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Jun 5, 2023

Live Therapy with Veena:

Part 3 of 3

Relapse Prevention Training

In the last two weeks, you heard Parts 1 and 2 of our live work with Veena, a young woman who felt devastated for fear she would be unable to conceive. One week after the work with Veena, I received a request from colleagues to have a Tuesday evening session at Stanford on Relapse Prevention Training (RPT). Jill and I decided to demonstrate the RPT techniques with Veena so we could demonstrate this technique in real time with a real situation.

Prior to the role play demonstrations that you will hear, I presented the highlights of RPT with four PowerPoint slides. Here are the guidelines when working with a patient who is depressed:

1. Do RPT immediately when the patient has recovered, and before you discharge the patient. This means that the patient’s scores on the Brief Mood Survey will be low and the patient is feeling terrific. If the patient’s scores are still elevated, they have still not recovered completely, and need more therapy work.

2, Inform the patient that the likelihood of relapse is 100%. Relapse is defined as one minute or more of feeling upset. By that definition, most of us relapse frequently, perhaps every day. However, these relapses do not have to be a problem if you anticipate them and know how to deal with them.

3. When they relapse, they will typically experience two kinds of negative thoughts. First, the negative thoughts that had previously will return. So, in Veena’s case, she will again be probably telling herself that “I cannot be happy without a kid,” “my in-laws will judge me and sideline me,” and so forth. Veena imagined having a relapse and prepared a Daily Mood Log prior to the training group. If you would like, you can review it here.

4. In addition, nearly everyone who relapses will have thoughts like these:

  • This relapse proves that the therapy did not work.

  • I’m a failure.

  • I’m a hopeless case and I’ll be depressed forever.

  • When I thought I’d recovered I was just fooling myself. I’ve been he same worthless person the whole time.

  • My recovery was just a fluke.

It’s crucial to challenge these thoughts with the Externalization of Voices technique ahead of time, BEFORE the patient relapses. That’s because they can easily see the many distortions in these thoughts when they’re in a good mood. But if you don’t do RPT, and wait until the patient relapses, the patient may be devastated, or even suicidal, and you, the therapist, will have lost much or all of your credibility.

In contrast, when I prepare the patient for relapse, I tell them that their first relapse will actually be a GOOD thing, because when they pull out of the relapse, then they’ll know for sure that they have the tools they need to defeat their negative thoughts whenever they’re upset for the rest of their life.

And that is the crucial difference between FEELING better, which is what happens the first time they recover, and GETTTING better, which is what happens when they recover from their first relapse.

I had them record their role-playing with me defeating their relapse thoughts with Externalization of Voices, and tell them to listen to that recording whenever they relapse. And that if they can’t pull out of the relapse on their own, they can always come back for a session or two for a tune-up.

I also tell my patients I hope they will relapse often, because if they don’t ever relapse, I won’t ever see them again, and this is a sad thought since I’ve just gotten to know them and really like them.

When I was in clinical practice, relapses were rare. Only a handful of patients ever returned for a tune-up, and it was almost always one or two sessions and then they were on their way again. Of course, this was not a controlled outcome study, since I was in private practice, but  it was definitely encouraging.

In summary, RPT can save you from a lot of grief when your patients relapse, and it may even save the lives of some of them. It doesn’t take long, 30 minutes or so at most, but the payoffs can be tremendous.

Thank you for listening today!

Veena, Rhonda, Jill, and David