By Dr. Evan V. Vida, PsyD
How do I maintain my therapy gains?
As a cognitive-behavioral therapy (CBT) practitioner, I prioritize treatments that are not just effective, but also efficient. That’s why when someone walks in my door for therapy, one of the first things I say is that my goal is to get you to fire me. Not because I’m doing a poor job, but because I want you to be able to rely on yourself to weather whatever storm you may face in the future. CBT aims to equip you with skills to navigate life's challenges, skills that endure well beyond therapy sessions. I expect us to merge our expertise—you in understanding yourself, and me in managing anxiety—so that you're equipped to apply therapy skills to your life's unique challenges by the end of treatment. With any good CBT, the final phase of treatment should focus on the maintenance of gains and relapse prevention. It is a core element of all effective treatments - just as important as every component prior. Before we dive into what relapse prevention techniques entail, let’s first discuss…
What is a lapse vs a relapse?
So, what is the expectation once therapy is over? Is it to never again fall back into old behaviors and routines? Not necessarily. People usually come to therapy after many many years of responding to adversity with behaviors that may not have served them well. Just like with any repetitive behavior, these become habits. The trouble with habits is that not only are they hard to break, but they’re easy to re-learn once we’ve broken them. But, repeating an old habit doesn't mean all progress is lost. This is the difference between a lapse versus a relapse. A lapse is a brief hiccup, a moment to recognize and rededicate ourselves to the strategies learned in therapy, whereas a relapse marks a return to old patterns, signaling a disconnect from the therapy skills once mastered. While a lapse is not usually indicative of a need to return to therapy, a relapse is. In fact, it's normal to experience lapses post-therapy; they're part of the journey. Our goal is to curb these lapses, preventing them from escalating into significant setbacks. The problem is that relapses are not always immediate, and can often be slow, insidious returns to old behaviors.
Let’s look at an example of two patients, Patient A and Patient B who successfully treated their nail biting. Both of our example patients may have terminated therapy and are totally nail-biting-free. Two months later, both patients find themselves in a very stressful situation and without thinking, notice they have bitten the nail on their thumb. Patient A acknowledges the slip and proactively contains the behavior. Maybe they put on a pair of gloves so that there is one extra barrier to nail biting. Patient A is utilizing their relapse prevention plan (more on this later) and is able to get back to where they wanted to be. Patient B, on the other hand, may not be as aware of what’s going on and let’s the behavior continue. Or, they do notice and tell themselves, “It’s just my thumb, maybe I can allow myself to bite only my thumb when I’m stressed.” Eventually, the goalposts will shift again and Patient B is now telling themselves, “I’ll just bite both my thumbs but that’s it!” Both thumbs will likely turn into all fingers, resulting in a full-blown relapse.
So, what can we do to stop ourselves from relapsing? The answer is coming up with a maintenance/relapse prevention plan.
Strategies for maintaining therapy gains
1. Develop a relapse prevention plan with your therapist before ending therapy
A relapse prevention plan is a detailed, specific, and individualized plan with information and skills learned in therapy that will help you maintain your gains. The information might include triggers to look out for, warning signs, skills to maintain, and more. There is no one-size-fits-all approach for these so make sure to talk to your therapist about developing a plan specific to your needs.
2. Review your treatment materials
A great way to keep yourself fresh months after ending therapy is by reviewing your treatment materials. There is no way to plan for every struggle you will face post-therapy, so it will be necessary to take what you learn and apply skills to these novel situations. Reviewing your completed homework, taking a look at your exposure hierarchy, or re-familiarizing yourself with your individualized treatment plan can help you stay sharp and remind yourself what to do when you face a difficult situation.
3. Make therapy skills a habit
Therapy's end doesn't signal the end of your journey; practice is key. Just like with any skill or habit, therapy skills require practice. Try your best to make your skills a part of your normal routine. It doesn’t need to be too complex! It can be as simple as devoting 5 minutes per day to mindfulness practice or filling out a thought log with a tricky worry.
4. Look out for “permission statements”
A “permission statement” is something we tell ourselves to excuse slipping back into unhelpful behaviors. As mentioned previously, bad habits reform in a slow, insidious manner. Similar to Patient B above, you may excuse biting your nails on one finger by telling yourself “It’s just one finger," but one finger turns into two, which then turns into a relapse.
5. Utilize support systems
No one has to go on alone. Family, friends, and other trusted individuals can be a crucial source of support. Depending on your personal comfort, letting trusted people know what you have struggled with and how you may be at risk of falling back into old behaviors can help you stay accountable. Two heads are better than one! A trusted person may be able to quickly spot changes in behavior or old habits subtly returning.
6. Know when to reach back out
Sometimes, we need a bit more support when our skills stop working. If that’s the case, reaching back out to your therapist is crucial. No, you are not back to square one. Typically, a session or two is all that’s needed to get back in the saddle. We like to call these “booster sessions,” which are time-limited re-engagements with therapy. You and your therapist can discuss the problems you’re facing and determine what is needed.
CBT can be an invaluable tool that re-opens doors previously shut by mental health struggles. But like any skill or habit, we can lose our edge if we don’t keep up dedicated practice. By using the suggestions in this article, your hard work can continue to flourish long after therapy ends.
Dr. Vida is a postdoctoral fellow at the Center for Anxiety & Behavior Therapy. He specializes in providing evidence-based treatments for a variety of anxiety disorders including OCD, PTSD, panic and agoraphobia, generalized anxiety disorder, social anxiety disorder, body dysmorphic disorder, body-focused repetitive behaviors, and more. Visit our contact page if you are interested in seeking treatment with Dr. Vida.