RELAPSE PREVENTION COUNSELLING AND MANAGING A RELAPSE - Written by Dean Gustar, Relapse Prevention Specialist

What is Relapse Prevention Counselling?

When working with behaviour change, particularly around substance use disorders, and behavioural disorders, it is important to have Relapse Prevention Counselling as part of a programme that includes a range of other interventions. Relapse prevention counselling is education, alongside skills training, development of self-awareness, risk awareness and risk management. It draws from a range of counselling and psychotherapeutic approaches and is mainly pragmatic and person-centred at its core. We look to develop an awareness of the relapse process – the “why”.

As a relapse can be a good source of learning, so can previous periods of abstinence or other examples of behaviour change. If there has been a period of sustained recovery, we can examine what worked, what supported recovery during those times, and what didn’t work. And where there has been a major behaviour change, such as smoking cessation, then the client has already implemented a change skillset. This can help with self-belief and motivation.

We develop the awareness of triggers that can lead to relapse and understanding of some of the thinking patterns that, on the other hand, can lead to relapse and education about cravings and how to manage them. We build up knowledge of risk and help the client to identify blind spots and potential bumps in the road. We examine previous relapses for lessons learned and use the `here and now` as a source for education and development. We reframe any potential or previous relapse as important opportunities for learning.

There are several important components to a recovery plan. A Relapse prevention counsellor works with the client to establish a programme designed around their personal needs to support ongoing recovery. It includes a balanced and manageable schedule and tips on how to manage various situations that may trigger a relapse.

We also find that involving family and friends in relapse prevention counselling is a real support to long-term outcomes. Some sessions with the family can be used to educate about relapse, draw up a plan together to manage any potential relapse, and identify any early warning signs that may indicate a person is heading toward a relapse. Often the people close to the client see a relapse unfolding way before it happens. We can also plan how to communicate these concerns, in an agreed manner, and how to get additional support if resistance to support is encountered.

At The Kusnacht Practice, psychotherapy plays a strong role in helping to identify underlying causes or unconscious drivers that may be feeding into the behaviour. This complements Relapse Prevention counselling and serves to strengthen recovery and support better long-term outcomes.

As I mentioned above, outcomes let us reflect on the importance of soft outcomes. Often, quite naturally, we focus on what is called “hard outcomes”. A hard outcome is one simple, measurable outcome. An example for someone with an alcohol use disorder could be an alcohol test. This would give one of two results, the person has drunk alcohol, or they have not. When we focus on such outcomes, they are easily viewed in terms of success versus failure.

Because a person with an alcohol use disorder is not drinking, it does not mean their life is improving. The same goes the other way around; a relapse doesn’t mean that everything has failed. A hard outcome is not a measure of how well a person is doing in their life. Plenty of people stop a behaviour but remain in a difficult place. They abstain, but they remain stuck in life. A recovery process is much more than changing one behaviour.

For example, for a person, who is trying to abstain from alcohol, a focus on a hard outcome can create internal tension. They may constantly be thinking, “Must not drink, must not drink”. This can become overwhelming and stressful. Nothing relieves tension quite as well as alcohol. Hard outcomes can encourage a negative mindset. A person might feel bad if they have a craving or thoughts of drinking.

Here it is why we need to consider soft outcomes as a tool to measure progress in a more balanced way across several aspects of life. Soft outcomes would include a variety of variable measures. It requires healthy goal-setting and gives a broader view of progress. They are not considered as pass or fail targets. Soft outcomes include such things as quality of life, relationships, health, work life, and so on. They take the focus away from the substance. We can start seeing recovery as a much broader path than just abstinence. Soft outcomes will alleviate pressure, boost motivation, and strengthen recovery. They will also help to manage any bumps in the road ahead.

It’s all part of the process

There’s an old joke about a man who goes to the doctor and says, “Doctor, every time I lift my arm like this it hurts”, and the doctor replies, “Then stop lifting your arm like that”. Usually, this is a visual joke, but I hope you get the picture. When we witness some of the devastations that often accompany a substance use disorder or a behavioural disorder we tend to project a similar rational mindset to the solutions. Why don’t you just stop, and then the suffering will stop? It is hard to understand why someone will pursue behaviour that causes them and the people around them such pain.

Then they do stop. Perhaps they stop on their own, or they get some support to stop. But they change their behaviour: everyone is relieved. Stress falls away from family and friends. Despair is replaced by hope. It feels like the nightmare is over, and everyone can breathe again. Then a relapse occurs.

A relapse can feel like the sky has fallen. It brings with it a disappointment. All the old feelings return. Here we go again. How did it happen? Why did it happen? How long will it last? The person who has relapsed will feel ashamed. They may feel despondent and hopeless. It generates a lot of feelings that perpetuate the behaviour.

The simple thing is that stopping and staying stopped is not so easy. Most of us have, at some point in our lives, tried to change a behaviour - stopping something, changing something, or doing something new altogether. Maybe a diet, implementing an exercise regime, or stopping smoking.

Think about your own experience of change, and you’ll begin to see that change comes with challenges, and progress is rarely straightforward. If you can’t think of an example from your own life, then I challenge you to go to your kitchen. Move your coffee cups from one cupboard to another cupboard. See how many times you go back to the original cupboard over the next days, weeks, and months.

Some tips for managing a relapse

Some people implement behaviour change and don’t look back. For example, they stop drinking and never relapse. These people are in a small minority. Most people will relapse at some point, and the way we respond to such situations can greatly impact the level of damage of such a relapse and how quickly a person can get back on track. Here are a few tips for managing a relapse:

1. Have a plan already drawn up

If we are aware that there is a strong likelihood that a relapse may occur, then plan for it. Everyone should be involved in developing the plan. The person of concern, the family, and any professionals that are supporting them. Such a plan takes some of the drama away from the relapse because you will already have a well-thought-through series of actions to take to manage the situation. It will reduce stress and uncertainty. We expect the best, and plan for the worst.

2. Offer compassion and encouragement

It is all part of the journey. We find it very important that a person knows that their loved ones will be there, ready to put an arm around their shoulder and say, “Don’t worry, it’s all part of the process; we will get through this together”. Even though there may be a disappointment, we show love and support and help strengthen the person's resolve to keep moving forward. This will encourage honesty and openness from the person who has relapsed.

3. Don’t panic and don’t overreact

Clear heads are required. There’s no need to panic. Stay sharp and focus on the path forward. Use your own support network to help you express and manage any feelings that may come up that can interfere with your ability to stay calm and work positively with the current situation.

Be measured in your response. If a person has taken one drink in a momentary lapse, don’t call a medical helicopter to rush them into detox. Go to the plan you already agreed on (see hint number 1) and implement it. Overreaction is another thing that will stop people from being honest. A person in relapse benefits from knowing that loved ones will be measured and rational in their responses. This will encourage people to come forward.

4. If required – get support

If you do feel overwhelmed, then get some support. Seek out people you trust who have knowledge of the situation or the issue. Get professional support if you think it will help you. If you are feeling alone, then reach out and share the burden. A relapse can put a lot of pressure on the family system. Find a safe space where you can express your own feelings.

Consider family support. We often find that family meetings with therapeutic support can be beneficial during times of relapse. It creates a managed space where people can express themselves, be focused on long-term goals, and agree on plans moving forward.

5. Be hopeful

Hope is important. It’s essential for all parties. In life, we have probably all seen impossible situations turn around against the odds. Often these can be the moments that become turning points. Understanding that a relapse is an opportunity for learning can help us stay hopeful.

Hope is not daydreaming. It’s having a firm belief that change is possible. Without hope, motivation can’t breathe. And without (at least some) motivation, recovery does become a daydream.

6. Be a team

Recovery is not a one-man show. It requires a team approach. Everyone is important. All team members can contribute and offer something. Together challenges can be faced, and nobody needs to feel alone. Here language can play an important role. Particularly one small word….We.

Part of being a team means everyone has a role. Everyone is important. Everyone can support the change process.

7. Create a safe space

Honesty will be essential on the journey. Work to create an atmosphere where people know it is okay to be honest. If they have relapsed, then everyone will understand without judgement. This will encourage disclosure of drug or alcohol use or any cravings or emotional struggles. We can’t overestimate how powerful this is. If a person hides their behaviour or feelings because of fear, this will only encourage secrecy.

A safe space means that you work together to keep stress levels as low as possible and to minimise potential triggers. This can mean people may have to change their own behaviour or the physical environment to support the recovery process. For example, if a person is trying to get back on track after a relapse on alcohol, the rest of the family drinking wine at dinner is probably not the way to create a safe space.

8. Encourage self-care activities

Getting back into a schedule can help to put some scaffolding into place to support a person to bounce back after a relapse. There are some activities that form an important part of a recovery-based schedule. It might include attending mutual aid meetings such as 12 Step meetings, exercise, counselling or therapeutic support, and regular mealtimes. A schedule should be manageable and not cause stress. A normal rhythm of self-care is the aim.

Written by Dean Gustar