What is a mental health relapse?

By David Joel Miller

Do people with depression, anxiety or emotional problems relapse?

Wellness and Recovery

Wellness and Recovery
Photo courtesy of Flickr (Portland Prevention)

The term “Relapse” is increasingly being applied to mental illnesses and for good reasons.  Many people are familiar with the idea that people with a substance use disorder, alcoholics and drug addicts can relapse. The idea that people with a mental illness can relapse is becoming a recognized part of the mental (or behavioral) health field.

Wellness and recovery.

We know more now than ever before about mental and emotional illness. Professional’s no longer think of the mentally ill as somehow different from others. We now know that them is us. In their lifetime half of all Americans will experience the occurrence of an emotional or mental health problem that meets the criteria for a mental illness.

Looking at mental health issues as chronic conditions rather than once and forever problems has helped us to understand how someone with a mental health issue can “relapse.”

Mental health and illness lie on a continuum.

There are not two discrete groups, the well and the ill. People who appear to be emotionally and mentally well may gradually develop symptoms. Disorders can come on suddenly or slowly. People with mental health issues can and do recover. They get better.

Along this continuum people can move from unwell (ill) to less unwell to well. Others can move from well to unwell. Across your lifespan you will probably make many trips back and forth on the continuum. You get sad and depressed or anxious and then you get better.

People can have a mental illness and then get better.

For professional treatment we have set the point at which people get diagnosed as mentally ill very far over on the continuum. Your condition needs to interfere with school or work, prevent you from having good relationships, upset you or impair some important part of your life for it to be diagnosed as a mental illness.

Plenty of people get life problems that almost, but not quite reach the point of being mental illnesses. These people benefit from counseling also if they are able to get some. For milder issues (subclinical) self-help books, blogs like this one, religious and social activities and so on can help them maintain their mental health.

Mental illnesses are often chronic conditions.

Mental and emotional issues are a lot like being overweight and developing type two diabetes. Once you have been diagnosed as a diabetic it is unlikely that this will come off your medical file. You may take medications, exercise and watch your diet. All those things may get your blood sugar back under control.

With chronic conditions, and mental and emotional disorders fit this pattern well, even once you recover there will be things that you need to do to keep your condition under control.

Our understanding of the need to do things to maintain mental health recovery is informed by the stages of change model. See Stages of Change for a list of all the posts on this process.

In that model we discovered that when someone recovers from a condition, excess weight, substance use, depression or just the normal problems of life, there are things that they will need to do to maintain those changes. We call that recovery the “Maintenance steps or Maintenance Stage of Change.

People with mental illnesses do relapse.

By relapse I mean a return to symptoms or an increase in symptoms that were previously under control. Sometimes that relapse is a result of new life events. Someone with PTSD or complex trauma may experience another trauma or something that reminds them of past trauma.

Someone with depression or anxiety may have an experience that is sad or makes them anxious. As these levels of emotion rise the person may become overwhelmed. If their support system is not being supportive or their coping skills are overwhelmed then the person moves to being less well, less able to cope and they may experience another episode of whatever we chose to call their mental or emotional issue.

This continuum of wellness and the possibility of recovery is easier to see when we talk about relatively well know conditions. Anxiety, the most common of all mental illness, and depression, that cousin of sadness, are good examples of how the journey from wellness to illness and back may occur.

We have all experienced some anxiety and can see how it may get better or worse. Depression is understandable. Sometimes in life we get sad, if we get too sad or stuck there to long that might turn into Major Depressive Disorder.

What about really serious mental illnesses, the ones were it is harder to understand the symptoms. Do people with Borderline Personality Disorder, Schizophrenia or Dissociative Identify Disorder ever recover?

There sure do. There are treatments for all those conditions. Most of these treatments are skills based. Someone who hears voices all the time, they can learn to listen to the police officers voice and not the one in their head. This is not easy, it takes lots of skill development and practice, but many people with even the most serious of emotional issues do recover.

Do you get the picture that I and other mental health professions are coming to be strong believers in wellness and recovery? Recovery happens. If recovery happens, sometimes there may be a return of symptoms. When that happens we expect a return to doing the things that helped the first time to help them recover even faster than the first time.

If there are other skills they need to learn, well during a relapse is a really great time to try out new skills and find a way to create your happy life, however you define it.

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Get the latest updates on my books, due out later this year by signing up for my newsletter. Newsletter subscribers will also be notified about live training opportunities and free or discounted books. Sign up here – Newsletter. I promise not to share your email or to send you spam and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books  

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Is relapse a part of recovery?

By David Joel Miller

Is relapse a necessary part of recovery?

Relapse Prevention

Relapse Prevention

You will hear this a lot if you hang around treatment facilities, even self-help groups. I suppose it comes from seeing people relapse and feeling helpless to prevent those relapses. But is relapse really a necessary part of recovery?

Mostly this is applied to substance abuse, drugs and alcohol, but more and more we are seeing that other emotional, mental and behavioral challenges can follow the same processes. People get unhealthy; they may get sick and then they recover.

Do symptoms have to get worse before they get better?

Every time one of my colleagues says that relapse is a part of recovery I cringe. It feels like saying that heart attacks are a part of treating heart disease. I do not believe that good treatment should accept any negative outcome as a part of the recovery process.

Relapse is common, but it is not universal. Some people, more than you might think, recover and never relapse.  A surprisingly large number of people report that they were able to quit drugs, get over their depression and anxiety and stay quit and recovered.

So how do they do recover without relapse?

We need to talk about several things. What is recovery, what is relapse, and how do people go about changing?

Emotional challenges and substance use problems are a lot like chronic physical disorders. If you have had a stroke there has been same damage done. If you have been diagnosed with diabetes you will never be “cured.” Some changes will always remain as a result of you experience.

While you will never be “cured” you can, and most people do, recover from that disorder. The same thing happens to those people who have had an emotional or substance use disorder. They can and do recover but they are never fully cured. There is a risk that if they are not careful they may slip back into an active stage of their problem but if they are vigilant about their recovery they do not need to keep getting sick again and returning to their provider to again and again be treated and recover over and over.

These ideas about substance use problems and mental health problems are both included in the The Big Book of Alcoholics Anonymous. Bill W. wrote about the issues that those with Bipolar disorder will face that may make their recovery more difficult than that experienced by people who do not have an underlying mental health disorder.

Bill W also wrote that in the early days of those who came to the program and stuck (meaning actually continued to attend and participate in the program) 50% quit drinking forever. That does not sound to me like he believed that relapse needed to be a part of recovery.

He went on to report that of the remaining half about 25 % had to quit a few times to get it right but those people did eventuality stop for good.

What about that last 25%? The big book reports that while some people never did mange to stay stopped those people, while attending A.A. were much improved. I take that to mean that while the treatment for a mental or emotional problem may not fully effect a cure, reducing your symptoms is a way to reduce the harm that a mental, emotional or substance use problem creates.

These days we are applying the stages of change model to both mental health and substance use disorders. Take a look at some of the books on how people change such as Changing for good.

Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward

I have written posts in the past on this model and how it can help you change and stay changed.

In this model we see that people need to recognize they have a problem, gather information, get ready to change and then go through the process of making real meaningful changes in their lives. In this model we see that maintenance, those things you need to do to stay changed once you have made a change, those maintenance steps are the key to preventing relapses.

Relapse is a failure to maintain recovery.

Relapse is not a part of recovery, but the result of failing to continue doing the things that helped you get better in the first place. Whatever you did to get your emotional problem or substance use issue in remission in the first place, those actions need to continue to be a part of your life if you want to insure yourself against relapse.

If you do relapse, do not beat yourself up. Get back into recovery and practice the things you need to stay well. Just know that repeated relapses do not need to be a part of recovery if you practice your maintenance program.

Want to sign up for my mailing list?

Get the latest updates on my books, due out later this year by signing up for my newsletter. Newsletter subscribers will also be notified about live training opportunities and free or discounted books. Sign up here – Newsletter. I promise not to share your email or to send you spam and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books

 

What causes an eating disorder relapse?

By David Joel Miller.

Relapse PreventionCan we predict who will have an eating disorder relapse?

People who work in the recovery field are struggling to figure out how relapses on mental health issues are like and how they are different from relapses involving substance abuse.

Eating disorders are a strong example of that difference.

With substance abuse, most authorities think any return to using or drinking constitutes a relapse. Some authors have tried to differentiate a “Lapse,” a single case of starting to pick up followed by a decision not to return to active use, from a relapse.

Most recovering people are uncomfortable with the idea that any case of picking up can be excused. Rule one for their recovery is “Don’t pick up.” Still if you do relapse the sooner the return to recovery behaviors the better the chances.

With eating disorders we understand everyone needs to eat, many of us may worry about our weight and sometimes do something excessive to control that weight. To be a relapse on an eating disorder we think we need to see not just one incident but a return to the overall pattern of bad relationships with food.

That part of an eating disorder relapse is similar to relapse to other disorders. The relapse begins before the picking up or purging behaviors. It begins with changes of thinking and failure to maintain your recovery.

Four key factors appear to predict who will have an eating disorder relapse (Per McFarlane et al 2008.) These factors may have an application for other mental health challenges.

1. How bad was the eating disorder before treatment?

The more severely affected the person was the more it will take to change those behaviors. People who have been starving, binging or purging or even overeating for decades do not become cured overnight.

They may make significant progress in a short period of time but they will need a lot more time to consolidate those improvements if they have had the disease for a long time and the symptoms have gotten severe.

2. Higher level of eating disorder symptoms at end of treatment.

This makes intuitive sense. Someone still running a fever is at more risk than someone whose temperature has returned to normal to relapse into a physical health crisis.

The more the urges and cravings, the harder it will be to continue on the path to recovery and not lapse back into old behaviors.

Sometimes professionals are in too much of a rush to fix people and we may send them out of treatment before they are ready. With eating disorder symptoms the more there are and the larger the symptoms are the more the risk of relapse.

Pressure from managed care systems to cut costs is once source of the rush but there are others. Patients want to get this over with and get home. They often think they were cured when the professional known the symptoms are not even all gone yet.

3. Slow response to treatment predicts an eating disorder relapse.

Clients who enter a 28 day program need to hit the ground running. There is no time to waste. Unfortunately many are still not sure they want to change or that they really have a problem. In drug treatment it is not unusual for clients to avoid treatment for the first thirty days. Somewhere along the way they see others getting better and they want that result for themselves.

Eating disorder clients who do not start to make progress until three weeks into treatment will not be better, regardless of what that scale says, at the end of the 30 days.

Clients who are slow to respond to treatment need longer to consolidate gains and they are higher risk for relapse which means they need more support as the treatment frequency decreases.

4. Higher weight related self-evaluation predicts relapse.

When your idea of your self-worth is based on an outward characteristic, like weight, it is hard to give up any control over your eating no matter how slight the risk.

This whole area of self-evaluation is a cause of a lot of mental illness and just plain unhappiness. Learn to like yourself for who and what you are inside and anyone who only likes you for your outward appearance is not worth your time.

Selling people things is big business. Sell people on the need to have and eat certain foods, sell them on the joys of eating large and high calorie foods, make extra fat a standard menu item on fast food menus and you will make money. Then when we get done selling you high calorie food we tell you it is your fault that you have gained weight.

Don’t buy the yo-yo. Learn to eat healthy in the first place but accept that no one keeps that elementary school figure without giving up a lot of life.

There is a whole lot more inside you than what will show on the scale. The secret to happiness is in keeping your life in balance, not in winning the prize for self-deprivation.

People who think their self-worth is all about their weight will never get happy. Get happy first and you will like yourself regardless of your weight.

Want to sign up for my mailing list?

Get the latest updates on my books, due out later this year by signing up for my newsletter. Newsletter subscribers will also be notified about live training opportunities and free or discounted books. Sign up here – Newsletter. I promise not to share your email or to send you spam and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books

Getting some recovery – preventing relapse

By David Joel Miller.

How do you get this recovery thing?

Relapse Prevention

Relapse Prevention

Moving from being “in the problem” to being “recovered” is a process. Many of the things that will take you from the pain to the solution are simple. That does not mean they are easy. Sometimes healing from the past can be painful also.

In past posts we have talked about Defining Recovery and how recovery is possible for anyone, and that recovery means having the best life possible not necessarily a cure from your condition.

In another post we looked at Why giving up the drugs and alcohol might not make you any happier. Just trying to not do the negative or dysfunctional behaviors will not be enough. Recovery literature talks a lot about using “recovery tools” (see: Getting your tools dirty) and things like internal and external triggers.

What may be missing are the blueprints for creating recovery.

Reader Sue made the following comment.

How exactly should one get their recovery tools dirty? Giving up something that is bad for one, you do expect to feel better but when you don’t you feel disheartened. What’s left is yourself and your problems. So you read all the self-help books and try and work on yourself but how do you connect the practice to the theory? All those learned responses and ways of coping are very hard to unlearn – is it about keeping a record, making new goals or just trying to get through without going backwards?

There are a lot of recovery processes in use today, 12 step models, CBT & REBT therapy’s, counseling and so on. They all have their place and they all have some common elements. Here are some basic steps for transforming your life from being hopeless and suffering to having a healthy recovery.

1. What is the problem?

You don’t get chemotherapy for depression or a drinking problem. Drug and alcohol treatment is not very effective for cancer. Make sure you are treating the real problem.

For most people who come to treatment for an addiction problem the drugs and the alcohol is not the problem! The drugs and alcohol are their solution. The real problem is that their coping method, drinking or drugging to ease the pain, is not working. The problem has become that they don’t know how to live without the drugs and alcohol.

Part of defining problems is to admit that your efforts to control the problem have not been working. This is sometimes referred to as “Powerlessness” which is not the same thing as being helpless. Applying this concept of powerlessness to ways to cope with family members who have the problem was the subject of another blog post.

Mental illnesses can play the same role. Depression, anxiety and dissociation can all function to avoid a painful life experience. The current problem, the one you need to solve first is how to live life without drugs, alcohol, depression, anxiety or any other negative coping mechanisms.

Most of the time we think the solution to drugs and alcohol is to just stop doing them. This rarely works. Once deprived of your coping mechanism people just suffer. The most effective treatment is to replace the substances with something positive. With clients that I work with we start by creating a Happy Emotional Life Plan (HELP). As a counselor I believe I am in the happy life business.

With emotional issues, as with eating disorders, it is a little more difficult. You can’t just give up sadness or anxiety and you have to eat and stay healthy. You need to learn to feel feelings without having them control you.

2. Are you ready to change? What help will you need?

Self-help groups talk about recovery being a “we” program not an “I” program. You need to be willing to accept help and support from any source that is healthy. Counselors, Therapists, 12 step groups all can assist in your recovery.

3. Change requires moving through a process

Twelve step programs refer to “working” the steps or “taking” the steps. Counseling involves some self-examination. To really change requires a lot of action steps. For a detailed description of the process see the series of posts on “Stages of Change”

Pre-contemplation
Contemplation
Preparation or determination
Early Action
Late Action
Maintenance

4. Even after you have changed there is more work to do.

For change to be lasting you will need to do some sort of maintenance. Our old behavior patterns are deeply grooved into the structure of our life. It takes work to avoid falling back into the same old groove.

5. Progress not perfection.

People in early recovery try to do everything now. They want to do recovery, get a job, find a new relationship and generally create the perfect life all in one week. Learn to take things “one day at a time.”

Relapse, in my view, may not be a required “part of recovery, ” but it happens often enough that it is nothing to beat yourself up about. If you relapse on substance or depression, just get back into recovery as quickly as possible and move on.

The goal, as the old saying goes is “progress not perfection.” Keep your eyes on the gains you are making, give yourself credit for anything well done and try to build on small successes until you create the bigger ones.

Life in recovery is a sort of experiment. We try things and learn from our efforts. Try to avoid experiments that result in a lot of pain or require time behind bars, but you will have to make choices and some of those choices will not work out the way you would have hoped.

This is a real life, sometimes I like it sometimes I don’t. Learning to sit and feel badly and know this will pass, but I can tolerate this feeling without using my negative coping mechanism.

So yes Sue recovery is about trudging forward, trying on new behaviors and sometimes it is hard or painful and sometimes we fall back but always keep track of what works and what doesn’t and keep moving forward.

Want to sign up for my mailing list?

Get the latest updates on my books, due out later this year by signing up for my newsletter. Newsletter subscribers will also be notified about live training opportunities and free or discounted books. Sign up here – Newsletter. I promise not to share your email or to send you spam and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books