478: Yikes! I've Relapsed!

Relapse and Relapse Prevention for Overeating Featuring Dr. Angela Krumm

On today's podcast, we proudly feature an old friend, Dr. Angela Krumm, on the topic of relapse prevention for habits and addictions. This is certainly a top of incredible importance, since all treatments for all habits and addictions seem to have extremely high relapse rates. Anything we could do to reduce that would be a major contribution.

Angela was on our Feeling Good Podcast #270 on Nov 29, 2021 describing some TEAM CBT methods she'd developed to deal with her own weight gain. In podcast #270 she taught listeners how to set process goals, instead of outcome focused goals. She then taught about the Triple Paradox, Habit Addiction Log, Devil's Advocate technique, and the Problem-Solution log.

In that first episode she explained that this was a difficult time in her life: her father had died, and she'd also experienced a traumatic fall which caused a concussion. So she fell off being careful about her diet, and one day was shocked that she could not recognize herself—due to weight gain--in a photo, and was on the fast track to Type II Diabetes.

As a result, she utilized many of the TEAM CBT techniques and slowly, but surely, lost weight and kept it off for multiple years. She explains that she was

"solid for a long time, but have to confess, with shame, that I eventually relapsed because I got over-confident. I'd been tracking what I ate, which was an important key for me, and stopped keeping up with it consistently, thinking I didn't really need to anymore."

We reviewed the kinds of tempting thoughts she'd had (and still has, of course, at times), when she feels tempted by her favorites: things like delicious brownies, red wine, and other sweet treats. She has tempting thoughts such as:

1. I deserve to take a break from tracking what I eat.
2. I deserve a treat—I've had a hard day.
3. It's silly to be so rigid. I deserve to eat whatever I want. Spontaneity is one of my core values!

During the podcast, we illustrated the Devil's Advocate Technique (DAT), which is powerful and a lot of fun, but sometimes trickier than it looks. When Angela gave a "good" but not "huge" response to one of these tempting thoughts, I automatically suggested a role-reversal.

Rhonda immediately and rightly reminded us that we never do role-reversals when people are stuck during the Devil's Advocate. Instead, we paradox the person and sit with open hands.

Rhonda modeled this beautifully and it worked like a charm. Angela had a sudden about face and blew the tempting thought out of the water immediately.

We made three teaching points on DAT.

1. Don't give in to the urge to "help." This will have the opposite effect of keeping the patient stuck.
2. Realize that if you're a therapist, and your patient cannot convincingly defeat all the temping thoughts in the office, the likelihood that they can defeat them when they're at home is 0%. So, the DAT is both a powerful technique to boost motivation with tools you can use when tempted, but it is also a powerful test of motivation.
3. Remember to Sit with Open Hands if your patients cannot convincingly defeat their tempting thoughts.

Angela shared that she now realizes that the main reason for her relapse was that she had skipped relapse prevention. This is the danger of being your own therapist, sometimes you make the mistake of cutting corners or getting overly confident. She asked to return to the podcast today to talk about that important mistake and help others prevent that mistake in the future. She wants us to emphasize the important of Relapse Prevention for all habits and addictions.

When Angela mentioned that she'd relapsed in her eating to a therapist who was just learning TEAM-CBT, the therapist seemed shocked and asked, "Oh, does this mean that the techniques we're learning don't actually work?"

This is such a great (but naïve and common) question, because we always emphasize that all patients—in fact all human beings—will relapse after recovery from depression, anxiety, a relationship conflict, or a habit / addiction.

That's why it's so important to tell patients about relapse before discharge from therapy, and do a brief but intensive relapse prevention intervention.

We reviewed several of the Relapse Prevention techniques, including the Problem Solution List and the Relapse Prevention Daily Mood Log, using and recording the Externalization of Voices.

When you do this step with a patient, ask them to imagine the future moment in time when they have relapsed. It's important to capture the thoughts that will lead them to give up and quit using the techniques. Often, these are hopeless thoughts about the usefulness of the techniques or their ability to remain in recovery.

If these thoughts are left unchecked, they will spiral the person into a deeper and more lengthy relapse. If they can predict the thoughts ahead of time and generate powerful rebuttals to use in that moment, then their first moment of relapse can be turned around quickly! We listed several of Angela's predicted negative thoughts during her relapse:

1. I should not have let this happen. 100%
2. I'm not strong enough. 60%
3. It's just too hard to start tracking and logging what I eat again. 65%
4. It will be too painful to have to track and see what I've eaten. 60%
5. This isn't fair. It should be so hard to be healthy! 70%
6. Screw it. I should just accept this and give up! 40%
7. Podcast listeners will judge me because I have gained weight again. 10%

We practiced challenging those thoughts with the Externalization of Voices, and Rhonda summarize several of the strategies that can be the most helpful:

1. Self-Defense
2. The Acceptance Paradox.
3. The Counter-Attack Technique
4. A combination of two or three

Angela summarized three important take home messages from today's podcast.

1. Always prepare a Relapse Daily Mood Log ahead of time, anticipating what you will be telling yourself when you relapse
2. Challenge those thoughts with EOV and record that role-play so you can listen to it in the future when tempted.
3. After you have lost sufficient weight, make a plan to continue your healthier eating after the acute phase. Do NOT make the common mistake of thinking, "Oh, I've achieved my goal of losing 30 pounds (or whatever), so now I'm done, and can go back to my normal eating habits and patterns again."

Thank you for listening today!

Angela, Rhonda, and David