048: Relapse Prevention Training

A reader ask how to handle relapses following recovery from depression. David emphasizes the importance of this question, since there is a 100% probably that every patient will relapse following recovery. And if the patient has not been properly prepared, the relapses can be disastrous. But on the other hand, if the patient has been prepared, the relapses do not have to be problematic.

What is a relapse? David defines a relapse as one minute or more of feeling crappy. Given that definition, we all relapse pretty much every day. However, some people can pop out of a bad mood really quickly, while others can get stuck in these "relapses" for weeks, months, or even years.

David describes the Relapse Prevention Training (RPT) techniques he has developed, but cautions that RPT does not make sense until the patient has experienced a complete elimination of symptoms. If the patient is being treated for depression, that means that the score the depression test has fallen all the way to zero (no symptoms whatsoever) and that the patients feel joy and self-esteem.

There are four keys to David's RPT, including:

1. The patient must be informed that relapse is an absolute certainty. The question is not "will this patient relapse" but rather, "when will this patient relapse?"
2. Patients have to know that the therapy technique that worked for them the first time they recovered will always work for them. It might be the Cost-Benefit analysis, Pleasure-Predicting Sheet, Acceptance Paradox, Double Standard Technique, Five Secrets of Effective Communication, Hidden Emotion Technique, or Experimental Technique, or simply recording their negative thoughts on the Daily Mood Log and identifying the distortions in them.
3. Patients need to identify and modify the Self-Defeating Beliefs (SDBs) that triggered their depression and anxiety in the first place, such as Perfectionism, Perceived Perfectionism, or the Achievement, Love or Approval Addictions. In several previous podcasts, David and Fabrice have described the Uncovering Techniques that can be used to quickly pinpoint any patient's SDBs.
4. Patients need to write down and challenge the Negative Thoughts that will inevitably emerge at the time they relapse, such as "This relapse proves I'm hopeless after all," or "This relapse proves the therapy didn't work," etc.

David and Fabrice illustrate step #4 using a powerful technique called Externalization of Voices. David has patients record this role play procedure on a cell phone or other recording device so they can play it and listen if needed during an actual relapse.

David explains that he used this approach with every patient he discharged, and encouraged them all to come back anytime they had a relapse that they couldn't handle. In spite of having more than 35,000 therapy sessions with individuals with severe depression and anxiety, David says that he can count on two hands the number who every returned for "tune-ups" following termination of therapy, and in most of those cases, the patients were able to recover once again in just or two sessions.

In the next Feeling Good Podcast, David and his highly esteemed colleague, Dr. Matthew May, will begin their live work with Marilyn, a severely depressed colleague who is facing "The Dark Night of the Soul." Fabrice, as usual, will narrate and elicit enlightening commentaries on the therapeutic strategies that David and Matt are using as the session with Marilyn unfolds.