Relapse Prevention for Co-Occurring Disorders
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs

Counseling CEU Course link

~ Define Relapse
~ Identify triggers and warning signs of relapse
~ Review Relapse Syndrome and possible interventions
~ Explore the acronym DREAM
~ Define and identify vulnerabilities
~ Define and identify exceptions
~ Develop a relapse prevention plan
Why I Care/How It Impacts Recovery
~ Relapse indicates that the old behaviors have returned either because
~ New skills were ineffective
~ Old behaviors were more rewarding
~ Recovery involves understanding what triggers each individual person’s relapse
Relapse Syndrome
~ Relapse generally follows a predictable and readily identifiable pattern
~ Return of denial “I’ve got this.” “I’m fine.”
~ Teach support people about recovery and relapse. Encourage them to probe about problems.
~ Write down problems on a daily basis and share this list with someone.
~ Avoidance of defensive behavior…Focusing more energy on fixing others than on working on self and failing to do relapse prevention exercises.
~ Surround themselves with support people who will encourage them to continue working on their relapse prevention program.
~ Maintain a “negative image” reminder of what it is like when they are symptomatic
~ Develop and review a cost/benefit analysis of their coping behavior.

Relapse Syndrome
~ Crisis Building…problems begin to pile up and it becomes more and more difficult to see options. The person develops tunnel vision and loses the ability to perform constructive planning
~ Remind them to take one day at a time.
~ Review coping behavior.
~ Encourage acceptance of personal limits.
~ Remind them that it is the thoughts about an event and not the event that is “bad” or “good”).

Relapse Syndrome
~ Immobilization When a crisis builds up, the person becomes crushed and trapped by the problems and incapable of initiating action A sense that nothing can be solved may develop.
~ Use the Serenity Prayer.
~ Use the support people that they have developed.
~ Review the concept of lapse as opposed to relapse (accept the reality that they may make some small mistakes but this does not mean that they have failed).
~ Confusion and overreaction While the problems continue to grow and the person feels stuck, he often becomes confused and angry leading to irritability, a general sense of tension, and sense that others are out to get him.
~ Identify the source of the feelings.
~ Accept responsibility for problems.
~ Possible professional intervention.
Relapse Syndrome
~ Depression. As the anger begins to build, so does a sense of hopelessness and begins to turn the anger inward in the form of depression.
~ Focus on those things that the person can control
~ Identify strengths
~ Set SMART goals to develop self-efficacy
~ Seek social support
~ Behavioral loss of control The person becomes unable to control or regulate personal behavior and a daily schedule.
~ Develop a routine
~ Regroup and redifine those people, things and activities that are truly important to a meaningful life
~ Make a task basket (or list)
~ Set more SMART goals to start taking steps forward
10 Most Common Triggers of Relapse
~ Withdrawal symptoms (anxiety, nausea, physical weakness)
~ Post-acute withdrawal symptoms (anxiety, irritability, mood swings, poor sleep)
~ Poor self-care (stress management, eating, sleeping)
~ People (old using friends)
~ Places (where you used or where you used to buy drugs)
~ Things (that were part of your using, or that remind you of using)
~ Uncomfortable emotions (H.A.L.T.: hungry, angry, lonely, tired)
~ Relationships and sex (can be stressful if anything goes wrong)
~ Isolation (gives you too much time to be with your own thoughts)
~ Pride and overconfidence (thinking you don’t have a drug or alcohol problem, or that it is behind you)

Types of Relapse
~ Emotional relapse
~ Mental relapse
~ Physical relapse

Relapse Warning Signs
~ Emotional Cues
~ Are you more angry, defensive or frustrated that usual?
~ Do you have more anxiety or depression?
~ Are you not asking for help when you need it?
~ Are you hanging out unhelpful friends?
~ Are you having more mood swings?
~ Are you feeling restless or bored?

~ Mental Cues
~ Are you keeping secrets or isolating?
~ Are you tending to see the worst in things?
~ Are you using cognitive distortions?

~ Physical Cues
~ Did you stop going to meetings?
~ Did you stop going to counseling?
~ Are you having difficulty sleeping?
~ Have you been taking your medication as prescribed?
~ Are you eating junk or not eating at all?
Dare to DREAM
~ Determination
~ Resilience
~ Exceptions
~ Awareness of vulnerabilities
~ Motivation

~ Recovery is not easy
~ People need a high level of tenacity to get through the rough points
~ In their addicted selves, people behave impulsively.
~ Recovery involves being able to forgo the easy or immediate reward to achieve longer term goals
~ The ability to bounce back
~ Part of resilience is hardiness
~ Commitment can be considered motivation
~ Control
~ How much control is rewarding?
~ How can too much or too little control be unmotivating?
~ Challenge
~ Why is it rewarding when something is challenging?
~ Why are things that are easy not as rewarding?

~ Qualities of Resilience
~ Self-Awareness and Self-Care
~ Healthy Habits (Vulnerability Prevention)
~ Distress tolerance
~ Rational, accurate cognitive habits
~ Social Engagement
~ Generosity
~ Integrity
~ Authenticity
~ Humility/Compassion
~ Identifying as a survivor, not a victim

~ Qualities of Resilience
~ Meaning
~ Purpose
~ Gratitude
~ Hope
~ Optimism
~ Attention and Focus
~ Curiosity
~ Flexibility
~ Persistence
~ Problem Solving Skills
~ Here and Now focus

~ Nothing is done all the time
~ Exceptions are what people are doing when they are NOT engaging in the target behavior
~ To identify exceptions, ask questions like…
~ Before this problem started
~ What was different?
~ How did you deal with stress?
~ In the past 6 months when you were not [engaging in the target behavior]
~ What was different?
~ How did you deal with stress?

~ Once you identify exceptions, help the client
~ Strengthen those
~ Do those things more

Awareness of Vulnerabilities & Relapse Warning Signs
~ Strengths/Vulnerabilities
~ Sleep
~ Nutrition
~ Medication
~ Chronic pain
~ Hormones
~ Estrogen
~ Testosterone
~ Social Supports

Awareness of Vulnerabilities & Relapse Warning Signs
~ Relapse warning signs are the way people act when relapse is imminent
~ Have people describe their addicted and sober selves
~ When the behaviors of their addicted selves start to emerge it is a warning that
~ Current strategies are not working
~ Current skills and strategies are not being used in lieu of old behaviors

~ People do the most rewarding

Motivation is Multidimensional
~ Motivation differs for each behavior
~ Example: Depression, Addiction, Relationship
~ Dimensions
~ Emotional
~ Cognitive
~ Physical
~ Social
~ Environmental
Motivation is Changeable
~ Stages of Readiness for Change
~ Precontemplation
~ Contemplation
~ Preparation
~ Action
~ Maintenance
~ Relapse*
~ Motivation is not linear
~ Mindfulness will help people identify when their motivation is waning

What to Include
~ Triggers
~ People, places and things that trigger cravings
~ How to avoid triggers
~ How to manage high risk situations that cannot be avoided
~ Managing Cravings
~ Emotional
~ Mental
~ Physical

~ Useful Tools
~ Gratitude list
~ Relaxation techniques
~ Stress management techniques
~ Support
~ People to call when you have cravings or stress
~ Mental and physical wellness
~ Problem solving skills

What to Include
~ Life Improvement
~ Family relationships
~ Spousal/significant other relationship
~ Support/friends
~ Legal issues
~ School
~ Employment/Work-life balance
~ Finances
~ Housing
~ Basic needs
~ Mental health
~ Spirituality
~ Purpose

~ Recovery Program
~ 12 Step work
~ Moral inventory/character defects
~ Ways to make amends
~ Identification of Relapse Warning Signs

~ Recognize recovery—Credit where credit is due
~ Acknowledge that a lapse is a normal experience and should not be viewed negatively.
~ Strengthen the motivation to change throughout the change process.
~ Identify high-risk situations
~ Develop coping strategies and skills to avoid high-risk situations and to deal with them when they are unavoidable.
~ Develop coping strategies and skills to deal with lapses.
~ Recognize and implement changes to the environment and lifestyle to minimize the frequency of high-risk situations and to strengthen commitment to change.
~ People in recovery have
~ Determination
~ Resilience
~ Exceptions (understanding of)
~ Aware of their vulnerabilities and relapse warning signs
~ Motivated to live a recovery lifestyle
~ Relapse Prevention planning
~ Minimizes vulnerabilities
~ Incorporates mindfulness
~ Contains an emergency response plan

~ Handling slips and relapses
~ Dealing with fear of change
~ Finding a new focus
~ What changes to the environment and lifestyle could be made to
~ minimize the frequency of high-risk situations
~ strengthen commitment to change.
~ Myths
~ Not working your program causes relapse
~ A person who relapses is not willing to stop
~ A person knows they are relapsing
~ Not using means you’re in recovery
~ Techniques
~ Index card emergency plan
~ Creating a relapse map that lets you write down what your options are when you're in a trigger situation. (Flow chart)
~ Hold an ice cube until the craving or urge passes. Splash cold water on your face to “reset.”
~ Do deep breathing/belly breathing to calm yourself
~ Distract yourself – call someone on the phone, cook, clean, watch TV, read, exercise
~ Reward yourself – buying yourself small gifts or treating yourself to dinner at your favorite restaurant when you are regularly embracing a recovery lifestyle.