Vol. 25 • Issue 22 • Page 26
Teaching patients self-management skills to identify setbacks before they happen and work toward lifelong wellness
By Reji Mathew
Relapse prevention is a system of emotional-psychological and behavioral skills that equip patients to prevent or recognize the signs of breakdowns in self-management of their medical conditions. Relapse-prevention training is a standard treatment intervention in the mental health field for chronic conditions such as addiction, depression, bipolar disorder and anxiety.
But relapse prevention (RP) also can be an invaluable skill-set for rehab patients. Maintaining the gains made in inpatient or outpatient rehabilitation requires self-monitoring or preventing relapses that could cause injury or stop functioning altogether, such as falls, back pain, spasms or fractures.
Identifying Patterns of Relapse
There are three steps to determine patients' patterns of relapse. First is information gathering, either during treatment sessions or by asking patients to reflect and report back in subsequent sessions on what they consider to be their relapse patterns in regards to pain or mobility challenges.
For example, for back problems, a lapse could start as a stiff or achy feeling. A relapse could be constricting pain that inhibits daily goals. A collapse would be when the back shuts down completely, leaving a person bedridden.
The next step is to get into the details of how a patient's relapse cycles get triggered. The mind-body connection is an emerging clinical framework that explores the impact of mental stress on the body and physical stress on the mind (see "The Mind-Body Connection," September 29, 2008). In other words, symptoms have many components: emotional, physical, cognitive and behavioral. Teaching patients to identify the signs of stress is a critical point of learning, as most patients' patterns are cyclical and repetitive. For example, one patient with sciatica suffering with chronic pain was able to identify significant components to her relapses (see Figure 1).
The third-and most important-component of identifying patterns of relapse is helping patients develop a warning-sign system, (i.e., "red flags") so they can self- monitor.
Symptoms within a relapse-prevention framework fall along three categories: chronic, warning and acute. Chronic symptoms are daily, mild levels of aches, stress or fatigue.
Warning symptoms are basically chronic symptoms that escalate, such as aches becoming acute pain. Acute symptoms occur when pain leads to feeling stressed-out and halts functioning.
Help patients come up with external cues that can alert them that they are heading for a relapse. For example, one patient with cerebral palsy uses this strategy: "When I start over-eating and I have not done my laundry or I start missing class, I know I am starting to show warning symptoms and I have to stop and call my family for help."
Building self awareness and self knowledge about how one relapses is the foundation skill to relapse prevention. Inventory training, a common technique in RP, looks beyond the "one day at a time" mindset. It encourages patients to "check in" frequently-morning, noon and night or every two hours, for example.
This self-monitoring helps the patient develop the skill of living in real time; it allows him to see, moment to moment, if he is headed in a direction that may or may not be helpful.
Managing a medical condition can be overwhelming, but when you teach patients to break each month into weeks, or days into units, self-care tasks are more manageable (see "Integrating Behavioral Skills," March 31, 2008). Support groups are a wonderful external "check-in" resource when patients are struggling with self monitoring. In addition, phone appointments, emails or contact with providers in between sessions can foster self-management skills.
Pinpointing Skill Deficits
The process of recovery often involves two steps forward and one step back. Once rehabilitated, chronic patients have to constantly cope with fatigue, pain and mobility changes; setbacks can be both emotional and physical.
Often patients relapse because of a skill deficit, either with a rehab technique or emotional coping strategies. Neither inpatient nor outpatient rehab settings can anticipate every unexpected life stressor a patient may face.
When setbacks do occur, the RP framework can reduce shame for the patient and burnout for the practitioner. Instead of viewing re-admissions as the "patient is back again," both parties can look at these re-encounters as part of the learning curve and another chance to build skills. It is critical to create emotional safety for patients to talk about what may have gone wrong so as to create opportunities for reflection and skill building.
Developing coping cards with patients after each relapse can be a starting point to strengthen coping. These cards can foster optimism and hope (see "Reaching for Possibilities," July 22, 2008), and can involve three main skills-training areas: cognitive therapy, positive self talk (see "Anxiety Management Training," May 26, 2008) and lifestyle modification. The following coping card is from a patient struggling with fibromyalgia (see Figure 2).
Relapse Prevention and Wellness
Dr. Scott Kellogg, cognitive-therapy and relapse-prevention expert at New York University, reminds practitioners that once a patient makes a commitment to his treatment, relapses are a process of "falling forward, not backward."
Relapse prevention skills require practice, patience and repetition. Patients who can master these skills come to learn that they are central to experiencing fuller lives.
Reji Mathew, PhD, is a psychotherapist/clinical instructor at New York University. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive-behavioral skills training. Reach her via e-mail at her Web site: rejimathewwriter.com.