April 1st, 2012

A relapse prevention plan

When I caught myself humming the refrain of a Frank Sinatra song under my breath after morning rounds, I knew I was in for a rough day. That’s the beauty of relapse prevention plans and the reason why we are spending increasingly more of our scarce professional resources teaching this simple method of keeping track of our stress level and learning to avoid or at least to manage situations that threaten to send us over the edge.

Over the edge, otherwise known as relapse behavior, means different things to different people. To the person living with mental illness who has learned to recognize the symptoms of his condition, relapse behavior may be the recurrence of delusional beliefs or strange perceptions, the paranoid thought, for example, that basically trustworthy people are intent on doing him harm or the appearance of voices that interfere with even the simplest tasks of everyday living.

The individual struggling to break the bonds of addiction will recognize relapse behavior in that first drink, ideally before he succumbs to the urge to take it. Even people who believe they have been wrongly hospitalized or imprisoned can develop relapse prevention plans by defining relapse as winding up in jail or on the locked ward of a psychiatric hospital. Relapse is any bad outcome we are trying to prevent or, in the immortal words of one student of the art, “doing something stupid.”

Relapse behaviors are closely associated with risky situations and triggers or events that increase the stress in our lives. Their emergence is often heralded by the appearance of warning signs that take the form changes in our behavior that we or perhaps only the people around us can see. We learn to prevent relapse by defining and trying to maintain a mentally and physically healthy lifestyle with plenty of sleep, good eating habits, meaningful activities to keep us busy, proper medical and mental health care and sharing our time with people we enjoy. All of this helps but, despite our best efforts, life is full of surprises that bring more stress and, before we know it, we are humming Frank Sinatra to ourselves at the locked door of the nurse’s station.

Now there is nothing wrong with a few sub-vocal “do-be-do-be-do’s” but, if you know yourself well enough, you may recognize this as a warning sign when it starts so early in the day. Your personal stress monitor may be calibrated to allow for a bit of spontaneous crooning after supper. After all, the work of a psychologist in a busy hospital is stressful enough even on the most ordinary of days but, when you surprise yourself with a bar or two of Frank so early in the morning, you know that you have entered the Realm of the Warning Sign.

The first rule of the warning sign zone is not to panic. You might remember the advice of the man trying to avoid doing something stupid who said that the first step is to do nothing and think about the consequences before you act. This is where your relapse prevention plan can help by reminding you of the coping strategies you have found especially helpful to manage stress. Old standbys include exercise, deep breathing, positive self-talk, listening to music, walking, talking with a friend, prayer, soothing your senses, distracting yourself, talking with staff and taking a nap.

Not all of these strategies will be equally useful or even possible in every stressful situation. Taking a nap, for example, does not go over well with most employers. Deep breathing, on the other hand, is always an option and it is something you can easily follow with some sober reflection after you have regained your sense of composure. I thought I would catch a few deep breaths in my office but I had to run up four flights of stairs to get there – even better, I reasoned, because now I was getting the chance to add the coping strategy of exercise. I hadn’t planned on listening to music but, as I approached my office, the corridor was swelling with the strains of the “1812 Overture.” The music seemed to come from the pipe organ in the staff stress reduction room where another frazzled colleague was taking a break to collect his or her thoughts. It wasn’t exactly the piece I would have chosen to soothe my spirits but with my door open the acoustics were decent and the music was free. I sat in my comfortable desk chair and breathed in to the count of three, then held for another three-count and exhaled a long stress-relieving breath.

Positive thoughts and constructive ways of re-framing the morning’s challenges started to flow through my cooling brain. It’s a tough job. We’re all under stress. One step at a time and we’ll get all of this done. By the minute I could feel myself getting calmer and more focused, re-gaining a sense of tranquility only to have it shattered by the organ’s rendition of the recurring cannon fire. So I stuck my head out the door and politely yelled a request to the unseen man or woman at the console. How about some Sinatra? Can you play “Strangers in the Night?” Sure you can. Everyone knows the one with the do-be-do-be-do’s. Here, let me hum a few bars.

Alan Bodnar, Ph.D. is a psychologist at Worcester State Hospital and a consultant in the field of leadership development.

By Alan Bodnar Ph.D.

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