Relapse Prevention (Trauma Recovery)

 

 “A lapse is often part of a larger pattern of recovery and

some people may have to cope with a future lapse in

order to continue on their way.”

-Dr. Francis Abueg and colleagues 

Experiencing a relapse is a normal occurrence when it comes to trauma recovery. The healing journey is filled with ups and downs. It would be nice if there were no setbacks or falls. However, there will be periods when some of the trauma symptoms return. These setbacks can serve as opportunities to revisit previously encountered coping skills and to process unresolved memory material. This chapter deals with the anticipation and prevention of symptoms and traumatic circumstances before they occur. We will also cover how a lapse is a great way to hone our coping skills. Relapse prevention includes six parts:

·         “Understand the dynamics of failure.

·         “Identify and anticipate high-risk situations or cues.

·         “Develop a sound coping plan.

·         “Rehearse the plan.

·         “Try out the plan in real life.

·         “Evaluate and make improvements if needed” (Schiraldi, 1999, pg.349).

Understanding the Dynamics of Failure

We are at a point in our life in which our trauma symptoms have lessened and for months we are less bothered by the past. Then we encounter a setback. Perhaps a feared situation such as a place where a traumatic experience occurred or a social situation that stirs up hurt feelings and/or not fitting in. All of a sudden, we notice intrusive thoughts and start ruminating. Our feelings come out sideways and we are treating people badly. Sideways is a term that is related to built up tension and then we overreact to a given situation.

    We are more prone to setbacks if we haven’t taken the time to take care of ourselves, make ourselves a priority. Sometimes a variety of stressful situations pile up on us such as car trouble, staying up too late reading (that is something I do), and we feel like we are falling behind on our household chores and we are not spending enough time with people we care about. It feels like we don’t have any of our ducks in a row and things are falling apart. We may blow up at our spouse or go somewhere angry and not be in the mood to see anyone. We may feel distant and out of touch with our friends.

    Failure can be uncomfortable to examine and we may associate it with rejection, abandonment, or punishment. The explanation can be negative and our fears can return with a vengeance. We can stop the cycle of negativity by applying the following actions.

·         “Immediately: Stop, look, and listen. Take a minute if you can to step out of the flow of events and try to get as rational a view as possible. Look for your own cognitive distortions as they are developing.

·         “Keep as calm as you can so you can function in the situation.

·         “After the crisis is past: Think of the situation as external, specific, and changeable. External means that we focus on the event, and do not condemn ourselves at the core. Specific means that we keep what is happening in the here-and-now. We do not assume that what is happening is a reflection of life in general. Changeable means that things can improve. The opposite of external, specific, and changeable is internal, global and unchangeable… This way of explaining failure leads to further distress.

·         “Keep setbacks from getting worse by looking at other self-talk. Many reactions get worse by self-defeating reactions such as shame, self-disgust, impatience, or discouragement. These emotions maintain arousal. They are preceded by negative self-talk. So learn constructive vs. destructive reactions…

“Replace the word failure. Failure has a self-defeating all-or-nothing quality to it.

Instead of failure, think of a return of symptoms as a setback, lapse, temporary detour, opportunity, normal and expected challenge.

“Stand your ground and renew your commitment to recover. Don’t give in to ‘What’s the use?’ (fortune telling) or ‘I’ve blown it’ (all-or-nothing). Remind yourself that setbacks are normal. Rember the benefits of recovering” (Schiraldi, 1999, pgs. 351-352). 

Identify and Anticipate High-risk Situation (Cues)

 

The most well-planned copers have been found to anticipate times and places that can be stressful and be prepared for them. We can be one of them and form an action plan rather than avoiding thinking about possible traumatic experiences and worrying without having a plan in place. Our action plan includes high-risk situations, or cues and we need to consider a variety of possible triggers. Some of the stressful events, places and people can be funerals, places, specific people, significant dates such as anniversary dates of traumas, fatigue and illness, interpersonal conflict, specific social situations and other triggers. Not all arousal is bad such as the birth of a newborn. To increase awareness of high-risk situations, fill out the table below.

    Emotional reactions may be anger, sadness, frustration, or fear. Physical reactions might be difficulty with breathing or a felt tension throughout our bodies. Behaviors may include leaving the situation or using food or alcohol to numb the pain. The fourth column covers connection to past trauma which serves as a vehicle to separate past trauma from current trauma. Or we might decide it is a new feared situation. The fifth column presents a percentage of how much stress we predict will happen. While the last column indicates the actual distress we experienced (Schiraldi, 1999).

  

High-risk Situation	Likelihood of Encountering       (%)	Expected Reactions (emotional, physical, behavioral)	Connection to Past Trauma	Anticipated Distress (%)	Actual Distress (%)

 

    For scheduled events that may be high-risk situations, write out a specific plan. Consider all things we need to do to cope effectively. For example, we may have suffered at the hands of our parents when we were children and accumulated multiple traumatic memories. We plan on spending time with our parents over the Christmas holidays and the traumatic experiences were never dealt with due to our parents’ inability to own up to their mistakes. Meeting them over the holidays can resemble a high-risk situation. What do we need to do to ensure that a setback does not result in a full-blown relapse? What do we need to tell ourselves? What do we need to do first and what order will all the possible disturbing things occur? The coping plan needs to involve preplanned, self-instructional statements. Imagining the difficult situation and eliminating unproductive thoughts. Our sound coping plan can contain an array of thoughts planned for before, during and after the situation. Also make a plan for immediate recovery if a setback occurs.

    Sometimes we have situations such as workplace circumstances in which we need to develop a sound coping plan and sometimes there are scheduled events that have caused us much angst. If it is a work situation and we need to pay the bills, we are going to have to develop a workable coping plan to help us get through the day without losing all sense of control. I had a tyrannical boss who placed a lot of responsibility on my shoulders while at the same time she treated me in an emotionally abusive manner. It reminded me of the ex-husband I left who was an abusive alcoholic, one in which I incurred many traumatic memories. This happened some time ago, but I could have really used a sound coping plan to help me deal with both circumstances. 

Develop a Sound Coping Plan

There is a certain amount of peace when it comes to preparation for high-risk situations and unexpected traumatic events. The plan for high-risk circumstances can be made well in advance. We can permit time to practice and gain confidence. It is useful for trauma survivors to learn about common reactions to trauma and find out what is normal.  When we learn about symptoms, we realize we are not alone.

    Here are some ways of coping with trauma symptoms and our coping plan can consist of some of the recommendations. 

    Unwanted disturbing memories, images or thoughts.

·         We need to remind ourselves that they are just that, memories.

·         Remind ourselves that it’s normal to have some memories of the trauma(s)

·         Discuss them with someone we trust.

·         Remember reminders of the trauma can feel overwhelming, the severity will lessen over time. 

    Unexpected feelings of anxiety or panic.

·         The reactions are not dangerous.

·         These feelings come with scary thoughts that are normally not true such as “I am going to die” or “I will lose control.”

·         We need to take time to slow down our breathing.

·         The scary sensations will dissipate soon and we can go on with what we were doing.   

    Each time we respond to the scary reactions in a positive way, we are working towards making it happen less often.   

       We feel like the trauma is happening again (flashbacks)

·         We need to keep our eyes open and look around and notice where we are.

·         Talk to ourselves and remind ourselves where we are, what the year is, and that we are safe.

·         Get up and move around. Have a drink of water and wash our hands.

·         Contact someone and tell them what is happening.

·         We need to remind ourselves that this is a common response concerning traumatic experiences.

·         Inform our counselor or doctor about the flashback(s)

     We may be having dreams and nightmares concerning the trauma.

·         If we wake up in a panic due to a dream, remind ourselves it is only a dream and we are not in any real danger.

·         We may want to get out of bed and reorient ourselves to the present moment.

·         We may need to engage in a peaceful and calming activity like listening to soothing music.

·         Discuss our nightmares with our doctor, certain medications may be helpful. 

    We struggle with falling or staying asleep.

·         We need to keep a regular bedtime schedule.

·         Avoid exercise a few hours before going to bed.

·         Avoid using our bed for anything other than sleeping and sex.

·         Avoid alcohol, tobacco and caffeine.

·         Do not fret or worry in bed. Get up and do something enjoyable such as reading a calming book, drinking warm milk or herbal tea. Do a quiet hobby. 

    Anger, rage and irritability.

·         We need to take time to cool down or think things over. Sometimes walking away from the situation is the best solution.

·         Exercise daily because it reduces body tension and relieves stress.

·         Remind ourselves that staying angry does not work and actually increases our stress and can cause health issues.

·         Discuss our anger issues with a counselor or doctor. Take classes to learn how to manage our anger.

·         If you became angry with friends or family, take the time to let them know how you feel and what you are doing to cope with your trauma reactions. 

    We may be having difficulty concentrating or staying focused.

·         We need to slow down and give ourselves time to focus on what it is you need to learn or do.

·         We can write things down and make to do lists. (I find this very helpful)

·         We may break down tasks into small doable amounts.

·         Plan a realistic number of events or tasks for each day.

·         Depression may be the culprit so discuss your problem with concentrating with your doctor or counselor.

     We have trouble feeling or expressing positive emotions.

·         Try to make sure to keep taking part in activities that we enjoy. Perhaps we may not feel like we will enjoy the activity, do it anyway and we may start experiencing feelings of pleasure.

·         Remind ourselves that this is a common reaction to trauma. We are not doing this on purpose and we should not feel guilty.

·         Take the time to remind our loved ones that we care, and express our caring in little ways such as sending a card, leaving a small gift and calling someone to touch base (National Center for PTSD, ND). 

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       Everyone is different as far as what feels the most helpful during periods of experiencing triggers and periods of distress. What follows is a list of suggestions that may help us create moments of balance and instill calming effects. Consider experimenting with these or other coping techniques to find out what works best for us. 

·         Creating a daily routine that helps us support a sense of predictability and control.

·         Maintaining a connection with our community.

·         Instill closeness and safe physical touch as a part of our daily life. We can curl up with a pillow, blanket or if available cuddle with a pet, child or partner in our homes.

·         Spending time outside by taking a walk, bike ride, gardening or yardwork.

·         Adding movement and exercise to our repertoire.

·         Looking for personal sources of positivity, inspiration, comfort and joy and apply these to our daily routine. We can read, listen or watch stories that inspire us, make us laugh, nurture our spirituality, or address our core values. Listening to music that lifts our spirits and playing an instrument can do wonders for us. Dancing and participating in rhythmic movements can lift our moods.

·         Being creative by baking, painting drawing, sewing, writing, collaging and making photo albums and scrapbooks can be calming and make us feel productive.

·         For the non-artists, some of us can combat rumination by light but focused problem solving activities such as jigsaw puzzles, crosswords, or Sudoku.

·         Limiting news and media input.

·         Asking for help is important (Pressley and Spinazzola, 2020).

    The activities listed above can be part of an ongoing coping plan to help us deal with unresolved trauma. A plan we can refer to on an ongoing basis.    

Rehearse the Plan 

This is an opportunity to practice our plan and rehearse in a low stress situation like an actress or athlete does to prepare for events. Rehearsing can be done in image or in role play. 

·         Take two to three minutes to recall all our coping actions and all the parts of our coping plan.

·         Examine how well the coping routine worked. What parts seemed to be effective and what was not so effective. At what points did you notice strong emotions?  What are the lessons learned? How would we imagine the situation compared to the real situation?

·         Practice beforehand a daily five-minute visualization of positive coping.

 

 Evaluate and Make Improvements if Needed 

If the plan worked well, or even partially well, we need to give ourselves credit for making and executing it. If the plan needs improvements, identify what needs to be done and practice them (Schiraldi, 1999).

    We need to keep our life in balance and remember to do things that keep us physically fit, nourished and rested. It is important to incorporate pleasurable and enjoyable activities in our life and be kind to ourselves. Like everyone, we are less than perfect and when things do not go smoothly, we are doing the best we can. And we need to remember that help is available when we need and want it.