The Better Mood Recovery Program, Week 12

RELAPSE PREVENTION

“Depression is recurring and cyclic. What we have is treatments, not cures. You're never really free of it; you are always living in the shadow of it. You always have to be prepared for a recurrence and be ready to stave it off.”

—Andrew Solomon, author of The Noonday Demon

Twelfth Week Overview

In this week you will learn the basics of relapse prevention—how to identify and respond to outer and inner stressors so that emotional stability can be maintained.

If, like myself, you are a fan of romantic movies from the golden years of Hollywood, you are no doubt familiar with those fairy tale endings where conflicts are resolved, lovers are united and everyone lives happily ever after. For many years, I believed that this kind of resolution could be applied to recovering from depression. I remember becoming euphoric the first time I emerged from a depressive episode. “Never again!” I emphatically proclaimed. I was sure that the demon of depression had been banished forever.

But the demon was not gone. Seven years later, and ten years after that, the disorder returned with a vengeance—catapulting me into three hospitalizations and one suicide attempt. Slowly, I faced the sobering truth, that surviving an episode of depression is not like having the measles—one does not develop an immunity to the disease. Although the symptoms of depression can be controlled, the underlying predisposition does not go away. While it is true that some individuals experience just one major depressive episode in a lifetime, half of those who have been severely depressed are at risk to become depressed again.

What can a person do to decrease the likelihood of having another depressive episode? The first step is realize that recovering from depression is not a one-time event but an ongoing process. While utilizing the tools of the better recovery mood program can help our brains and nervous systems to stay well, there are times when powerful external stressors or internal biochemical anomalies will disrupt the brain's delicate balance. In such instances, we need a plan for identifying and responding to symptoms before they get out of hand and lead to another breakdown. This process of nipping depression in the bud is known as “relapse prevention.”

Relapse prevention can be compared to steps in fighting off a cold. When you first feel yourself coming down with a cold or flu, the proper response is to drink tea, take vitamin C and rest. If, however, you ignore these early warning signs and continue with your busy life, the cold might enter your lungs and turn into bronchitis. If you continue to ignore your body's cry for help, the infection may penetrate deeper into the lungs and become pneumonia. If the case is serious enough, you'll have to be hospitalized.

In a similar manner depression can easily “sneak up on you” if you are not paying attention. Fortunately, having a depressive breakdown does not occur overnight. Clinical depression is a gradual process of falling out of recovery, ultimately leading to the inability to function. By regularly monitoring the state of your body, mind and spirit, it is possible to identify relapse symptoms early on and take action to prevent a return to major depression. In addition, you may want to ask a good friend or family member to monitor your moods, since an objective person may be able to spot the return of symptoms from the outside before you can.

Identifying Relapse Triggers

Last week we learned the principles of stress management—how to activate the relaxation response in order to free the body from the damaging fight-or-flight response. Relapse prevention takes stress reduction one step further by identifying those particular stressors (which I will call triggers) that can initiate the symptoms of anxiety and depression. Triggers can manifest as thoughts, events, or situations. An example of a trigger for a compulsive overeater would be a slice of chocolate cake; for an alcoholic, it would be finding himself in a bar and offered a free drink; for a compulsive gambler, it would be playing a game of video poker.

Each of us has our own unique set of triggers. Some of these triggers can be linked to traumatic events from the past. Examples of such triggers include:

Other triggers include financial setbacks, health challenges, loss, role transitions, social isolation and career changes. Of these, the most powerful trigger seems to be loss. Relationship break-ups, divorce, the death of a parent, the death of a grandparent, and even the loss of a pet have the potential to send us spiraling downward into depression. Humans are intensely social animals, and our desire for connectedness is both our greatest strength and our greatest vulnerability.

Another way to do to understand triggers is to use the acronym HALT, which stands for hungry, angry, lonely and tired. (This term comes from the recovery movement.) Whenever a person is hungry, angry, lonely or tired, he or she is more likely to reach for booze or drugs. For people who suffer from a mood disorder, being overly hungry, angry, lonely and tired can make us more vulnerable to experiencing symptoms of anxiety or depression.

Finally, remember that stress of any kind is a potential trigger for relapse. Thus, it is important to regularly practice the relaxation response that you learned last week.

Avoiding Triggers

An excellent relapse prevention strategy is to stay away from circumstances that have the potential to serve as triggers. Here are some situations that my clients say they try to avoid.

You will have the opportunity to list your personal triggers when you fill out your personalized relapse prevention plan at the end of the chapter.

Recognizing and Responding to Triggers

Once you know what your triggers are, your job is to be on the lookout for the return of the symptoms of anxiety and depression when the trigger gets activated. These symptoms occur in three stages:

1) early warning signs.

2) the beginning of a crisis (the onset of moderate symptoms).

3) a full blown crisis (the onset of severe symptoms which can lead to a breakdown).

Stage 1: Early warning signs

Early warning signs are those subtle changes of thinking, feeling, and behaving that indicate a worsening of your condition. While they are usually associated with a triggering event, they may also come “out of the blue.” Often they go unnoticed because they are subtle, or because the person is not paying attention.

Here is one example. A few weeks ago, my nephew who in recovery from a bipolar disorder, looked more tired than usual.

“You look a bit beat,” I observed.

“Well, to tell you the truth, my sleep cycles have been a bit off,” Jesse replied.

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I became suspicious and upon further questioning I learned that Jesse wasn't getting to sleep until three in the morning. Given the fact that sleep disruption is often a prelude to a manic episode, I told Jesse that his sleep irregularities should be dealt with as soon as possible. (This story will be continued later in the chapter.)

Please turn to the list of symptoms for depression and anxiety on the following page. Use this list to create your own list of symptoms that signal the onset of your particular mood disorder. In addition, keep track of your daily moods using the daily mood scale depicted above. As long as your ratings remain between a -2 and +2, you are experiencing normal fluctuations in mood. If, however, they creep up to a -3 or -4, and remain there for more than a week, you are in mild danger of relapse.1 If this occurs, you can implement the following coping strategies: (If a clear external stressor such as a divorce or other major loss is evoking this pain, you may not be suffering from clinical depression, but should still take these steps.)

 

Early Warning Signs of Depression and Anxiety

The following are some of the common symptoms associated with the onset of depressive and anxiety disorders. Create a list of your own, and keep it by your mood diary so that you can note the return of any symptoms.

 

Stage 2: The beginning of crisis—things are breaking down.

Despite your best efforts, your symptoms may progress to a point where they begin to interfere with your normal ways of functioning. In such a case, you would find your symptoms would register a -4 or worse on the daily mood scale. Rather than “tough it out,” now is the time to reach out for support. Here are some good ways to take care of yourself:

An example of the successful handling of a Stage 2 crisis can be seen in the story of Jesse which I began earlier. About a week after telling me about his sleep irregularities, he phoned me and said that he was unable to concentrate enough to complete two relatively easy college term papers. He also dropped an introductory astronomy course because he had not been able to concentrate enough to study for an upcoming test. The night before, he had admitted himself to the emergency room, complaining of fatigue and dehydration.

I remembered that just eighteen months ago, Jesse had phoned complaining of similar symptoms while attending college away from home. With no family member nearby to lend support, he stopped eating and became nearly catatonic.

Fortunately, Jesse agreed with my suggestion to attend a local day treatment program—a structured, full-time regimen of group and individual psychotherapy. (See pages 32–40 for a description of how day treatment helped me.) Within a few days of attending day treatment, Jesse's eating, drinking and sleeping patterns became normalized. Within two weeks he was able to attend the program part-time. A month later he was discharged. With the permission of some of his college instructors, he was able to make-up his coursework over the summer.2

Stage 3: Major crisis—the symptoms become extreme.

Stage 3 takes place when the symptoms of Stage 2 have not been successfully resolved and you are beginning an episode of clinical depression or panic disorder. The numbers on your daily mood scale are likely to be close to -5.

Ideally, you should take the same actions that were outlined in Stage 2—i.e., enlisting your support team to help you deal with your crisis. However, your symptoms may have become so disabling that others may need to take responsibility for your care and make decisions for you. (This is what occurred during my last episode when my wife and friends decided that I needed to be hospitalized.)

Take a moment and consider one or more people whom you would trust to act on your behalf if you became disabled by severe psychiatric symptoms. In the next few days, ask them if they would like to become your supporters and advocates in the event of a relapse. Good candidates include a primary care mental health professional, a family member, or a good friend. (You will have the opportunity to write their names and numbers in your personalized relapse prevention plan at the end of the chapter.)

 

Avoiding the Hole in the Sidewalk

The following story, The Hole in the Sidewalk by Portia Nelson, is a wonderful metaphor for relapse prevention. Think of the “hole” as some stressor or habit pattern (i.e., not getting enough rest) that increases the likelihood that you will slip back into anxiety or depression. Recovery is a function of learning to make new and healthier choices that will decrease the likelihood of falling into the pit.

The Hole in the Sidewalk

Chapter 1: I walk down the street. There is a deep hole in the sidewalk. I don't see it. I fall in. I feel lost and hopeless. It isn't my fault. It takes forever to find my way out.

Chapter 2: I walk down the same street. There is a deep hole in the sidewalk. I pretend don't see it. I fall in again. I can't believe I'm in the same place again, but it isn't my fault. It takes a long time to get out.

Chapter 3: I walk down the same street. There is a deep hole in the sidewalk. I see it. I know it is still there. I still fall in it. It's a habit. My eyes are open. I know where I am. It's my fault. I get out immediately.

Chapter 4: I walk down the same street, see a deep hole in the sidewalk and walk around it.

Chapter 5: I walk down another street.

 

In addition, you might ask one of these people to monitor your moods and behaviors on a regular basis when you are well. Since we don't always see ourselves with 20/20 vision, an objective observer may be more adept at noticing the early warning signs of relapse and reporting those changes to you.

This Week's Goals/Assignments

These are you assignments for the coming work:

1. Fill out the “Personalized Relapse Prevention Inventory” on the following two pages. Take as much time as you need. You may want to answer the questions on a separate piece of paper. I strongly advise that you keep a copy for yourself and then give a copy to each of people whom you list as your supporters in question #3. Also show it to your coach/buddy as well as to those folks whom you listed in question #3.

Think of this document as a valuable piece of insurance. Ideally, it will serve as a road map that will prevent you from becoming ill and show you how to take actions that will restore your stability and wellness.

2. In addition, if you have been previously hospitalized, you may want to create a “Relapse Prevention Document” in which you authorize certain people to act in your behalf if your symptoms disable you. On such a document you would list the following:

1) Your early warning signs of depression.

2) Signs that the symptoms are worsening.

3) The names and phone numbers of your support team and health care professionals.

4) The actions you authorize them to take.

5) The facilities where you would willing to be admitted.

6) The name of your attorney (if you have one).

You would then sign and date this document, and give it to all the members of your support team.

Ongoing Self-Care Activities

 

My Personalized Relapse Prevention Plan

Answering the questions that follow will help you to identify the thoughts and behaviors that are your personal warning signs of relapse. They will also help you to specify actions you can take once you become aware of those warning signs.

1. What are the warnings that indicate that you are becoming depressed or anxious? You may want to review what led up to any previous depressive episodes in order to answer this question.

2. When you notice theses warning signs, what actions might you take that will even out your mood? Some of these responses were listed in the previous pages.

3. Whom can you call or talk with in order to get support? Whom will you share your relapse warning signs with? Please list (if you can) three or more people below.

Name Phone
a.  
b.  
c.  

4. Sometimes others spot relapse warnings signs in us before we do. How would you respond if others express concern that you are in danger of relapse?

5. What are your personal “triggers”—those thoughts, events or situations that can initiate symptoms of depression or anxiety?

6. What steps can you take to reduce the chance of being depressed an anxious in those situations?

7. Is it possible to avoid such triggers altogether? How might you do so?

8. What are some of your old ways of thinking (cognitive distortions) that you have seen produce feelings of depression or anxiety?

9. What are some new thoughts or beliefs that you an use to challenge those old ways of thinking?

10. Are there any changes could you make in your daily activities that would reduce the risk of relapse?

11. What areas of your life are you still working on in your ongoing recovery work?



 

 

My Goal Sheet for Week 12

This week's starting date_____________My coach/buddy ____________________

Date/time we will connect _____________________________

Goal or Goals _______________________________________________________

___________________________________________________________________

___________________________________________________________________

Benefits of attaining this goal____________________________________________

___________________________________________________________________

___________________________________________________________________

Action plan _________________________________________________________

___________________________________________________________________

___________________________________________________________________

Ongoing goals (check off the ones as you accomplish them)

______ Read my vision statement daily (upon awakening or before bed)

______ Chart my moods in the Monthy Mood Diary

______ This was my average mood on the better mood scale.

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How was my mood this week?

Record your moods below for each day of the week.

  Day Mood    Comments
  Mon    
  Tue      
  Wed    
  Thu    
  Fri      
  Sat    
  Sun    

1 If you have a bipolar disorder, then ratings of 4 and above could be warning signs of an oncoming mania.

2 Jesse's story supports the idea of having a buddy or someone in your life who can recognize and evaluate potential warning signs before they get out of hand.