 Today, we're going to be talking about relapse prevention for co-occurring disorders. And I know we've talked about relapse prevention a whole bunch of different times, but there is so much to consider and there are so many different people and different approaches and different needs that, you know, you can talk about relapse prevention for pretty much an entire semester course if you really wanted to. Today we're going to define relapse, explore the acronym DREAM, define and identify vulnerabilities, define and identify exceptions and develop a relapse prevention plan. Relapse indicates that the old behaviors have returned either because the new skills were ineffective or old behaviors were more rewarding. And one of the things that's interesting with people is they talk about relapses coming from out of the blue or they talk about relapses as if it's something that happens to them. Basically relapse is choosing to go back to those old behaviors. Now why is that choice being made is something that we can ask the client. Why is it more rewarding to do X instead of these new healthy behaviors? And you know, from a clinician's perspective, from a coach's perspective, we want to encourage them and increase motivation for people to engage in the recovery life style behaviors. But we have to remember that the recovery lifestyle, while we as people in recovery, people who are healthy, people who are clinicians may see it as a great, rewarding thing, isn't always great and rewarding. You know, we focus on the positives. For our clients, the recovery lifestyle is learning a whole new way of living and it's difficult. It's challenging. It's exhausting at times. Just to say that they shouldn't do it, but it is rewarding in its own way. But each and every individual behavior within that new lifestyle needs to be rewarding. So if people are reporting that, you know, recovery is just kind of blah and all they see is shades of gray, that we want to ask them what that means to them. It may mean that they don't have enough healthy social support. It may mean that they don't have their mood disorder under control. It may mean a whole host of things, which is going to be different for each person. Those old behaviors are still going to have certain rewards and they can be romanticized rewards. Decisional balance exercises, I say it almost every class, whenever somebody is doing a behavior and they want to change, they need to tip that decisional balance. So they need to be able to identify the benefits to their current behavior and figure out how to make it not so beneficial. Recovery involves understanding what triggers each individual's person's relapse. Now that doesn't mean that lack of sleep is going to trigger everybody's relapse. You know, hungry, angry, lonely and tired, that acronym from 12 Step Thinking, HALT. That's a pretty good rule to use in order to gauge whether somebody's going down that relapse path. But when someone gets overtired, it doesn't mean for everyone that they're going to relapse. Likewise, and I use sleep because, you know, I'm a big proponent of sleep and circadian rhythms, but for some people, even a small change in their sleep habits could precipitate a mental health relapse or relapse of depression or relapse of anxiety and or relapse of substance use. So we need to know for that individual what is going to trigger it. We need to know for that individual what things, get them upset, get them stressed, get them angry and try to help them figure out how to avoid those things. This is an election year as you know, you can't help but know. And for some people, talking about politics in the election is just a really fiery topic and it gets their blood moving, gets their blood pressure up, gets them all upset and freaked out and whatever else the case may be. So we need to say, well, is that something you have to be engaging in? You know, okay, sure, you want to know what's going on in politics. You want to, you know, be an educated voter or all that kind of stuff. That's great. So how can you do that in a way that doesn't get you all in a tizzy? And, you know, here's a hint, Facebook's probably not it. Encouraging them to figure out healthy alternatives to meet their same needs. So dare to dream, determination, resilience, exceptions, awareness of vulnerabilities and motivation. And I like acronyms because it gives clients something to hang on to and they can remember 12 step theory is full of different acronyms. You know, it's just, it's a thing. Determination. People make the mistake of thinking recovery is something you do for 28 days and then you're fixed. No, no, that's, that's not how it is. Recovery is not easy. It's a full-time job. It took you two, three, 20 years to get where you are. You're not going to fix it in three weeks. Recovery is an ongoing process. And the first few months is a full-time job and people need to recognize that. It's not easy. So we need to really help our clients focus on the small successes and get rewards wherever possible, which takes us to people needing a high level of tenacity to get through the rough points. When things get tough, I remember when I was working on my dissertation, I had a really good friend and, you know, thankfully she was, well, she started out a little bit ahead of me and then I ended up graduating before her. But the thing was, when I got to that point where I was like, Steph, I can't do it. I just, I'm done. I can't do it anymore. She would say, yes, you can. Look how far you've come. Look what you have done already. And all you have to do is make it this one step further. With our clients, we're not telling them to look six months ahead. We're telling them to get through the day to day. And we need to make sure that we don't set goals that are too large for them. Sometimes it's just an hour. You know, if they're having a really bad day, it may be an hour by hour thing. So, you know, you talk to them in the morning and you're like, okay, let's touch base, touch base at lunchtime. Okay, let's touch base, you know, at the end of the day and see where you're at. Now, obviously this is more towards coaching or sponsorship than counseling because we don't want to establish a dependency in counseling. But it is important that they have someone who can be there to touch base with them and help them maintain their level of tenacity. So asking our clients, who is it that can be there just to check in with? I told you in one of the earlier classes, one of my mentors said he would never do counseling with someone with an addiction because he'd be outnumbered. And I thought that was so strange, but he pointed out that the person with the addiction has the addicted self and all of the stinking thinking that goes along with that and the sober self. So you have two different cognitive approaches competing in the same mind. You can think of it as id and superego. You can think of it as wise mind and emotional mind. You can call it whatever you want to call it, I don't care. But when people have these, both of these voices, for lack of a better term, this battle going on inside their own head, they need an external person to say, hey, let me be a sounding board. Let me keep track or keep score of what's going on here for you. In their addicted selves, people tend to behave impulsively. So one of the things that goes with determination is helping people figure out how to get through that initial impulse of, I need it. I need it now. That knee-jerk reaction, the adrenaline rush, the emotional mind. You know, like I said, we can call it depending on your school of thought. You can call it a whole bunch of different things. It's impulsivity. How can people slow down and put on that filter and go, is this getting me to where I want to be next week, next month, next year? Recovery involves being able to forego the easy or immediate reward to achieve longer term goals. So thinking about that again, in recovery, in our addiction, people want rewards, reinforcement, relief right now. That's a lot of ours. I need to use that in something. Anyway, I digress. In recovery, people need to be able to say, you know, it would be really, really awesome to have this right now, but it would be more awesome to achieve this goal that's out here. So when they wake up in the morning, maybe they don't feel like going to work, it'd be really, really awesome to stay in bed and just, you know, call in sick today. But the long-term reward is wanting to get a paycheck at the end of the week and maybe wanting to get promoted in your job, helping people focus and find the motivation in those long-term rewards. Now, if the reward is too far out, like they're sitting in bed in the morning and it's raining outside and it's nasty and they just want to stay under the covers and telling them, well, think about the promotion you could get in 18 months. That ain't going to do it. We need to have a more proximal reward to that. What is it that can help them say, yep, I can do this. I can get out of bed and go to work. So forgoing the immediate rewards, and this is where the referee or sounding board or support person or whatever you want to call them comes in in the determination phase. It helps people figure out what they want to do and have the stick, stick to itiveness, have the cheerleader behind them. Like I had Stephanie behind me going, you got this girl. Just take a deep breath, put your head down. You're going to get through today. And then tomorrow it won't seem so bad, which takes us to resilience or the ability to bounce back. Resilience is something that we don't teach enough of, but people kind of do it naturally because as humans, we want to survive. We want to be resilient. We get sick, we bounce back. We have a bad day. Hopefully we bounce back. Most of us just don't unpack our stuff and stay in this place where we're miserable. Part of resilience is hardiness, and this is a concept that was proposed in the 1970s, but it's just because it was proposed way back when doesn't mean it doesn't have a lot of utility. Hardiness says that people are going to be more resilient, more likely to do something more motivated if they perceive it as having three characteristics. Commitment, control, and challenge. Commitment, they need to want to do it. Control, you know, we keep going back and forth about talking about how much control is too much control. They need to feel like they can affect a solution. If they do something, then something good is going to come out of it. If they feel like they've got too much control or the weight of the world is on their shoulders, they might get stuck. If they feel like if they do the next right thing, then good things will happen, then that's enough control. That means they have control over them and the universe will kind of fall in line most of the time. And challenge, why is it rewarding when something's challenging? Well, because if something's not challenging, you put it off till the very last minute, or, you know, you're like, eh, you know, it's not even worth exerting the effort to do that. Challenging says, hmm, I wonder if I can do this. So people have to have self-esteem and believe they can do stuff. They have to have to have a sense of self-efficacy to find something challenging. But think about things you've been motivated to do in your life, whether it be recovering from a car accident or an illness or getting through graduate school or parenting, oh my gosh, you know, these are all challenging tasks. So when you think about it, what is it that makes you go, I want to be the best that I can be? Things that come too easy is just like, yeah, you know, in graduate school, at least where I went to graduate school, you didn't get Ds or Fs, you knew you were going to get a C, a B, or an A. And that made it a little bit less intimidating to hand in papers and stuff, because you knew you were going to pass, it was just how well you passed. So it wasn't as rewarding as other classes. And in, you know, again, where I went to school, they didn't grade on a bell curve. So a lot of people ended up getting really high grades, because it was just like, you know, yeah, they turned in really good stuff, but they weren't going to rank us. We only had a cohort of eight, so it would have been a small bell. But anyway, things that are too easy, people just don't take pride in. They're just like, yeah, of course I got an A, or yeah, of course I got that. We want it to be slightly challenging so people can go, I did that. Thank you very much. We want them to feel like they have control over it. It's challenging, but it's doable. And we want them to be motivated to do it and have a commitment to see it through from beginning to end. So what are some of these qualities of resilience? Self-awareness and self-care. Healthy habits, vulnerability prevention. We talked about this last class, so I'm not going to spend a whole lot of time on it now. But you need to start with a firm foundation. Distress tolerance. If people are not able to handle distress, they're going to have a hard time bouncing back. You know, something's going to hit them and it's going to kind of keep them down. If they've got distress tolerance, they can tolerate a little bit of distress. Think about if you take a beach ball and you hold it under the water. You know, it is exerting force to get back up from under the water because of lots of physics. But when you let it go, eventually it finally bounces back up. Distress tolerance. People need to be able to withstand some adversity, but still bounce back up in the end and not exhaust all their energy or give up as soon as the road gets rough. Rational, accurate, cognitive habits. Not saying you have to wear rose-colored glasses all the time, but being accurate in your perceptions of what's going on, checking yourself. We all, you know, nobody is exempt from having cognitive distortions. It's whether or not you can check yourself on them and figure out what is actually rational and accurate that will go a long way toward self-awareness and self-care. People who have rational, accurate cognitive habits tend to feel less like the world is collapsing down in on them. Or the world is going to end. They tend to be less extreme in their thinking. Social engagement. Resilient people are socially engaged because our social relationships are one of our greatest buffers against stress. So what does that mean? That means that people who are resilient tend to be generous, not necessarily financially. You know, not everybody has finances to give, but they're generous with their time. They're generous with their emotions. They're generous with their compassion. They have integrity. They know what they stand for, and they are going to abide by that. They're authentic. I mean what I say and I say what I mean, you know, within reason. We don't want to hurt somebody's feelings, but we also don't lie, manipulate, omit the truth, those sorts of things. Humility and compassion for themselves as well as for other people. And that's crucial. Humility and compassion for themselves as well as others. And identifying as a survivor, not as a victim. You know, thinking about that beach ball again that was being held underwater, the survivor bounces back up out of the water. The victim goes down to the bottom. They're not a victim. They are a survivor. They came back. Uh, why are these qualities of resilience? Because people who have healthy social relationships and a healthy sense of self and values are more able to handle distress and more able to bounce back and not be taken down by one event or one something. People with resilience tend to have a sense of meaning in their life. They have a purpose. They're not just kind of ambly and aimlessly ambling along, going, eh, you know, I'll get up. I don't know what my purpose is. I don't know what my function is. I don't really know. I'll just kind of do whatever I'm going to do. On the, on the Kiersey or Myers-Briggs, I am like extremely structured. So just even thinking about that thought process makes my head spin. But people have a sense of purpose in their life, whether it's to be a mother or to be or a father or to be a school teacher or to be the best person they can be to be a compassionate human being. However, they define their purpose kind of sets the stage for what types of activities they're going to find rewarding. They have gratitude. And this is one of those things that an attitude of gratitude helps us focus on those little rewards, because sometimes the big rewards are way out there. But an attitude of gratitude says, Hey, it was a good day. The car didn't break down. I didn't get into an accident. Had a decent day at work. You know, nothing major happened. I didn't win the lottery, but it was a good day. People that don't have an attitude of gratitude tend to focus on all the stuff that, you know, did happen that was negative. Yeah, I got up. I went to work. I got stuck in traffic. I had a whole bunch of paperwork to do. And, you know, I came home and the dog had thrown up on the floor or something. Instead of focusing on, you know, the positive things and there's always positives and negatives. That's what you choose to focus on. Resilient people have hope. Think about the beach ball. You know, it hopes that you're going to let it go because then it knows it can bounce back up. It knows it can bounce back up. And yes, I'm personifying a beach ball. But, you know, let let that go for a minute. The hope that if you do the next right thing, you can emerge from any cocoon and come out of butterfly. Optimism, they feel good about it. There's hope. There's optimism that things are going to get better. They have a pretty good outlook on things, but it's realistic at the same time. Resilient people also have good attention and focus. And in early recovery, a lot of our clients don't have either one of these. Not because they're dumb, not because they're incompetent, but because their brain chemistry is all wonky from, you know, not sleeping for days on end or, you know, taking too many opiates or whatever the case may be. Attention and focus take a little while to come back into play, but we need to start focusing, if you will, on it. When I first started working in residential, I got really frustrated because people would come to group and they would sit there and kind of stare off into space. And I talked to my supervisor and I, what am I doing wrong? I am not engaging our clients. And he just kind of sat back and got his smirk across his face. And he said, how many of those people just came out of detox this week? I was like, well, most of them. He's like, and you really expect them to be engaged and excited. He's like, I am thrilled that they got out of bed. They came and they stayed awake. And I was like, oh, okay. You know, that's a different perspective, but that was all that they could do at that point in time. They were showing up and giving me as much attention as they could. And the fact that they were there, they were there on time. They didn't disrupt and they didn't go to sleep. Showed that they were trying to pay attention. Curiosity, you know, how can I get better? Tell me about this 12 step program. Tell me about this recovery strategy. Being interested in learning about how this fits for them. Instead of trying to dash everything and say, well, that won't work for me. That won't work for me. That won't work for me. I would rather people learn about different strategies and say, wow, that is really interesting. I think, you know, of this theory, you know, let's take dialectical behavior therapy, you know, these core concepts, I can really, they really resonate with me. Now, maybe the whole thing doesn't, but what can I take from that? Instead of just pushing stuff away, they're taking things out and they're owning them. Flexibility, the willingness to try things and the willingness to experiment a little bit because what you were doing before clearly wasn't working. So let's figure out what was working because some of the things worked. And let's figure out what you need to do differently now. So we want to talk about flexibility in their approach to recovery. Before you say no, say, tell me more. Before you say, I won't do that, say, you know, let me give it a try and dip my toe in. I'm not committing to anything, but let me explore and experiment. It's kind of like when, you know, we graduated from high school and we went off to college and we were trying to figure out what we wanted to be when we grew up. That's that curiosity and flexibility that I'm talking about. And then persistence, not every method, not every trick, not every tool is going to work for everybody. Not every thing you do, not every time you go to work, is it going to be a rewarding day? But being persistent and going, you know, eight times out of 10, it's a really good day. Or eight times out of 10, it's really successful. That's the persistence I'm talking about. Being able to tolerate the fact that very few things are 100% anything. So let's look for the things that are most rewarding most of the time. The same thing when we're talking about recovery from like depression. In the DSM, we talk about their depressed mood and they don't find pleasure in most things, most days. It doesn't say 100% of the time. It says most things, most days. So when we're in recovery, we want to talk about being able to find pleasure and happiness in most things, most days. Yes, they are going to have some down days. They're going to be days they get up and they just got up on the wrong side of the bed. People need to understand that that is normal. Everybody gets up on the wrong side of the bed sometimes and then figure out how they're going to deal with that. So understand that being persistent, just because they got up on the wrong side of the bed and they're grumpy and cranky, it doesn't mean they're going into another depressive episode necessarily. Now, they can probably work themselves into one real fast, but it doesn't have to mean that they can be persistent in their recovery activities. They have problem-solving skills and they know when to ask for help. Sometimes you go through all those ways to solve a problem that you know of and you're just like, I'm coming up empty, but my friend Jim Bob over here has a good head on his shoulders. Let me ask him if he has any ideas and they have a here and now focus in their addiction, in their mood disorder, a lot of people are focusing on the past or the future. They're regretful, resentful, guilty, angry about stuff that already happened, that they can't change, or they're worried about stuff that hasn't even happened yet. So they have a bunch of energy that's just tied up outside of the here and now. In 12-step recovery, we talk about if you have one foot in the past and one foot in the present and the future, all you're doing is squatting on top of the present and there are various forms of that saying. Helping people figure out how they can focus on the here and now and that takes practice. Helping our clients practice that when they get upset, when they're in session, as well as when they're out of session, bringing them back and going, okay, you start having a bad day, how can you step away from it for a moment and figure out what the here and now is all about and figure out what part of the past you're letting creep in or what you're getting anxious about that hasn't even happened yet. For some people, it means journaling for other people. It means going on a walk and thinking for a minute. How can your clients do that? So we want to really develop this quality of resistance, resilience, not resistance, resilience in our clients so they can resist relapse. Nothing is done all the time. And I'm sure you can find an exception to that, but in large part, when people do a behavior, it's not all the time. They're not always screwing up. They're not always late for work. There are probably days where they've been either not as late for work or they've actually been on time. What was different? Exceptions are what people were doing when they were not engaging in the target behavior. So you have a client who is, you know, has just moved into that land of self pity, and it feels like they are always focusing on the done me wrongs. So we want to say, what are they doing differently when they're not focusing on those? What is different and help them focus on that? When they're talking about how there's families always mean to them, okay? They may be unusually aggressive or whatever word you want to use. Was there ever a time when they weren't mean to you, even if it was just for like a phone call, what was different? So there are different ways to identify exceptions. Ask them before this problem started, before the depression kicked in, before the addiction started, what was different? How did you deal with stress? We know that that garbage term stress, anger, anxiety, depression, whatever, all comes back to, or all underlies most of our major mood disorders and addiction. So when we talk about stress, it's just kind of one of those generic terms we use. So we don't have to go, okay. Back before you started doing this, how did you deal with depression? How did you deal with grief? How did you deal with resentment? That's long and tedious. If you say stress, we'll get a good idea about what their coping skills were. Ask them in the past six months, when you're in a situation where you were not engaging in the target behavior, and obviously I put little brackets around that because you want to say when you were not depressed, what was different? How did you deal with stress? How did you deal with these other things? Those are their strengths. That's what they already do. So let's build upon those, help them identify exceptions so they can see that it's not always happening. If somebody says they're constantly eating, well, you're not constantly eating. You don't eat when you're asleep. Most people don't. I mean, there are a couple of disorders there where people actually do sleep eat, but for the most part, you're not eating when you're sleeping. When else are you not eating? I don't eat when I'm in the shower. I don't eat when I'm in the shower. I don't eat when I'm at the gym. I don't eat when I'm and fill in the blank. And those are the times you want to extend. So if somebody is trying not to be eating constantly, trying not to be grazing or smoking, smoking is another example, you say, okay, when you get the urge, let's take smoking. When you get the urge to smoke, if you don't smoke in the shower, if you're at home, go take a shower. If you're at work, when you're not smoking, what are you doing? Let's do that more. You know, go talk with a friend. Yeah, depends on where you work, what you can do when you're at work to prevent that kind of a behavior. But there are alternatives. Is it the panacea? No. All you're doing is helping the person get past that craze. There was something that triggered that craving that still needs to be dealt with, but we do want to help them figure out how they already deal with cravings and urges. And then we can start figuring out, you know, what's triggering you and how can we deal with that? Once you identify these exceptions, help the client strengthen those. I had a client way back when he used to smoke marijuana a lot. And he was like, okay, I'm going to do that. He used to smoke marijuana a lot. And he was overweight and he was on blood pressure medication and he was on probation. And we talked about it and he really didn't want to give up smoking weed. And I'm like, well, okay, there are a couple problems with that. You don't want to go back to jail either. And you don't want to lose your kids. And smoking weed gives you the munchies, which is contributing to your weight problem. So let's talk about when you're not smoking weed. What are you doing? Because while you're on papers, which is when you're on probation, while you're on papers, you can't be smoking weed or you're going to come up dirty and you're going to end up back in jail. So we talked about it and he said, well, you know, when I'm around my kids, I don't smoke. And I said, okay, so what do you do when you're with your kids? And he talked about going over homework and playing basketball with them. And I was like, okay. So, oh, and his significant other also was an active user. He said, and I'm not around her. I said, okay. Well, he wasn't ready or willing to address any issues with her use in the house. But he was willing to start spending more time with his kids because he really enjoyed spending time with them. So long story short, low and behold, six months later, he had started spending a lot more time with his kids. He had gotten the courage on his own to ask his significant other not to smoke weed in the house. He's like, you know, you can do what you want to do, babe, but I can't have it around me right now. And so she quit smoking weed in the house and he had ended up because he was spending more time playing ball and doing homework with his kids and stuff, losing enough weight where he had cut his blood pressure medication in half. You know, so we want to figure out what people already do, what they like to do, and what's motivating for them because they'll do those things. My initial relapse prevention plan wouldn't have been, you know, so you don't smoke weed. Let's see. You're going to play ball with your kid two hours a day. Yeah. That wouldn't have been something I would have come up with right away, but their relationship improved and the kids grades improved. And it was just a good thing all around. Did he go back to smoking weed? I don't know. You know, I discharged him before he got off of probation, but the entire time he was with me, he was clean. And he had seen the benefits and he was really excited about being in better health and feeling better. Encourage the clients to do those exceptions more because if they're not engaging in the target behavior, which we'll call the dysfunctional behavior, that means they're not feeling the need to engage in that escape or numbing or rewarding behavior because something else is equally or more rewarding. Ha. Strengths and vulnerabilities. Get that sleep in there. Nutrition. They need to have good nutrition. If they are vegetarian or even if they're not, I really recommend each person at least read up on nutrition, but ideally get a consult with a nutritionist to make sure that they're eating a healthy diet. You remember the quick tips I had for you before, so clients don't get too bogged down, use a salad plate, only eat when you're at the table and have three colors on your plate at every meal. If you do that, your nutrition is probably going to be pretty good and you're less likely to overeat. Medication. They need to make sure every doctor knows all the medication and supplements that they're taking because these can interact. They can also have side effects. If somebody comes in and they're reporting, being tired all the time and hungry all the time and thirsty all the time, you know, a doctor might think diabetes. But then you also might look at, you know, what medications that they're taking and if they're taking a certain atypical antipsychotics, those are side effects of certain atypical antipsychotics. So we might want to look at how to deal with those side effects or change, have them talk with their doctor about changing their medication. Chronic pain is not good for anybody. Have them talk with their doctor about different ways to deal with chronic pain other than or, you know, in addition to opiate-based medications or gabapentin, which is not an opiate, because those medications tend to make people sleepy and they tend to have a high risk of addiction with them. They need to be aware of their hormone levels and it's not just women. Men can get hormonal too. There's been a really big trend lately and I'm not sure why of men starting to get testosterone injections. Now just let that sink in and you can imagine what the side effects are. You know, we have people that are experiencing basically like mini-roid rage. Men who are getting more testosterone than they've had in a while and they don't know how to deal with the effects, the emotional effects, the cognitive effects that happens when the testosterone levels go really high. I mean, you're taking a 35-year-old man and basically turning him into a 16-year-old again and it's like, oh, hold different ballgame, hold different animal. When testosterone is too low, people are going to have effects, you know, depression, anxiety, lethargy, those sorts of things like when women have too much estrogen. So if they don't have too much testosterone, they don't have enough testosterone. It's not balancing out the estrogen. So, you know, and there's progesterone and all kinds of other hormones in there too. My point is being hormonal is not just a woman thing. It isn't everybody thing and we need to keep our bodies in balance and for thinking about or looking at depression or anger management issues, that's where my mind goes first. Let's go get, go see your doctor, get a blood panel, make sure your thyroid and your hormones are, you know, where they're supposed to be. Social supports can be a strength or a vulnerability. You know, some people are awesome social supports and some people just suck the energy right out of you. Does it mean you have to get rid of the ladder? Certainly not. You know, I'm not going to kick my friend to the curb just because, you know, every other day, he's got some kind of a crisis, but I also have to learn how to set healthy boundaries and say, you know, I'm really sorry that your life is in turmoil right now. I'm here to listen. I'm here to, you know, be a friend, but I am not going to repel down into that dark well with you and stay there for days and weeks on end. Relapse warning signs are the way people act when relapse is imminent. So if they're paying attention to their vulnerabilities, they're paying attention to their health and wellness, they're living with integrity, they've got support systems, they're being all kinds of resilient, that's great. But you know, sometimes life happens and all of that stuff starts to feel overwhelming and kind of get jumbled. Relapse warning signs are the way people act when relapse is imminent. So what were they like when they were in their addicted self? One of my favorite activities to do in, you know, in residential recovery and early recovery, because it's one people can, doesn't require a whole lot of, you know, conceptualization. Tell me what you were like when you were in your using state of mind, in your addicted self. And they'll come up with all kinds of things like impatient, they'd withdraw, they would snap at people, they would lie, manipulate, rationalize, deny, all those things. Have them write it down. And then I'd have them write down, tell me what you're like in your sober self. Tell me what you see, what do you envision a healthy you being like. And, you know, we go down this list of things. And some of them they're going to have to work on, like patients. That's what we all have to work on though, it's not just people who are recovering from mood or addictive disorders. But I want you to tell me what your sober self looks like. This is something they share with their sponsor, with their social supports, and with themselves. They can go over this list every day. I recommend for the first three months they go through it every day when they're doing their self check-in and go, okay, which of these addictive behaviors am I holding on to today? And why? And which of the sober behaviors am I holding on to or could I start using? And how do I do that? In relapse prevention, mindfulness and self-awareness is just so crucial. I recommend the first three months, people do a morning self-check-in and an evening self-check-in. So they know how they're starting the day. They know how they're ending the day and they can figure out from there what needs to happen. The next three to six months doing a check-in either at the beginning or end of the day depending on what feels best for that person. And then after that, you know, for the next year or so, at least once a week, doing a really thorough self-check-in to make sure that they are using their healthy wellness tools. They're checking in. They are not on autopilot. Even if they've been on autopilot for a week, it's not too late to turn back on and take over the controls. But it is important to realize before you start flying into a cloud bank. So when behaviors of their addictive self start to emerge, it's a warning that their current strategies are not working. Current skills and strategies are not being used in lieu of old behaviors, which means the old ones are more rewarding. I mean, yeah, we know that they may be easier in some ways, but in the big schema things, it's really not. They need to play the tape all the way through. Yes, I had a really bad day today. If I went to the bar and I had a couple drinks, it might help me relax, play the tape through. But I know that I probably won't just have a couple of drinks and I'll keep drinking and I'll blow my whole paycheck and then I'll go home. I'll be drunk. My spouse will get mad. They'll kick me out and, you know, yadda, yadda, yadda. So the initial reward, yeah, but that's not the whole tape. You got to play the tape all the way through and see what the long-term consequences are. Play the tape through. Remembering my happy little decisional balance exercise as clinicians, as coaches, as people in recovery, we need to figure out the benefit to the target behavior. Whatever it is that the dysfunctional behavior you are doing, those benefits need to go away. You know, it helped you relax. Okay, what is more rewarding when you play the tape all the way through? There are some other ways that you can relax that don't have those negative outcomes. So we need to take away the benefits to that dysfunctional behavior. And we need to take away the drawbacks to the new behavior. Okay, so exercise. Maybe if I went to the gym after I had a bad day, it could help me relax, but, oh, getting to the gym. That means I got to go home and I got to pack a bag and I got to get changed and yadda, yadda, yadda. That's just too much work. Keep a go bag in the back of your car. So if you have a bad day, instead of going to the bar, you can go to the gym. It doesn't mean you have to, you know, work in your target heart range for, you know, 45 minutes. Maybe it just means you go and you sit in the hot tub. But that's a whole lot better and more relaxing long-term than going to the bar. So we need to take away the drawbacks or excuses for not using the new behavior and take away the benefits of the old behavior. That's why they're in red. And then we need to pump up the benefits to the new behavior and maybe the drawbacks to the target behavior. So the benefits to going to the gym, you know, you sit in the hot tub, relax all your muscles. You're probably going to sleep better in a better mood and maybe even your spouse can meet you at the gym and you can, you know, sit in the hot tub and chat about your day and whatever. It's all about tipping that decisional balance. Motivation is multi-dimensional. So when we talk about tipping the decisional balance, we need to talk about all of the reasons, not just the really obvious ones. What are the emotional reasons that this is more beneficial? You know, what are the rational, cognitive reasons that you want to do this? What are the physical reasons you want to do this? You know, long-term health, not dying early, not getting a communicable disease, but also pain reduction, you know, being more awake and alert to spend time with your kids, whatever the case may be. The social dimension. What are the social rewards for these new behaviors? Who are these new friends that are so awesome to hang out with? What are the benefits? And the environmental dimensions. When you are in your sober self, you're going to be in different environments probably than you were when you were in your addicted self. What is awesome about these environments? Now, remember, not every addicted environment is scary or dirty or, you know, we're not talking about just flop houses. There are some very, very wealthy, well-off business people and very smart people who have addictions. And that's not the kind of environment, you know, hanging out at the country club, drinking martinis or whatever they do. That's not an environment that someone in early recovery needs to be in. So let's look at what this new environment looks like. Tap into as many of these cognitive, or as many of these motivational dimensions as you can in order to make the motivation stronger. It'll feel better, it'll make you happier. It's the right thing to do. It goes along with your integrity and your perseverance and all that kind of stuff. You know, really make a case for the new behaviors. Well, actually better yet, really have the person, your client, make a case for these new behaviors and against the old behaviors. It'll mean more if it comes from them than if it comes from you. Remember that motivation is changeable. Pre-contemplation, I ain't got a problem. You can't tell me I have a problem. I ain't going to do anything about it. Contemplation, yeah, I may have a little bit of a problem, but I got it. I don't need your help. Preparation means people are saying, yeah, you know, I've got a problem. I may need some help, but let me see what my options are. I'm not ready to do anything quite yet. And then action is when they choose and they start doing something. Maintenance is when they've learned these new skills and they've got to put them into practice. Relapse is not a requirement for recovery. Now, there will be slips here and there where cognitively they start going backwards. But if we encourage clients to really develop a good relapse prevention plan and stay mindful continuously of where they're at, what they're doing, what the triggers are, a full-blown relapse is not necessary. Will it happen in a large portion of cases? Yes. And when people relapse, they come back and I say, okay, what did we miss? What happened that this got by you? You know, it's not a time for blaming. It's a time for tuning up the relapse prevention plan. Motivation is not linear. Mindfulness will help people identify when their motivation is waning. Some days you may get up and you're going to be like, I have got the world by the tail. And I've got this. I've got recovery. I'm looking forward to meetings. Other mornings, the person's going to get up and go, I really, really wish I could just stay in bed and sit on the couch and drink and watch TV all day. Does that mean they relapse? No. Does that mean they're headed down a relapse path? Yeah. So we need to look at why their motivation is waning. What is not rewarding and how can we start to address that? In treatment, you'll have people that will come into treatment and they will be like, I am here. I'm going to do this. I'm going to get it right. I'm going to recover yada-yada. You know, their first week in there, they are going gangbusters. Their second week in there, they're talking about leaving AMA. They don't have a problem. Their problem is not near as bad as anybody else's in here. That's that motivation waning. They're going back to pre-contemplation because it got painful. And the pain of recovery overcame the pain of addiction and they're like, no, I'm going to go back out to where it's safe. As clinicians, it's up to us to say, okay, let's put on the brakes here. You were doing great last week. You did all these things. What changed? And you know, where do we may—where maybe do we need to back off a little bit? What changed? Relapse prevention planning means developing a plan that minimizes vulnerabilities. You can't eliminate them just like you can't eliminate triggers. They need to be aware of triggers. They need to be aware of what a craving feels like and they need to have an emergency plan. Because when that craving hits, the cognitive part, the wise mind, ain't there. When the craving hits, they're craving. So what do they do? You know, for lack of a better analogy, it's kind of like when you've got a child and that urge to go to the bathroom hits and they're like, mommy, I got a peepee. And you're like, okay, you got to wait for a few minutes. No, mommy, I got a peepee. That urge hits and they've got to do something about it. So it's not the time to say, okay, well, let's, you know, sit back and talk about it. It's the time to have a plan in place. On their index card, on their cell phone, something that they can look at and go, I need to call so and so. I need to go to a meeting. I need to remember people can go to 12-step meetings online at in the rooms. I think it's .org. Just Google in the rooms and it comes up. So even if they can't get to a brick and mortar meeting, they can get to a meeting. But recovery also has online meetings that people can go to. So they're never alone. They never have to be alone. It may not be their social crowd of choice, but there is a safe place, you know, using that term kind of loosely that they can go to. Relapse prevention planning incorporates mindfulness and I don't necessarily mean meditation. Some people don't like that term mindfulness or meditation. It incorporates self-awareness. Do they know where they are, how they feel, what they can do? And that emergency response plan. So thinking back over the past week, what are three ways that or three things you might have used in order to help your clients avoid relapse? And if you are a clinician who works with people that mainly or their main presenting issue is mental health, you know, that's fine. Relapse is relapse is relapse. So what are three ways or three things you could have done differently with them or you could have helped them do differently? You know, and maybe some of this stuff you already knew, but we're just kind of pulling it out of the archives and going, oh yeah. I remember when we talked about that in graduate school. You know, part of continuing education isn't necessarily about teaching brand new skills. It's about building on the skills you have and dusting off some of the tools that you haven't used in a while. People in recovery have determination, resilience, and understanding of the exceptions to the negative behavior. What can I do instead? And awareness of their vulnerabilities and relapse warning signs. They're personal ones, not just general ones. And they're motivated to live a recovery lifestyle emotionally, mentally, cognitively, physically, socially, and environmentally. Social factors, peer pressure is huge. It can suck people back into addiction or it can keep them going on the recovery path. Relapse prevention planning minimizes vulnerabilities, incorporates mindfulness, wow. And contains an emergency response plan.