less diligent about your recovery activities? A lot of clients will then start finding it difficult to experience pleasure. All of A sudden, you know, they got overconfident, they stopped doing the next right thing. Now those old behaviors of maybe staying up late or not eating well or whatever it is, those are starting to kick in and you're starting to feel the way you used to feel. So it starts to be more difficult to experience pleasure. I encourage them to be aware of the things that trigger their negative emotions, even if they are in technically straight addiction recovery. A lot of times we find that people in their addiction were self medicating some sort of mood disorder. Now that may have not have existed before the addiction, but once the addiction was there and the neurotransmitters got messed up, there was a mood disorder. And when they would start to sober up, you know, let's take cocaine for example. A lot of people when they start to sober up from cocaine, you know, they've been running hot for a long time. So they're feeling apathetic and unmotivated and depressed. And people don't want to feel that way. So a lot of times they go back out and use again. But I also encourage them to look. A lot of times people overlook some of the secondary emotions, if you will. They think about anger, you know, what really ticks me off. But I also want to look at resentment. A lot of people hold a lot of resentment and it's exhausting to hold on to that stuff. Okay, that's another one that, you know, kind of pops up pretty easily for people. Jealousy and guilt, not so much. So we want to look at and encourage people to look at issues surrounding jealousy and envy and guilt, because those are also very draining emotions. And a lot of times we don't give them kind of the credit they deserve for how much energy they take. What a toll they take on our self esteem and our social relationships and all that other stuff. We want to look at what triggers anxiety and fear, but also stress. A lot of people don't think of the things that trigger their anxiety or their worry as being the same things that trigger stress. Stress, they put in a category by itself. They had a stressful day. It wasn't necessarily worrisome, it was just kind of overwhelming. So that's, okay, fine, however you want to describe it. And then depression. But any of those dysphoric feelings that people can say, yeah, I felt that, well, then we want to look at what triggered it. Sometimes they can avoid those triggers. I've shared with you before that I avoid at all costs watching any ASPCA commercials. They just are devastating. And cut to my Core, so I won't watch those. It's not something that's something I have to do. There are other things that are kind of challenging emotionally that I do have to do, and that's okay. But anything that you can get rid of that's not mandatory. I don't like driving in lots of traffic, so I try to avoid, whenever possible, driving during rush hour. So that's another way to avoid some triggers for negative emotions, because the more of those you avoid, the more energy you have to deal with the stuff you can't avoid. Makes sense. Oops, I got a little eager. Negative emotions make us uncomfortable. So we want to have people identify the emotion, explore why they are feeling that way, and take steps to feel to fix the problem. So when clients feel will just take anger. When a client feels angry, I want them occasionally. They're not going to be able to do this every time they feel angry or they'd never get anything done. Most people experience 15 anger situations a day. So, you know, nobody has time to do this for every time. But reflecting on one or two times that somebody got angry, if they can do it in the moment, even better. But I'm happy if they just reflectively think about it at the end of the day, identify the emotion, explore why they felt that way, and what steps would it take to fix the problem. Reminding them that they can become stuck in emotions sometimes by nurturing it and blowing it out of proportion. When they get angry, just dwelling on it and thinking, oh, how dare they? And, you know, I think we all go there every once in a while and we step back and we're like, well, that doesn't make any sense to have an argument with somebody in my own head. They compound it with other emotions like anger and guilt. Getting angry at yourself for being angry about something again doesn't make a lot of sense, but we do it. So encouraging people to say, is this a good use of my energy? Is it going to fix anything? Personalizing something and thinking it's all about me, or catastrophizing or just trying to escape from it and fight it and go, well, I shouldn't feel this way, I shouldn't feel this way. Well, you feel that way. So instead of fighting with it, kind of like fighting with quicksand and getting sucked deeper down into it, people can learn distress tolerance skills to let that feeling go. And one of the images I like to use is a cloud, because I love laying out on the grass and watching the clouds and making little cloud animals. Yes, I'm 45. And I still do that, but, well, but watching the cloud just kind of come and go. And just like those little cloud animals, they may be one thing, it may be a dinosaur, but then it morphs into something else, like a teddy bear. Imagining their feelings just kind of floating by like a cloud, or maybe even morphing as it floats by into something more positive. Remember that emotions are just cues, like a stoplight. You don't have to act on them. It's suggested, you know, when you see a stoplight, a green light. Yeah, you can keep on going. Yellow light. You know, that depends on your prior experiences whether you should gun it or slow down. But it doesn't necessarily mean that something has to happen. You know, it could be a green light. Remembering that they feel how they feel in the moment and trying to tell themselves they shouldn't feel that way or change it, you know, it is what it is. You can improve the next moment. And that's a lot of semantics. And it takes a while for some people to kind of understand the difference between changing their feelings and improving the next moment. But once they get the hang of it, the sense of relief is pretty palpable. Preventing emotional relapse. Practice mindfulness. You want to try to encourage yourself to be aware of where you are. Identify any vulnerabilities that may make you more prone to emotional dysregulation and address those, but also increase positive experiences. If you can't do it for real, you know, maybe you've got a really busy day and you can't go walk in the park or watch the birds or whatever it is that you do. Fine, take 15 minutes and do. Close your eyes or sit in a chair somewhere quietly and go through some guided imagery. Go to a happy place, if you will, and just try to imagine something positive. Or, you know, you can also find some videos or turn on a comedian that you really like, anything that will increase positive experiences because you can't be miserable and happy at the same time. Now, you may not be going from being completely stressed out to giddy as whatever, but you can be less unhappy. You can take the edge off, you can buffer it and get away. Put some distance between you and that negative emotion for a few minutes. Encourage people to keep a gratitude journal. Sometimes just reflecting on, yeah, things kind of suck right now, but in the big scheme of things, this is a moment. And in the big scheme of things, it's not so bad. You know, my life is pretty good. I've got these things going for me. Encourage people to Avoid personalizing things that are not about them. You know, that's one of those pretty prominent cognitive distortions that we see. And once people start looking for the possibilities, and I, you know, my favorite number is 3. Identify three possibilities that this could have happened other than you. You know, if you run into somebody who's grumpy, identify three reasons that they might be grumpy. That has nothing to do with you. The car breaks down. You know, the first thought people have is, oh, why me? Well, it's not about you. Most likely it's about something that has to do with the car. So encouraging people to kind of put themselves, give themselves some distance. Remember, the negative emotions are the mind's way of telling them to kind of get off their butts and do something. My father used to call it the idiot. Like when you'd be driving that light that says the low fuel light would go on or the low pressure light, and that's our way, you know, that's the car's way of saying, we're gonna run out of gas if you don't stop and get some gas pretty soon. But negative emotions are our mind's way of saying you're gonna run out of gas if you don't do something to change this situation. Dwelling on nurturing, avoiding or hiding from negative emotions never makes it better. We can let it go. And again, that's a semantic difference. You're not avoiding by letting it go. You're identifying it, acknowledging it, and letting it move past going, this is not worth my energy. And that's different than avoiding the emotion. Avoiding the emotion would be if somebody did something that really made you angry and you just walked away, but then you were still dwelling on it and it gets stuck. You can choose to feel and fix or relapse and repeat. People need to feel their emotions, even the unpleasant ones, but it's okay to feel them. And that's where the distress tolerance skills come in. Empowering people to learn that, you know what, I can feel this feeling and I don't have to act on whatever urge it is, whether it's self harm or using or screaming at somebody or whatever it is that they do. And they can feel that, and then they can fix or improve the next moment, or they can avoid feeling with it, avoid feeling it, stuff it down somewhere where they're constantly going to have to devote energy to holding it down because they haven't dealt with it, and you're going to keep repeating the same cycle. We want to encourage clients to identify and put in Place triggers for positive emotions. And this is kind of a new concept, triggers for positive emotions. You can put alarms on your smartphone, you can put sticky notes on your microwave. You can put, you know, I usually write in lip pencil because it's easier to get off, but I'll write on my bathroom mirror or something. You can do a variety of things to remind yourself to do some happy things. Today I have an app on my phone that's knock knock jokes. It doesn't take much to amuse me and, you know, they're inane. They are designed for, you know, like five to eight year olds, but according to Netflix, that's how old I am anyway. So, you know, whatever, whatever makes you happy and laugh. But it doesn't do any good to have the app on your phone if you don't open it. So what triggers can you put in your environment that remind you to look at the knock knock jokes or do something happy each day and encourage people to start slow. You know, one or two things each day, they'll start feeling better and they'll start wanting to do more positive things. Have people list 10 things that they chose to get anxious or angry about over the last week. And this is a good group activity. They do this. Well, I have them do this on their notepad. Identify the 10 things that they chose to get anxious or angry about. I have them identify why they got upset. What was your mind telling you needed to be fixed, what needed to be changed? What did you need to do? And I have everybody go through and identify that for each of the 10 things. And then we go around the room and I ask, does anybody want to share one of the things that they got upset about? And what do you think your mind was telling you needed to be fixed? And it's not uncommon to have people get upset about very similar things, but identify that different ways of fixing it. So then, you know, I summarize and identify that, you know, Sam and Julie both had similar issues, but they fixed it different ways. And so there's not always one way to fix something. But encouraging people to be psychologically flexible and willing to look at different options to fix a problem. We'll talk about whether holding on to upsetness did any good. If, you know, because they got upset about it. And if it's one of the 10 things that makes the list probably was something you're still thinking about. So does holding on to that do any good? And that's generally a no. And they shake their head and okay, we go to the next question. What Was your initial reaction when this happened and was it helpful? So for everybody who shared, you know, I'll go back around and I'll ask them that question. When your boss told you that you were going to have to work late or whatever it was, what was your initial reaction? And you know, your initial thoughts were whatever. What were your initial behaviors? And was it helpful? And sometimes they do choose helpful behaviors. You know, their initial reaction was one of frustration and disgust and disdain and all kinds of stuff. But they chose to say, yes, sir and you know, the boss walked out. But then they dwelled on it. Dwelt dwelled. Anyway, they were unhappy about it for the rest of the day and staying after. And while they were working overtime, they were grumpy and disenchanted. So we talk about what could you do differently the next time to change or fix the situation and improve the moment? So when you're working that overtime, what could you do? Is it doing you any good to hold on to this resentment for having to work late? How can you change how you feel about the situation and walk the middle path? You know, when I think about overtime, hopefully we're talking about an hourly employee, so at least they're getting overtime pay. And if all else fails, how could you practice radical acceptance and just let it go? Except it is what it is. I've got to work a double tonight. I don't want to, but I have to. How can you accept that and be able to be okay with it? In mental relapse, there's a war going on in their minds most of the time. Part of them wants to stay positive. They want to stay on that recovery path. But part of them is struggling with tolerating the distress. And this is where we come in. This is, you know, where we shine. Because we are really good at helping people find tools to help them tolerate the distress. But first we've got to understand what the distress is. Signs of mental relapse are focusing on the negative and or having a pessimistic, helpless or hopeless attitude. So when people are in group or even an individual session and I notice that their attitude has changed a little bit, I call them out on it and I'm like, you know, I noticed that you seem to be struggling a lot more with having a positive outlook. What changed? Helping them identify early on when they start getting a little bit more negative. When I do iop, one of the reasons I love IOP is you see people so much. It's easy to, you know, on a day to day basis, you See them and you can say, you know what? Today you're seeming kind of off. I'm wondering if something happened, if you've got extra stuff going on. A lot of times in early recovery, when people are still in Iop or even outpatient, they may not be self aware enough to actually pick up on it. They just know that they're exhausted. So we can help people identify that their distress may be getting kind of to a boiling point. If people have an addiction during a mental relapse, they also may start thinking about people, places and things they used with, and I use the term used very, very loosely, we're talking about all sorts of addictions, from substances to gambling to sex to pornography. So they. But they start thinking about those behaviors and the times when they were using, glamorizing that use, going, oh, if I could only get back there, I could be happy for five minutes. They start lying to themselves and others about what they're doing, about whether they're thinking about it, justifying any behaviors. They start getting more manipulative. They minimize the impact of just one drink, one hit, one bet, one evening of Internet porn, whatever it is for them. And eventually they get to a point where it's just kind of a screw it attitude. It's like, I don't want to live like this. And a lot of times one of my clients talked about how it was hard to stay clean in early recovery because everything was gray. There were no colors, there were no highs, there were no lows. Because we know, you know, we clinicians know that the neurotransmitters responsible for your excitatory responses, your norepinephrine and your glutamate and to a certain extent, your dopamine, they're not being released nearly as easily right now. So it's hard to get excited about anything because your brain is not letting you. So it's hard to stay clean and sober. For that particular client, he did significantly better when he got on some psychotropics in order to help him get through that period until the brain balanced out. But, you know, it's going to be different for every client. The point is being aware that if somebody has an addiction, that addiction was their best friend before they stopped using it, didn't judge them when they used it, made them happy or at least made them forget. And it was pretty infallible. You know, if it, if half a bottle of whatever didn't do it, they drank a whole bottle. You know, sometimes it took a little bit more, but eventually it would kick in and they would get that numbing or that escape that they needed in order to tolerate their distress. We don't want them to have to go back there. We don't want them to have to escape from it. We want them to develop the tools so they can survive the distress. So again, encouraging people to identify things that trigger negative thoughts. Now, negative emotions are, you know, depression, anger, anxiety, yada, yada. Negative thoughts are those pessimistic, you know, kind of rabbit holes you can go down where you hear something on TV that really ticks you off and you just go spiraling with it. And, you know, Chicken Little, the sky is falling, whatever. People, certain people can trigger negative thoughts if they oftentimes, if they're negative themselves. But we want to look at, you know, what triggers a negative attitude in you. And I know for myself, I have certain hot button issues that just really grind my gears. And it can trigger negative thoughts in me. Being aware of that and being aware when I encounter one of those triggers, I can adjust accordingly. But our clients in early recovery have not developed that stop and adjust part. They just feel it and they start thinking negatively. So again, encouraging them to identify the thoughts that they have that make them feel those negative ways. You know, I'm a fan of charts. And so here's another one. You can have people list their feelings, the unpleasant feelings they frequently have down here across the top, the fears that they're related to. And we want them to identify the thoughts that make them feel angry, irritated and resentful, that relate to their loss of control. Identify the thoughts that make them feel angry, that relate to feelings of failure. Identify the thoughts that make them feel angry that are related to isolation. You see how this goes the other way. You can do it in a, again, in a group setting, and I love group because you've got so many different perspectives coming in. And I think it's more helpful, but some. So if you do this in a group setting, each one of these little squares can be a flip chart page around the room. And you can do maybe one emotion each group. So we can talk about angry, what angry thoughts are related to loss of control. And then the next station is what angry thoughts are related to a fear of failure. And then you can talk about that, normalize it for the group about the thoughts that many people have that are related to, for example, a fear of failure and why it makes them angry. Because a fear of failure triggers our fight or flight response. So anger is a natural response. And then we can talk about what to do about it. When you start having those thoughts, when you start having thoughts of everybody's against me or whatever the thoughts are, how do you counter those? So to prevent mental relapse, we want to keep it simple. Trying to change too many things at once can lead to failure. So really have them focus on one or two things. And going back to that last slide, For example, if you find that they have a theme that a lot of their anger triggers, the thoughts that trigger their anger are related to a fear of failure and rejection. Alright, well that tells me let's try to work on some self esteem. But you want to find the opposite issue for them to work on. So if they're afraid of failure, then we need to work on developing acceptance. But we don't want to have them try to change everything all at once. So we're just going to focus on that one thing. And they probably have other dysfunctional thoughts. We all do. But let's start somewhere and remember that some of the simplest things can have the greatest impact. So they don't have to change the world overnight. They don't have to become a whole different person overnight. Let's change one or two things about themselves that they want to work on changing. We also want them to prevent and address vulnerability so they can focus. That can make them focus on negative things or have strong negative emotional reactions. So we go through the whole vulnerabilities thing, make sure they're eating, getting quality sleep. I check in with everybody about how they slept in group or an individual to make sure that they're paying attention to not only the quantity, but the quality of their sleep and then good orderly direction. And this is for those planners out there, life and recovery can be viewed like a roadmap. The destination is recovery and happiness. And so before you act, think whether that keeps you on the right road from where you are right now, wherever it is, to your destination, or is it an unplanned detour? I have absolutely no sense of direction. Even if there's a traffic jam on the interstate and I have to get off, I end up getting turned around and wasting a whole lot of gas and spending a whole lot of time I didn't need to spend trying to figure out how to get around the traffic jam because it was just going to take too long. And recovery is kind of the same way. A lot of people will detour from the main road because they don't want to wait. Recovery is taking too long. It's not as fun. There's something and you know, if you Detour around could take you a lot longer. You could actually end up backtracking. So staying on the path and being patient is part of it. And maintaining head, heart and gut honesty. We talked about this in dialectical behavior therapy. The head being your rational mind, the heart being your emotional mind, and the gut being your wise mind. Because it takes the logical and the emotional and synthesizes the two. And if all three of those say yeah, this is a good idea, then you're probably good to go. So just like the negative stuff, we talk about positive things. What thoughts can people have? And this is what I want on their thought journal that can help them feel empowered and happy. What thoughts can they have that can help them feel successful and happy, accepted and happy? I have them keep a sheet, you know, it's generally just one page of pleasant thoughts that they can review about themselves or about their situation that help remind them that they've got this. They are capable, they are resilient, they are able to succeed in whatever they're doing right now. They are acceptable and lovable and they have to come up with that because, you know, you can tell them to tell themselves all kinds of things, but if they don't believe it, it won't do any good. So I want them to identify their self empowering thoughts and their thoughts about how they are successful and what they're successful in. So social relapse is returning to the same old people and places who co sign on your stuff. And this is very, very true for addiction, but it's also true in anxiety and depression. Because when we get into this negative frame of mind because we're anxious, we're worried, we're pessimistic, we're, you know, any of those things. A lot of times our attitude is, you know, such that we attract people who are having similar thoughts and they're going to co sign and they're going to validate it, which is going to take you further down that negative spiral of the sky is falling and everything is going to wherever in a handbasket. So encouraging people to maintain social supports that are positive, uplifting and keep them going in the right direction and maybe be neutral with regard to, you know, whatever the stuff is that you might want them to co sign on, but they won't tolerate you being like worried and pessimistic about everything. They'll be like, you know what? You are just freaking out today. What the heck? Sometimes that's all it takes is a good friend to call you out and go, you know what? You're getting back into old behaviors. Other signs of social relapse are withdrawing from social supports because your social supports will call you out on your stuff. So you don't, you don't want to be called out, so you hide. Becoming self centered, it's all about me and feeling like everything is a personal attack or just withdrawing altogether and kind of going into bed. Not only from your social supports, but also from yourself. You're not even checking in, doing mindfulness activities. You're just sitting there watching Oprah and eating bonbons. I think she still has a channel on somewhere. Social relapse is critical because our social supports are some of our greatest buffers against stress. And they're also some of the first people that can call us on those early relapse warning signs and go, hey, there's something a little bit different about you today. Are you doing okay? So encouraging. Again, looking at the triggers for social relapse, are there things that encourage you or trigger you to push people away or to basically hideaway? Preventing social relapse contacts your social support or supports on a daily basis for the first three months after you start recovery. And that sounds difficult and it is. I mean it takes some practice to get used to. But reaching out and calling them, it doesn't have to be a long discussion and it could just be a text or a couple of texts, you know, if you don't, if you're not big on the phone. But reaching out and establishing that contact, keep a business card in your wallet with the names of three social supports. So if you're having a moment, you know who you can call now with smartphones, keep it on your easy dial screen or whatever it is. Change your phone number if possible and destroy contact information for people who might trigger a relapse. This is more true for people with addictions. You don't want your dealer calling you, but it is also true for people who are trying to get out of anxiety and depression and they have a lot of people in their life who are depressed and anxious and you know, calling them a lot and they feel like it's a trigger. Now it may not feel like a trigger for them, so that's obviously their call. But definitely for people recovering from addiction. We don't want your dealers calling you and we don't want other people trying to find stuff calling you. Find at least one pro social activity to do each week. Volunteer, go to church, go to the gym. I mean, I'm not asking you to do, go out to the library. Some of these you don't even have to interact with other people, but you're around other people, you're engaging, you know, in the same place with them. If nothing else, a lot of people find it helps them from withdrawing quite as much if they have to get out and interact. What triggers can you put in your environment to remind you to use these tools? And I may be a little bit overboard on alarms on your smartphone. I find that works easiest for me because I never know if I'm going to be at work or down at the barn or up at the house or where I'm going to be at any particular time. And that reminds me that I need to do something. But whatever works for people. And some people may choose to save all their recovery activities kind of for the end of the day. So they only need one alarm. That's cool. Physical relapse is characterized by fatigue, increased anxiety, difficulty sleeping, neglecting physical health. And if there was an addiction, there also may be cravings and dreams about the drug. Once people start getting more anxious or angry or neglecting their physical health and not getting enough sleep, you know that HPA axis starts going into overdrive, and it's going to start altering hormonal balances and neurotransmitter levels. When people are starting to physically relapse, we know the emotional relapse probably isn't far behind and vice versa. So remember the acronym. Hungry, Angry, Lonely, and Tired. Hungry. Obviously, people need good nutrition, but people can also be hungry for happiness. So encourage them to nourish their mind with activities and things that increase their happy chemicals. If you are angry, you want to reduce chronic stress. If you're lonely, you want to nurture social supports to buffer that stress and be willing to ask for help if you're tired. Make sure that you get quality, sufficient, sufficient quality sleep and address any issues that are preventing quality sleep. But also remember that tired can also mean just kind of being over it. I know there are times being a parent, I've walked in to the house and I just put down my stuff and I'm like, y', all, I'm really tired of coming home to fill in the blank. So encourage people to think about tired as not only just sleepy, but over it and, you know, frustrated with something. All of these can help prevent physical relapse. Encourage people to review their strengths. What is life like when they're happy? What's different? What's the same? Because these are the things, the things that this is what they want their life to be like. So let's Start building those up. Let's worry less about eliminating. I mean, we're going to address those things. But while we're eliminating behaviors, we also want to be adding. Adding those behaviors back that were there and present when the person was happy. Have them identify three ways they know they can cope with stress. It may not be the healthiest way all the time, but at least they know. Have them identify things that they like to do, because remember, we're putting in triggers for happiness activities and have them increase their awareness of their positive qualities and strengths. I have my clients keep it on that sheet. They have a gratitude journal. Then they have a sheet that has their positive qualities on it. All these things they can go back and review when they're having a negative moment and kind of get their head back on to the recovery path and encourage them to review prior relapses. And we all have them. If you've had a depressive episode, if whatever happens, even if you are just trying to start eating healthier and you're doing really good, and then one weekend is just like a free for all, okay, well, what happened before that relapse? What was going on? Why did you choose this other behavior? And a lot of times you'll find that people had quit engaging in their recovery behaviors or what they were doing. Whatever it was wasn't providing the level of reward that the behaviors were. So if you're eating healthfully and maybe you're just really trying and you've changed your diet 100% and you're not getting the same satisfaction out of your food and your mealtime as you were before, then that could prompt a relapse. So encouraging people when they make changes to make sure that it's equally rewarding. Relapses occur when old behaviors are more rewarding than and, and. Or stronger than new ones. So what became more rewarding than the recovery program? Why was this behavior more rewarding? And I'm not judging. I just want to know why. Because we've got to change the recovery program to meet that need so you don't feel compelled to relapse again before you've relapsed in the past, what has changed in your emotions, thoughts, behaviors, and how you interacted with others. Most people, if they look back over two or three relapses, will start to see some patterns. Encourage them to create a plan identifying the most common pitfalls for their relapses, what they can do to prevent those pitfalls and identify what's worked in the past. Let's build on that, let's start on what they already have. Encourage them to create a schedule including recovery activities. Their work, of course, reflection time. And this doesn't have to be 30 minutes or an hour. It can be 10 minutes while they're taking a shower or something where they just kind of reflect and do their mindfulness activity. Positive health behaviors, including nutrition, exercise, and sleep. So make sure they schedule in plenty of time for quality sleep and maybe moving around a little bit and nurturing positive relationships. This is one we forget to include in a lot of relapse prevention plans. They need to have time scheduled in somewhere or they need to make time somewhere to actually interface with people intentionally. And the forgotten parts. The two main things people forget when they try to make a change plan is that we do what we do for a reason. And any substitution must fill the same function to the same degree. And that's hard. I mean, when you're talking about somebody with an addiction to cocaine, you're like, how can we replace the same? And you've got to look at the big picture of what they were trying to do. They were trying to feel better. So we've got to figure out how they can feel better in recovery. You wouldn't replace chocolate with celery on a diet. You at best, or at least replace it with an apple or something sweet, probably. So we want to look at what was the function of that old behavior and make sure that we're still fulfilling that function. It's more about living a healthier lifestyle guided by purposeful action than removing any one behavior. If you remove the behavior without an adequate replacement, you're going to relapse, most likely. So if you tell somebody to stop smoking, you know, go cold turkey. And when you get stressed, I don't know, you know, you'll figure it out. That's not going to work. We need to give them a tool to put in place. So, okay, if they're not smoking and they get stressed and they used to cope with stress by smoking, what are they going to do? We can't just take away that behavior and go, good luck, Godspeed. If you remove the behavior but are still around the same people, places and things, you may relapse because all those triggers are there. You may not be able to change all of them, but you need to be aware of them so you can deal with them. And if you're immersed in positive activities, you're going to have less time to make the wrong choices. So encouraging people to avoid as much dangerous time, you know, some people need downtime or idle time each day. But removing as much dangerous time as possible is going to be important in early recovery. And, and you know, it depends on what your triggers are. I bite my fingernails when I watch tv. You know, I know it's a gross habit, but I found that if I crochet while I'm watching tv, I can't bite my fingernails. So have some competing responses in there too. All right. Increasing motivation. You want to do some decisional balance exercises. You want to strengthen the client's commitment to the benefits of the new behavior and awareness of the drawbacks to the old behavior. And you want to decrease how they view the benefits of the old behavior. And you want to decrease any potential drawbacks or hesitations about the new behavior. Encourage them to find meaning in everything. After they do an activity or read any literature related to recovery, ask themselves, what was in this for me and what's one thing I can take away from this, even if it only reminded you how much you don't want to go back to that old behavior again? In our unhappiness, we often forget what makes us happy or neglect the things we love. All work and no play puts you at risk, even if a lot of work is on the recovery. Make a list of things you enjoy doing, would like to do, and anybody that might have similar interests. And try to do at least five of these things a week. Five is a big one, but if we're just talking about playing a game of Scrabble, you know, you can probably work that in. Include time in the morning and at night to use mindfulness skills to get grounded. Identify and prevent or mitigate vulnerabilities each day. So once you figure out what your vulnerabilities are, do something about it. Avoid that dangerous time. If your mind tends to wander to dark places. Incorporate positive experiences each day. Set realistic goals and give yourself credit for positive accomplishments, even if it's just getting through a meeting without biting somebody's head off. Relapse triggers can be emotional, mental, physical, or social. For each trigger people identify, have them describe at least one way they can deal with it. Encourage them to practice mindfulness each day to become aware of their personal vulnerabilities for relapse. And for each general category of relapse. Emotional, mental, physical, social. Have them identify three things they can do to continue their journey towards happiness, recovery, whatever you want to call it. Okey dokey. We are done. I appreciate you hanging with me. Do you have any questions? I saw somebody had typed something back here earlier. Okay, let's see. One of the participants in class today shared this from Notre Dame on workplace wellness so you may be interested in that. Feel free to check it out. If you have any questions or comments or concerns, please let me know. You can always reach me. At my email if you have any questions about any of the clinical or, you know, educational material. Well, thank you for being here everybody. Have an amazing weekend. If you're in one of those cold places, try to stay warm and I will see y' all on Tuesday. 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.