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Handout 6:
Reducing Relapses

“My dreams seemed to get more intense before a relapse was coming, and I would find myself getting up earlier. Racing thoughts were another sign. They seemed to come on rapidly. I would think of new things to produce, such as sculptures or a story. Not everything about it was bad, but I needed to treat it swiftly or it would get out of hand.”

David Kime, artist, writer, floral designer

Introduction

This handout discusses strategies for reducing symptom relapses or minimizing the severity of any relapses that occur. In order to reduce relapses it is helpful to identify stressful situations that have contributed to relapses in the past. It is also helpful to identify your own personal warning signs of an impending relapse. This information can be combined to develop a relapse prevention plan. This plan can be even more effective by including a significant other, such as a relative or friend.

Why do people have relapses?

The symptoms of mental illness tend to vary in intensity over time. Sometimes the symptoms may be absent; sometimes they may be mild or moderate; sometimes they may be strong.

When psychiatric symptoms become severe, it is usually referred to as a “relapse” or an “acute episode of the illness.” Some relapses can be managed at home, but other relapses require hospitalization to protect the person or other people.

Mental illness affects people in very different ways. Some people have a milder form of their illness and only have an episode once or a few times in their lives. Other people have stronger forms of their illness and have several episodes, some of which require hospitalization. Some people constantly experience symptoms, but do not have severe episodes that require hospitalization.

Scientists have not been able to identify all the reasons that people have relapses of their symptoms. Research has shown, however, that relapses are more likely to occur when:

People are under more stress
People stop taking their medications
People use alcohol or drugs

Mental illnesses tend to be episodic, with symptoms varying in intensity over time.

Preventing and reducing relapses

There are many things you can do to prevent or reduce relapses. You have already learned some important relapse reduction strategies in the earlier educational handouts, including the following:

Learn as much as possible about your illness.
Be aware of your own individual symptoms.
Be conscious of when you are under stress and develop strategies for coping with stress.
Participate in treatments that help you recover.
Build social supports.
Use medication effectively.

In this handout you will learn some additional helpful strategies for staying well:

Recognize events or situations that contributed to relapses in the past.
Recognize the early warning signs that you might be starting to have a relapse.
Develop your own relapse prevention plan to respond to early warning signs.
Use the help of other people, such as family members, professionals, and friends, to prevent early warning signs from becoming full-blown relapses.

Different strategies can be used to prevent or reduce relapses.

What are common events or situations that can “trigger” relapses?

Some people can identify certain events or situations that appear to have led to relapses in the past. The events or situations that seemed to contribute to relapses can be thought of as “triggering” relapses.

The following chart lists some examples of common triggers. Please check off the examples that reflect an experience you have had.

Examples of Common Triggers

Personal Descriptions of Triggers	I experienced something like this
“I noticed that when I started staying out late, and not getting enough rest, I tended to relapse.”
“When I’m under more stress at work, like having strict deadlines, I’m likely to start having symptoms again.”
“Every time I go back to drinking beers every night, I end up needing to go back to the hospital.”
“When there’s a change in my life, even a good change like moving into a better apartment, I tend to feel stressed out. Then the symptoms seem to come back.”
“If I have arguments with my boyfriend, it really brings me down. Sometimes the symptoms get worse then.”
“The biggest problem for me is when I stop taking medicine. I decide that I’m feeling better and there’s no need to take medicine any more. Before long, the symptoms start again.”
Other:
Other:

Once you have identified a situation that appeared to trigger a relapse in the past, it is helpful to think about how you might handle the situation differently if it were to occur again. For example, if you noticed that drinking beers with your friends tends to trigger an episode, you could plan some activities with them that do not involve drinking. If you noticed that being under stress tends to trigger an episode, you could plan to use a specific relaxation technique, such as deep breathing, the next time you encounter another stressful situation.

Identifying situations and events that triggered relapses in the past can help you reduce the risk of future relapses.

Questions:

Have you experienced any relapses of symptoms?

Are you able to identify situations or events that triggered relapses in the past?

If so, what could you do to handle the situation differently?

What are “early warning signs”?

Even when people do their best to avoid it, their symptoms may start to come back and they may have a relapse. Some relapses may occur over short periods of time, such as a few days, with very little or no warning. However, most relapses develop gradually over longer periods of time, such as over several weeks.

There are often changes in the person’s inner experience and changes in their behavior when a relapse is starting. For some people, the changes may be so subtle at first that they may not seem worth noticing. For others, the changes are more pronounced and distressing. When people look back after a relapse, they often realize that these early changes, even the subtle ones, were signs that they were starting to have a relapse. These changes are called “early warning signs.”

Early warning signs are the subtle changes in a person’s inner experience and behavior that signal that a relapse may be starting.

Question:

Have you experienced any relapses of your symptoms?

If you have, did you notice any early signs of your relapses?

What are some common early warning signs?

Some early warning signs are quite common. Others are more unusual. The following chart lists some examples of the more common early warning signs. Please check off the examples that reflect an experience you have had.

Examples of Common Early Warning Signs

Early warning sign	Individual Example	I experienced something like this
Feeling tense or nervous	“Even going to the playground with my kids made me nervous. It seemed like the merry-go-round was going faster and that there were accidents waiting to happen everywhere.”
Eating less or eating more	“First I started skipping breakfast. Then I started skipping lunch. I lost weight even though I wasn’t trying.”
Decreased need for sleep	“When I started to relapse, I didn’t feel like I needed sleep. I would start working on my inventions and stay up all night.”
Trouble sleeping too much or too little	“I was tired and wanted badly to sleep. But somehow I couldn’t fall asleep. I was exhausted all the time.”
Feeling depressed or low	“I started to feel that my work wasn’t any good. And that I wasn’t a good person. I couldn’t take pleasure in anything. My mood was sliding down and down.”
Social withdrawal	“I only wanted to be alone. I even waited to eat dinner until my roommates had gone to bed.”
Feeling irritable	“Even the smallest things would irritate me. For instance, I would fly off the handle if my husband called to say he was going to be 15 minutes late. I had no patience.”
Stopping medication	“I stopped taking my medicine. I even threw away the bottles. I stopped going to my support group.”
Trouble concentrating	“Knitting usually relaxes me. But I couldn’t concentrate enough to do the stitches right. My mind was wandering.”
Thinking that people are against you	“It seemed like people behind the counter at the fast food restaurant were talking about me. They even seemed to be laughing at me. I couldn’t understand why.”
Hearing voices	“The voice was not loud at first. Sometimes it just said my name.”
Drug or alcohol use or abuse	“Usually I don’t drink. But when I was starting to relapse, I found myself pouring a drink of scotch every night. I think I was just trying to get in a better mood.”
Increased spending or shopping	“I used up my checking account and then charged two credit cards to their limits.”
Being overconfident about your abilities	“I thought I was such a great driver that the traffic laws didn’t apply to me. I was stopped by the police going 30 miles over the speed limit.”
Other:
Other:

Common early warning signs include:

• Feeling tense or nervous
• Eating less or eating more
• Trouble sleeping too much or too little
• Decreased need for sleep
• Feeling depressed or low
• Feeling like not being around people
• Feeling irritable
• Stopping treatment
• Trouble concentrating
• Thinking that people are against you
• Drug or alcohol use or abuse
• Increased spending or shopping
• Being overconfident about your abilities

Question: Have you experienced any of the common early warning signs? Which ones?

What are some other early warning signs?

Some people have early warning signs that others don’t have. These unique warning signs are equally important to recognize.

Some examples of unique warning signs are:

“Before my last two episodes, I cut my hair very, very short.”
“My brother noticed that I was whistling all the time.”
“I started buying lottery tickets two or three times a day.”
“I started wearing the same clothes every day. The same khaki pants and blue T-shirt.”
“I became preoccupied with martial arts. I practiced martial arts moves for hours.”

Some people have early warning signs that are unique.

Questions: Have you experienced early warning signs that other people don’t have?
If so, what are your unique early warning signs?

Is there a systematic way to identify your own warning signs?

The following checklist contains a list of common early warning signs. Check off the early warning signs that you experienced in the week before your last relapse.

Early Warning Signs Questionnaire

(Adapted with permission, Herz and Melville, 2001)

Early warning signs	I experienced this sign
My mood shifted back and forth.
My energy level was high.
My energy level was low.
I lost interest in doing things.
I lost interest in the way I looked or dressed.
I felt discouraged about the future.
I had trouble concentrating or thinking straight.
My thoughts were so fast I couldn’t keep up with them.
I was afraid I was going crazy.
I was puzzled or confused about what was going on around me.
I felt distant from my family and friends.
I had the feeling that I didn’t fit in.
Religion became more meaningful to me than before.
I felt afraid that something bad was about to happen.
I felt that other people had difficulty understanding what I was saying.
I felt lonely.
I was bothered by thoughts I couldn’t get rid of.
I felt overwhelmed by demands or felt that too much was being asked of me.
I felt bored.
I had trouble sleeping.
I felt bad for no reason.
I was worried that I had physical problems.
I felt tense and nervous.
I got angry at little things.
I had trouble sitting still. I had to keep moving or pace up and down.
I felt depressed and worthless.
I had trouble remembering things.
I heard voices or saw things that others didn’t hear or see.
I thought that people were staring at me or talking about me.
I had a decreased need for sleep
I was more irritable.
I was overconfident about my abilities.
I increased my spending or shopping.
Other:
Other:

Do people always recognize that they are experiencing early warning signs?

People are not always aware when their behavior has changed and they are experiencing an early warning sign of relapse. For example, someone might not realize that he or she is feeling unusually irritable. Instead, it may seem to him or her that other people are being especially annoying.

Friends, family members, co-workers, healthcare practitioners and other supportive people often notice when someone seems different or is acting out of character. They can be helpful allies in recognizing early warning signs.

If you ask them, your family members, friends and mental health practitioners can be your “extra eyes and ears” for noticing early warning signs. You can tell them some possible early warning signs to look for, and let them know that you would like them to inform you when they notice these signs. You can also include them in your “relapse prevention plan” to help you take action to keep early warning signs from becoming relapses.

Family members, friends, mental health practitioners and other supporters can help you recognize early warning signs.

Question:

Whom would you like to help you recognize early warning signs?

You can use the following chart to record your answer.

People Who Could Help Me Recognize Early Warning Signs

Friends?

Family members?

Support group members?

Practitioners?

Co-workers?

Spouse or significant other?

Others?

What can be done when you become aware that you are experiencing an early warning sign of relapse?

The more quickly you act on early warning signs, the more likely it is that you can avoid a full relapse.

When early warning signs are noted, it helps to ask yourself the following questions:

Is my stress level high? What can I do to reduce it?
Am I taking part in the treatments I chose? Am I going to my support group, doing my relaxation exercises, going to my appointments with my counselor, etc.?
If medication is part of my treatment, am I taking my medication as prescribed? If not, how can I make sure I do?
Should I arrange a special appointment to talk to the doctor? Do I need to start a medication? Do I need a higher dose of the medication I am taking?
Should I contact someone for extra support?

The following list contains examples of what other people have done when they recognized they were experiencing early warning signs. Some examples may sound familiar to you.

“When I started to feel so irritable with everyone, even my best friend, I realized that I was under a lot of stress with changes at the office. I talked with my practitioner about strategies for coping with the stress better so it didn’t affect me so much.”
“First someone called from my synagogue, asking why I hadn’t been coming to services like I used to. Then someone from my support group called and asked why I hadn’t been coming for the past three weeks. I realized that something might be wrong. I decided to go to the next support group, and asked a friend to give me a ride.”
“I thought my medicine wasn’t helping me. So I didn’t renew the prescription when it ran out. My thinking got very confused. I kept forgetting things, too. I called the pharmacist about getting the medicine renewed, and then I called the doctor to talk about what had happened.”
“My brother noticed empty beer bottles in the kitchen when he came to visit. When we got to talking, I realized that I was starting to use alcohol to help me fall asleep. The next day I called my counselor.”

The more quickly you act on early warning signs, the more likely you can avoid a full relapse.

Question: Have you had an experience where you were able to avoid early warning signs from becoming full relapses?
If so, what did you do?

How can you make a Relapse Prevention Plan?It’s not possible to predict who will have only one or two acute episodes of the symptoms of mental illness and who will have more. Making a Relapse Prevention Plan can help you avoid relapses and minimize the severity of episodes that do occur.

In developing a Relapse Prevention Plan, you may find it helpful to consult with the supportive people in your life. Peers, practitioners, family members, and others can help you remember details about what helped in past situations and can make suggestions about possible steps to take if early warning signs appear.

Support persons can also have a part in the plan itself, if you want them to. For example, you might ask family members to let you know if they notice early warning signs or ask them to help you reduce stress by taking walk with you. Of course, you make the final decision about what you want in your plan and whom you want involved.

Plans for preventing relapses are most effective if they contain the following:

Reminders of past triggers
Reminders of past early warning signs
What helps you when you’re having an early warning sign
Who you would like to assist you
Who you would like contacted in an emergency

The following pages contain an example of a Relapse Prevention Plan completed by Alberto.

Relapse Prevention Plan: Alberto’s Example

Reminder of events or situations that triggered episodes in the past:

broke up with my girlfriend
smoked marijuana

Reminder of early warning signs that I experienced in the past:

felt tense, irritable
thought people were picking on me, didn’t like me
couldn’t concentrate on TV

What I think would help me if I am experiencing an early warning sign:

If I’m smoking marijuana again, I need to stop, and maybe go back to my “Double Trouble” group.
If I’m upset about something that happened, I need to talk to my friend Juan or to my brother Martin.
If I’m feeling stressed out, I need to make sure I’m doing something to relax me every day, like listening to music or biking.
If I start to feel like people are picking on me or I can’t concentrate, I need to talk to my counselor.
If I still don’t feel better, I need to consider more medication—at least for a short time.

Who I would like to help me, and what I would like them to do:

Juan or Martin could tell me if they think I’m starting to get irritable.
Juan could go biking with me.
My counselor could help me think of ways to relax.
My doctor could help me decide if I need more medicine.

Who I would like to be contacted in case of an emergency:

Martin, my brother, ###-####
Maria Rodrigues, my counselor, ###-####
Dr. Rose, my doctor, ###-####

Before developing his Relapse Prevention Plan, Alberto talked with the supportive people in his life (his friend, his brother, his counselor, and his doctor). He asked them what they had observed before his last relapse and included some of their observations in his list of early warning signs. He also asked for their suggestions in making a plan for responding to an early warning sign and asked them whether they would be willing to play a specific part in carrying out the plan.

After writing up his Relapse Prevention Plan, Alberto asked his friend, his brother, his counselor and his doctor to read it. He then gave copies to each of them. Alberto keeps a copy of his Relapse Prevention Plan in his desk drawer, where he also keeps his checkbook. Whenever he writes a check, he makes a point of looking over his plan.

A Relapse Prevention Plan can help you in case early warning signs appear. The plan should contain:
• Reminders of past triggers
• Reminders of past early warning signs
• What helps you when you’re having an early warning sign
• Who you would like to assist you
• Who you would like contacted in an emergency

It can be very helpful to have friends, family members, practitioners and other supporters involved in making the Relapse Prevention Plan and helping to carry it out.

Questions: What would you include in your Relapse Prevention Plan?
You can use the following planning sheet to record your answer.

Relapse Prevention Plan
Reminder of events or situations that triggered relapses in the past:

1.

2.

3.

4.

Reminder of early warning signs that I experienced in the past:

1.

2.

3.

4.

What I think would help me if I am experiencing an early warning sign:

1.

2.

3.

4.

Who I would like to assist me, and what I would like them to do:

1.

2.

3.

4.

Who would I like to be contacted in case of an emergency?

1.

2.

3.

4.

Examples of people who have been able to prevent or reduce the number of relapses they experience

David

“My strongest early warning signs are having vivid, bizarre dreams and not being able to sleep. When that happens, I start doing things to keep myself calm, like taking walks and listening to music. I give my checkbook and credit card to my parents because then I won’t be able to go on spending sprees and buy things I don’t need. Doing artwork helps, but I try not to work on projects late at night, because that makes it harder to go to sleep. If I need to, I call my doctor. Sometimes having some extra medication has helped me avoid a relapse. These things might not work for everyone, but they have kept me well.”

Tamika

“I’ve noticed that I start to feel down about myself. I can’t think of anything good about the present, and I keep dwelling on the past. I don’t understand why, but I start thinking about a boy I dated in high school, even though that was over 15 years ago. I’ve found that it helps to talk to someone, like my sister, about what I’m feeling, instead of keeping it to myself. It also helps me to schedule something every day that gets me out of the house. Even if it’s just going to the post office to mail a letter, it’s better than staying inside those four walls at home. Going to support groups helps, because they understand what I’m feeling. If it gets to the point I’m thinking about life not being worth living, I know it’s gotten very serious. I call my doctor right away. For over two years I’ve been able to avoid a relapse.”

A Relapse Prevention Plan can help you avoid having relapses of your symptoms.

Question: What do you think will help you most in reducing the risk of relapse?

Summary of main points about preventing or reducing relapses

Mental illnesses tend to be episodic, with symptoms varying in intensity over time.
Different strategies can be used to prevent or reduce relapses.
Identifying situations and events that triggered relapses in the past can help you reduce the risk of future relapses.
Early warning signs are the subtle changes in a person’s inner experience and behavior that signal that a relapse may be starting.
Common early warning signs include:
- Feeling tense or nervous
- Eating less or eating more
- Trouble sleeping or sleeping too much
- Decreased need for sleep
- Feeling depressed or low
- Feeling like not being around people
- Feeling irritable
- Stopping treatment
- Trouble concentrating
- Thinking that people are against you
- Drug or alcohol use or abuse
- Increased spending or shopping
- Being overconfident about your abilities
Some people have early warning signs that are unique.
Family members, friends, mental health practitioners and other supporters can help you recognize early warning signs of relapse.
The more quickly you act on early warning signs, the more likely you can avoid a full relapse
A Relapse Prevention Plan can help you in case early warning signs appear. The plan should contain:
- Reminders of past triggers
- Reminders of past early warning signs
- What helps you when you’re having an early warning sign
- Who you would like to assist you
- Who you would like contacted in an emergency
Friends, family members, practitioners and other supportive people can be helpful in developing your Relapse Prevention Plan and carrying it out.
A Relapse Prevention Plan can help you avoid having relapses of your symptoms.

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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

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Handout 6: Reducing Relapses

Handout 6:
Reducing Relapses