Living Your Fears Away
From the beginning of your work on reducing the effect of negative emotions in your life, you understood that avoiding fears, anxieties, and safety behaviors generally serve to reinforce and give credibility to irrational beliefs.
No two fingerprints are alike. No two people are alike–even identical twins have personality differences. Likewise, even a manualized treatment will have differing results with individuals given the same diagnosis. Therapists generally love it when a client attributes positive changes to the wonderful treatment technique or insight that came from the therapist’s skilled communication.
Caution to therapists: if you’re working for that kind of feedback, you may benefit from more therapy. Your job is to become a scientist/practitioner and every client is a unique study of one person (in research, N=1).
Caution to clients: your experience in counseling may simply lead you to recognize the benefit from taking a break in your day. Even so, you should continue to use the tools suggested and practiced in counseling and engage in your own scientific study of the outcomes that result from your application of those tools. Be on the lookout also for the effect of changes in the environment or the serendipitous finding that contact by an old friend lifted your mood. Write that down! Try to capture and document what exactly has improved and what you believe brought about the improvement, then create a plan that you can continue to update and revise during and after active treatment. Follow up with your therapist every six months to a year or during big life transition periods.
Therapists should begin relapse prevention plans when clients begin noticing improvement. As we begin these plans, we focus on what clients have noticed and to what they attribute the improvement.
If you refer to the example of a relapse prevention plan on page 61, an improvement noted in “Healthy Behaviors or Improvement” may be a decrease in the frequency of anxiety triggers (1.a). The client may attribute that decrease to their booster exposures (2.c) or their use of cognitive restructuring techniques (2.b).
Relapse Prevention Plan
Relapse prevention is a process that includes taking positive steps to maintain one’s health. It is a practical plan that addresses avoiding possible pitfalls that may occur during and following recovery. People naturally tend to put aside preventative and protective behavioral habits the moment they start feeling physically well. It is a process that begins well in advance of any act of relapse (e.g., binge eating, drinking alcohol, or engaging in obsessive-compulsive behavior). Because relapse factors are unique to each individual, the faster someone can recognize the symptoms that signal relapse, the faster they can take positive action toward recovery. Therefore, we like to begin developing a relapse prevention plan early in the treatment phase and well before we discontinue active CBT.
The basic elements of a plan include: 1) making a list of healthy behaviors (cognitive and behavior) or improvements; 2) creating a plan for maintaining these healthy behaviors; 3) identifying and listing signs of relapse; 4) creating a plan of intervention if there are signs of impending relapse; 5) identifying the most serious signs of relapse, and 6) creating a plan of steps to take if a full relapse becomes evident.
Anticipating possible relapse doesn’t represent a pessimistic view of recovery. It takes substantial insight development and practice to gain mastery over some symptoms such as those in OCD, PTSD, and social phobia. We also know through observation and research that people tend to put aside preventative and protective behaviors when they feel well. For example, patients recovering from a sinus infection will stop remembering to take their antibiotic medication. People in recovery from addictions will think they can begin to use some substances and not completely relapse. People with anxiety disorders will put off exposure because it’s not convenient and their symptoms have become less intense. After seeing many clients through this process, we have come to believe that lapse and relapse should be anticipated so that a planned response can be initiated and the debilitating effects of symptoms can be minimized as quickly as possible. We don’t see lapses and relapses as a failure, but a structured Relapse Prevention Plan acts as a clear early-warning metric to track your status and map out exact behavioral adjustments.
Healthy behaviors, maintenance, and warning signs will look different for each individual, but some basic signs and steps for preventing relapse based on one client’s plan are listed below:
Six parts of a working plan
This is the plan the paragraph above points to. It is one person's, quoted exactly as the manuscript sets it out — the numbers, the letters, the percentages and the hours are all theirs. Yours will look different.
1) Condition Green: Healthy behaviors or improvement
- a) I find my triggers elicit less anxiety and are less frequent. I experience SUDs of two or three, eight to ten times per week or less.
- b) I am able to inhibit my ritual behaviors 99% of the time.
- c) I am sleeping better and waking up on time, about seven and a half hours per night.
- d) I am feeling more motivated at work and at home. I’m completing tasks at work and keeping the house maintained.
- e) I am going out and doing more on a daily basis–grocery shopping, lunch with friends, exercising, etc.
- f) I have started thinking more positively about things, setting goals, making plans, appreciating my spouse and children, etc.
2) I will do the following to maintain my signs of improvement:
- a) Attend my counseling sessions regularly and do my homework assignments.
- b) Continue to use techniques learned in therapy to help dispute my anxiety-provoking thoughts, e.g., “It’s just my OCD.”
- c) Challenge myself to keep up my exposure.
- d) To engage at least once a day in rewarding behaviors that I had lost interest in, like art, reading, music, etc.
- e) Surround myself with people who can support me.
3) Condition Yellow: Warning signs of relapse include
- a) An increase in negative thinking patterns throughout the day (e.g., I’m worthless, nothing will ever work out for me, etc.).
- b) An increase in the frequency of suicidal thinking (Upon the occurrence of suicidal thinking, I will call my mental health professional.)
- c) A decrease in daily activity.
- d) Difficulty getting out of bed (i.e., two out of seven times a week).
- e) Not taking medication as recommended by my doctor or mental health professional.
- f) Not bathing or keeping hygiene up as well as before.
- g) Skipping therapy sessions and counseling homework occasionally.
- h) Isolating myself from my support group.
4) I will do the following when I notice Condition Yellow:
- a) Begin engaging in behaviors mentioned in 2).
- b) Begin speaking to members of my support group about my struggle.
- c) Call or speak with my mental health professional.
5) Condition Red: Warning signs of relapse include
- a) Spontaneously stopping medications or failing to comply with your medical or mental health professionals’ recommendations.
- b) Suicidal thoughts and a plan to commit suicide (I will call a mental health professional, go to the emergency room, or call 911 for help.)
- c) Frequent irritability.
- d) Hanging around old friends and engaging in situations that trigger certain thoughts or negative behavior.
- e) Insomnia (not feeling rested after waking).
- f) Failure to attend treatment.
- g) Increased sadness.
6) I will do the following when I notice Condition Red:
- a) See my counselor immediately or call the emergency line if I need help after office hours.
- b) Contact someone in my support system who can help me.
A note on Condition Yellow and Condition Red
Two items in this plan name suicidal thinking and say what the client will do about it. They are quoted because they are part of the plan. If either is live for you now, that is not a workbook exercise — call your clinician, go to an emergency room, or in the United States call or text 988.