Episode #88

Relapse Prevention & CBT

Relapsing after reaching an important goal can feel crushing.

How can you respond constructively to a relapse?

How can you know what ‘normal’ is for you?

How can you avoid relapsing?

Join me, Dr Julie Osborn, as I share with you the answers to these powerful questions.

Click to listen now!

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Full Episode Transcript

Hi! This is Dr. Julie Osborn. Welcome to My CBT Podcast! I'm a Doctor of Psychology and a licensed clinical social worker, specializing in Cognitive Behavioral Therapy.

I'm here to help you bring the power of CBT into your life. So I want to start off, as I do many times, sharing emails and reviews you guys give me, which really keep me humble and focused on why I'm doing the podcast and so happy that it reaches so many people out there. And it's got a wonderful, wonderful five star review on Apple podcast. So I'd really encourage you, if you can, to subscribe if Apple is the platform you listen to and give me a review, because then it just gets to more people and they can start listening and benefiting as well.

So I just received this the other day. It's five stars. And they posted,

“This changed my life. I thought I was doomed to live a life of pain, depression, and anxiety. This podcast helped pull me out of a dark hole, and it's giving me hope that I can stay afloat and maybe even lead a fulfilling and contented life. I believed all of my negative thoughts, and I didn't realize that I deserved and was capable of thinking positively about myself. I can now appreciate my good qualities, which in turn is less than my depression. It makes me look forward to each day rather than wishing it would all end.”

So thank you for that review. You know who you are! And again, I'm really grateful and really humbled that this podcast has such, so many people and made such a difference in so many people's lives.

And I know that that's what productive therapist can do for people. And again, that was my intention when I started back in March of 2020. And we will continue to march forward and continue to have more podcasts. And I want to just keep teaching you guys and as always, reaching out to me, which I'll talk more about how to contact at the end of the podcast. But I love your ideas and sharing with me how this has helped you and being able to answer any of your questions.

So today I thought a really good podcast that would be helpful is Relapse Prevention. So we want to prevent relapse. But let me first start saying that we all relapse, okay? It isn't that. Oh, my God.

I relapsed. I never want to relapse. Of course we never want to relapse. I'll talk about more what that even means, but it's going to happen. So let's get prepared for it, right, and prevent it as much as we possibly can.

And there are ways that we can do that. And it doesn't have to be overwhelming. It doesn't have to be some huge chore. But it's important to know, because when you do relapse from depression or your anxiety or maybe anger or whatever you're going through, I don't want you to freak out and think like, oh my God, I went back to where I started, because that's not true either. Relapses can be small, medium, and large, right?

And the sooner we catch them and we'll talk about how to do that as well, the more we will be able to get back on track quicker and get back to where we want to be. So let's first talk about what's quote normal regarding your moods. So what's normal is that, say if we're thinking about a week, seven days out of the week, we want a good four or five days. We're feeling good, and we might have a couple of days earlier, our best days. We get frustrated, things happen.

Things may be in the news we watched or in the world, right? And kind of got us down for that day, but we're able to bounce back, get refocused, have our thoughts be balanced, and we're doing okay. So that's what we're going for. We're not going for happiness 24/7, because that's not realistic, and I don't want you to have these unrealistic expectations. I always say I want everyone to be content, and our happiness goes high to medium, to kind of just our baseline.

So it comes and goes depending on what's going on in our lives. But in general, to be happy and to be content is what we're looking for. But we're human beings, right? And we have lots of different emotions, and that makes us who we are. And all of our emotions are good, right?

So it's not that I want you just to avoid, avoid, avoid not feeling sad or feeling worried or anxious because they have a place in our lives, but we don't want that to be overriding your life. So let's say that you got to a place or you are at a place that you're feeling pretty happy and feeling good, and then all of a sudden you're like, I'm starting to have more anxiety than not, or I'm starting to feel my depression more than I was last week, or it kind of feels like it used to feel. What do I do? What do I do? Before I give you specific tools, I just want to mention that sometimes we stop using our cognitive behavioral skills we've learned because we're feeling better, right?

And that's totally normal, right? Like, I feel good, so I don't need a quote, like, practice as much. And we're not using the skills on a regular basis, so that's why it's important to create ways to continue to practice your tools on a daily basis, especially when you're feeling good. When I'm teaching you is not like, I'm going to use these tools and okay, now I'm better, so now I'm done, right? It's that I want to maintain my happiness and my mental health and how well I'm doing.

So I need to continue to find a way to maintain that. And part of that is using the skills so I know I've said this probably almost every podcast, but I use the tools every single day because if I got 80 or 90,000 thoughts in my head, I need tools on how to manage all of them, right? So that's the first thing we want to remember is that I'm feeling well. But that's because I'm changing how I'm thinking and I'm challenging my thoughts and all the other tools that I've used within the school of CBT that I need to continue to use them so I stay well. So that's something to remember.

That when or if you relapse to first say am I still using my tools? What's changed here for me? And we don't have to reinvent the wheel that whatever works for us before usually will work again. So whether it's the thought record, your gratitude list, working on acceptance, using your cognitive distortions, which we'll talk about in a minute, and addressing that with your thoughts, and all of these are podcasts I've done before, whatever has worked for you, that's what I want you to keep using. Not every tool works for everybody.

So you want to hone it in and say these ones really make a difference for me, so I need to keep practicing them. So let's first talk about ways to reduce the likelihood of relapse and then I'm going to also give you specific things to do to avoid even getting there or to keep your eye on it. It may be a better way to say it. So we first of all want to over practice. I say our tool.

So what does that mean? overpracticing means whenever I can do a full record, whenever I have a negative mood, I'm going to ask myself what am I thinking? What am I thinking? Even if it's little like I'm frustrated, the red light is so long and I'm going to be late for my appointment, what am I thinking? In my head I'm thinking something because I'm feeling frustrated.

Remember, it doesn't have to be huge situations to do for records whenever you have a negative mood. So you want to over practice because the more you practice, the more you practice these tools, it will become more automatic for you and you'll see that you're using them more often. And it's not even that you have to remind yourself as much as just that's how you are. My brain is like a thought record. I say, right, I'm in my thoughts way faster than I used to be when I do have my negative moods.

So you want to over practice. Another thing is you want to identify possible high risk situations in your life. So when you've worked through all the exercises, if you're using Mind Over Mood or the other book I refer to Last Feeling great by Doctor David Burns, you'll notice that there are certain situations that are more difficult for you. So you want to plan for those. So if you know you're going to have a meeting or you have to maybe see a particular family member or whatever you have to deal with in your life.

These have always been tough situations for me, maybe public speaking, right? Lots of different situations come up that people really struggle with. So know what your high risk situations are and prepare for that. So how can I prepare? Do a full record, right?

What am I thinking that's causing me to feel nervous or anxious or angry or scared about the situation? So if I prepare for it, I'm less likely to have a relapse because now I know how I'm going to handle it and I know what I'm going to say and I have new thoughts that I've been able to balance out regarding the situation and I'm not going and just hoping that it's going to work out. Because I always say hope is not a plan, we want to have a plan. So identifying those high risk situations and not just thinking, well, I feel better now, so I'll just flow through. It not necessarily true because something could really trigger you.

Identifying early warning signs is the second thing that you can do. So if you're using the Mind Over Mood book in chapters 13, which is understanding depression, in chapter 14, which is Understanding Anxiety, they both have what they call a Mind Over Mood Depression Inventory and a Mind Over Mood Anxiety Inventory, So when I work with my clients, I have them fill this out every single week or once a week for sure. And then whenever I meet with my clients, I always get their scores because it gives us a baseline of where they're at when we start therapy, and then we can see their progression throughout therapy. And then when people finish therapy and they're moving on with their lives. I recommend that with the inventories that for the first six months after you finish therapy is that you still do them every other week and then the next six to twelve months to do them once a month.

Because I've had a couple of clients that didn't really feel the changes. But they noticed their numbers were going up because these inventories have symptoms of either depression or anxiety that you can see what your symptoms are. And then again you can have your baseline and if the numbers start going up. That's a good time to. If you have a therapist.

Go back and get a booster session. As I call it. Or go back and open up the book again. Look over your old thought records. Do a new thought record.

Okay? So doing the inventory is a great way. So how can you remember to do that? I recommend a lot of clients because people forget all of us. We're busy, right?

Weeks go by and we're like, oh, I didn't do a thought record or I didn't do an inventory, so put something in your phone as a reminder. So when you do the inventory, you want to do it the same day every week or the same day every month, whatever you're choosing to do. Maybe like the first day of each month would be great if you're doing it once a month. So put a reminder in your phone that just reminds you they take, like, five minutes. So we need things to do to remind us.

So using your phone is a reminder if you're using certain books or you have a journal you're using, as long as you're comfortable, leave it out so that you just see it. It's just a visual reminder, kind of a subliminal, like, oh, yeah, there's a Mind Over Mood book. Oh, there's a feeling great book, or whatever. There's my journal that I write in. There's my gratitude list.

Leave it out because we get too caught up in our lives and we just forget. And especially when we're feeling good, right? And I don't want you again to relapse and then be like, oh, I should have done this before, or not to do all this work to get back to where I was. So we're wanting to prevent that or catch it in its early stages. So think over your past experiences.

What are your early warning signs? We also call this symptom management. I'm going to manage my symptoms, so I want to write a list. What are my symptoms when I'm feeling negative moods regarding depression, anxiety, anger? Again, whatever moods you're having, I know I keep using those three.

I apologize because there's so many, but whatever you struggle with, what are my warning signs? If you're really not sure, you can always ask people you trust in your life your partner, your family, good friends. What do you guys notice when I'm feeling down? They might say, well, you don't text me back right away, or you don't seem to answer the phone, or you don't engage as much. I ask you, go get some dinner, and you say, no, thanks.

So you isolate more, or maybe you're a little more short when I talk with you. Right. Or I noticed that you're sleeping a lot, you're not really eating too much. And what do you feel? What are your physical things?

Do you have muscle tension? Do your headaches start to come back? What are the things that would be your symptoms and your early warning signs? And become aware of that and make notes and write that down. And again, doing the inventories, just going down those, you'll be like, oh, okay, here are some symptoms.

Yes. I didn't think about that happened for me. Another tool that you can use is to prepare a plan of action, right? So again, what am I going to do that tells me in the past when I'm starting to feel sad or anxious or whatever the moods are that are coming back? What has happened in the past so have it prepared.

So a great thing to do with your thought record is right now, when you're in a good place, I'll have you do a thought record about what might I think about if I did relapse.

So I know I've talked to guys in previous podcasts that you can do for records about past things that are still bothering you, current situations and things that might be coming up in the future. So this is kind of that future thing. So a lot of times when people relapse their hot thoughts, which are your thoughts that are not 100% true, might be thinking that therapy didn't work, that you really didn't get as better as well as you thought you did, right. That your problems are too difficult and too severe, that the therapy didn't really help in the long run and it was just kind of luck that I felt good for a while. Believing that you really are worthless.

If there was a belief that you had or a thought thinking you're going to be anxious or depressed for the rest of your life, thinking there's something wrong with you because why did you relapse? And other people are doing well. So these are just some thoughts, hot thoughts that you might have. And obviously you can add to that. What would your thoughts be if you did relapse?

Say, we're doing a thought record, right? The situation is relapsing and then you can put down what your moves would be and then what are my thoughts? And then what we want to do is we want to challenge those thoughts. So you're already coming up with new thoughts that will be prepared and ready for you. Because when you're in that state of relapse, it's hard to be positive and think, OK, what do I need to do instead of like and feeling hopeless again or thinking, I got to start all the way from scratch, which is another hot thought, what is it that I can do to get back on track as quick as I can?

And you're already five steps ahead because you actually know the tools, you just maybe need to go back and use them again, right? So if you do a thought record or journal about what would your thoughts be? And then we can challenge them. So how can we challenge them? So in one way and again, I have a podcast on your cognitive distortions, if you guys want to listen to that.

But once you get your thoughts down and identify which ones are hot, probably all of them would be my guess. You want to say, am I having the all or nothing thinking? Am I over generalizing when I say, you know, that I'll be depressed forever, right, or anxious forever. A mental filter is when you're only focusing on the negative, which is that you relapse is it is saying, hey, you know what, I caught it, I see what it is I can get back on the bandwagon and get going again and feel better. And my fortune telling saying because this happened I'll never get better again.

Fortune telling your future that I'm always going to be this way. So there's ten cognitive distortions. You can identify which distortions are being played out here within your thoughts. All right? And then you would go on to say is there any evidence for my hot thought?

What evidence doesn't support it? And then what is my new balance thought? So that's your whole fall record and remember just as reference doing a fall record, my podcast it's called the ABCs of CBT will walk you through that. So doing one ahead of time when you're feeling well on if I relapse, what would I think? So this is a great powerful tool that you can just have there right?

So you can just go to it. You're not like oh I've got to think of something. What am I going to do right now? I don't know I'm just overwhelmed. Hey I can pull out my thought record I already did or my journaling about what my thoughts would be.

What are the distortions I'm using right now that are hurting me and what are my new thoughts so that I can start engaging again in the tools that were most helpful for me. And let me tell you regarding the distorted thoughts they're going to be really strong distortions about your negative thoughts when you relapse because it's just so distressing. And again that's why you don't want to wait to challenge and then have something prepared beforehand so that you feel more empowered to handle this when and if it happens. Another good way of thinking about relapse is seeing that it's actually an opportunity to grow and even though it can be painful and frustrating to go through that you don't want to get too discouraged and say okay here's an opportunity remember Doctor Julie talking about this that I most likely would relapse at some point. Here's an opportunity for me to say hey can I use my tools again?

Can I get started again? Let me pull up a journal, let me look at my gratitude list, let me see what I did to prepare for this and to say here's an opportunity for me to see that I can empower myself and I can get better and I can get better pretty quick and this doesn't have to last too long. So then I can take all that fear away that if I notice that I'm struggling a little bit I know what to do and how great that I have all these tools already that I just have to kind of go back into my basket of tools right and say oh yeah these things really worked for me to be honest. I've been pulling away. I've been feeling good.

I haven't been paying attention. I need to get back and pay attention because my thoughts don't stop and they keep going, and I need to maintain it. It's kind of like an example I use is if you work out a lot or if you're lost weight, once you get to your goal, like, okay, I'm done. I can go eat whatever I want again, right? Or, oh, I don't need to exercise anymore.

I'm where I want to be. That is, nobody has to tell you that you need to maintain the weight loss or the gains in the exercise by continuing with whatever plan you're on. And they say maintenance is like the hardest part. The hardest part to keep it going. When you're losing weight, you usually have a plan that I'm going to eat every day.

Boom, boom, boom, right? And then you get there and you're like, okay, now what do I do? Because I have to adjust this a little bit. I'm not trying to lose more. I'm trying to maintain.

So it's kind of automatic that you have a plan. It's the same for your mental health that we all have to have a plan going forward. What works for me, what do I know is good. It makes a difference. And you probably can look in your past and you've probably realized before you've heard this podcast and seen like, yeah, I just kind of stopped doing this or that, or maybe I got sick for a while and I never got back to the gym.

That happens a lot. I hear people as an example with taking care of yourself, that when people stop, they have a hard time getting going again. So if you look at it like, okay, here's an opportunity for me to see that I can get back to where I need to be and I can have good self care. It's a different shift, a different way of looking at it instead of it being all negative. Now, if you're in therapy already and your therapist has not mentioned relapse prevention, ask your therapist, hey, when we're done with therapy, I really like you to teach me some tools for relapse prevention and not just to call you and come back to you.

That's always an option. Obviously, you can always call your therapist, which is great, but what are some things I can do for myself? How can I prepare for that? So that would be a great thing to ask for if your therapist has been offering. In the two books again, I referred to today in My Mind over Mood, which is my go to in chapter 16.

It will talk about the relapse prevention and go over some of the things I spoke about. And also in Feeling Great, they have a section also on stain, Feeling Great and talk about relax prevention there. So those are some specific things you can look at within those books. But also taking the suggestions that I made today and thinking about the basics of cognitive behavioral therapy is we're having balanced thoughts, right? We're acknowledging that maybe some of our negative thoughts, that there's some truth in them and there's also parts that are not true.

And that's what I love about it. And that's why people get better, because we're really being honest with ourselves. And now we're just doing positive thinking, like, oh, you'll be fine, don't worry about it. Or if you don't feel good again, it'll go away. Like, that doesn't work and relax.

Prevention with a therapist might take 30 minutes to teach you. So it's not like you have to go back for sessions and sessions, but you need to come up with a plan. And that not thinking and worrying about relapsing, but just knowing if and when that happens, I know what to do, so I don't have to worry about it. And that's my balance. Thought it could happen, but I know what to do about it and I don't have to be lost.

And all the time and work I've put into getting well are the tools that I'm using the rest of my life and can sustain me the rest of my life. So I can work on always having good mental health and taking care of myself. So that's it for today. I hope it was helpful. It's a really important tool within cognitive behavioral therapy is looking at the big picture and what happens when I don't or I'm not feeling good still, right?

What part am I planning it? What do I need to do? How can I change that?

So remember, you can always reach me and email me at mycbtpodcast@gmail.com.

I'm on Instagram under mycbtpodcast and my website is mycognitivebehavioraltherapy.com.

You can find other contact information there my email, my office phone number, if you want to give me a call. If you have questions.

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Again, I really appreciate any reviews you would give me that's really helpful to get my podcast out there to more people so I can continue to help and reach more and share this podcast. If you know anyone that would benefit from it as well as you go through regarding if you want to order any of the books I talked about, you can click on the Mind Over Mood book, as well as the Feeling Good, in my podcast and get more in depth tools.

And again, you can always reach out and ask me if you have questions or if you want to even referral to someone in your community if I'm not able to work with you, depending on where you live.

So thanks again for joining me.

Stay safe and remember to make decisions based on what's best for you, not how you feel.