Rationale
A significant positive development in the mental health field is growing recognition that a
diagnosis of mental illness is not a life sentence to an incurable condition that invariably will
have only negative consequences for a person’s life course. This was the view that, until
recently, was commonly held by many consumers, their families and clinicians. While the
onset of mental illness is undoubtedly a serious life event, many people who have
experienced mental illness live full and meaningful lives: some remain symptom free after
their first episode, while others adapt to the symptoms that they recurrently experience. It is
now recognised that it is not inevitable that a first episode will lead to further illness and that
even when further episodes do occur, it is not necessary for such illness to put an end to the
positive aspects of life.
There are three possible scenarios following the initial onset of mental illness:
• no further episodes of mental illness;
• occasional recurrent episodes of mental illness; and
• chronic mental illness with repeated episodes.
For people who have experienced a first episode of mental illness, the risk of future episodes
is increased, and efforts to prevent recurrent episodes are essential to reduce the impact of
mental illness for consumers, their families and carers, and their communities. Consequently,
ways to prevent recurrent episodes and reduce their impact on wellbeing have become a
valuable area of investigation. A growing body of evidence attests that such relapse
prevention is possible.
Relapse prevention has been recognised as a high priority for some time. The National Action
Plan for Promotion, Prevention and Early Intervention for Mental Health (2000) [Action
Plan 2000] acknowledged the importance of relapse prevention and early intervention for
recurrent mental illness and identified these as areas for future action. It was noted in Action
Plan 2000 that many of the issues related to promotion, prevention and early intervention for
mental health were also relevant to preventing relapse, but that there were likely to be unique
factors for people who had already been diagnosed with a mental illness that warranted
separate consideration in another document.
The Evaluation of the Second National Mental Health Plan (2003) reported that early
intervention, for both first and recurrent episodes of mental illness, was an area where there
was still considerable need for improvement in terms of Australia’s mental health care
system. Continuity of care, in all its forms—across the course of an episode of illness, across
the lifespan, and across service sectors—was also an area where greater emphasis and
innovative approaches were urgently required.
Most recently, relapse prevention is clearly evident in the National Mental Health Plan 2003-
2008 as an area that requires increased focus. Factors related to relapse prevention are
emphasised throughout the Plan, particularly in the sections on preventing mental health
problems, access to care, continuity of care, support for families and carers, consumer rights
and legislation, and consumer and carer participation.
Page 2
Aims
This paper considers the issue of relapse prevention for people who have been seriously
affected by a mental illness. Of primary importance throughout the document are the voices
of people affected by mental illness and their families and carers, whose experiences are
highlighted. The paper investigates the role of relapse prevention within the recovery process,
through the following:
• definitions of relapse prevention and a discussion of its place within the recovery process;
• a review of the literature in terms of what is currently understood about the effectiveness
of relapse prevention and the types of processes that are involved;
• a description of the elements of relapse prevention;
• a consideration of the unique needs regarding relapse prevention for significant
population groups in Australia; and
• a summary of the main actions that need to be undertaken to implement relapse
prevention as part of continuing care.
Exploration of the multiple views regarding a definition of relapse prevention is first
undertaken. The paper then considers the place of relapse prevention within the spectrum of
interventions for mental health and its role within a recovery framework. The current level of
evidence related to the factors that may impact on relapse is presented: these are the factors
that need to be understood to develop interventions to enable people with mental illness to
stay well by reducing the likelihood and impact of relapse. The basic elements of relapse
prevention are then described, followed by consideration of how these elements need to be
considered for population groups with special needs and that are of particular significance
within Australia. Finally, the actions that need to be prioritised under the current directions of
the National Mental Health Plan 2003-2008, in order to maximise wellbeing for people with
mental illness through relapse prevention, are considered.
The overall aim is to present the issues related to relapse prevention as currently understood
in an Australian context. It is hoped that collating this information will provide a resource
that enables people affected by mental illness, their families and carers, as well as policy
makers, service planners and providers of clinical and non-clinical support services, to
implement relapse prevention as an essential component of continuing care for people who
have been seriously affected by mental illness.
Audiences
The monograph has been developed to inform several different audiences, recognising that
understanding relapse prevention needs to be progressed from multiple perspectives. These
diverse audiences are:
• People of all ages who have experienced mental illness — It is hoped that this
monograph will provide information to enable people who have experienced mental
illness to understand the factors that may affect their risk of relapse so that they can more
effectively self-manage their condition to maximise their wellbeing. These people also
need information to enable them to negotiate the mental health care system to access all
the services they require to prevent relapse. For some, it is also important to have
information to enable them to advise and advocate for consumers, in general, and to be
able to participate in ensuring the safety and quality of services by advising service
providers, service planners and policy makers.
Page 3
• Families and carers — Families and carers also need information to understand relapse
prevention and how they can provide effective support for consumers. They need to be
aware of their role in self-management and also to be able to negotiate the mental health
care system to obtain the services they and their family member require to prevent relapse
and support recovery. Some family members and carers also need to be informed so as to
be able to advise and advocate for carers, in general, and participate in ensuring the safety
and quality of services by advising service providers, service planners and policy makers.
• Primary care services, particularly general practitioners — Primary care providers,
including general practitioners, have an essential role in relapse prevention. They need to
be informed and supported in this role to ensure that effective relapse prevention is
implemented for their clients/patients.
• Case managers — Case managers also have a vital role in relapse prevention for many
people who have been seriously affected by mental illness. Case managers need to be
recognised and supported in this role and be able to ensure that relapse prevention plans
are in place for their clients and that their clients receive all the services they require to
maximise their recovery.
• Providers of non-clinical support services — Providers of non-clinical support services
need to have their essential role in relapse prevention recognised and supported.
Psychosocial and psychiatric rehabilitation services need to be integrated within
continuing care pathways, and be appropriately resourced to meet the level of population
need.
• Providers of clinical services — Providers of clinical services, both acute and non-acute,
must begin to routinely implement relapse prevention planning for their clients/patients.
This means ensuring that the care pathways, support services, communication systems
and partnerships are in place to support continuing care through support for selfmanagement,
rehabilitation and recovery.
• Service managers, workforce planners, policy makers — The management, planning
and policy-making systems that are necessary to support implementation of relapse
prevention need to ensure that the procedures, workforce skills, infrastructure, policy and
funding frameworks are put in place to enable relapse prevention to be routinely and
effectively incorporated within continuity of care.
• Whole community — Community education is required so that all members of the
community understand the impact of everyday actions, particularly stigma, on the
wellbeing of people who have experience mental illness and their families.
Scope
There is no simple or universally agreed definition of mental illness, and a wide range of
conditions and disorders can be included under this term. In the National Mental Health Plan
2003-2008, mental illness is defined as “a clinically diagnosable disorder that significantly
interferes with an individual’s cognitive, emotional or social abilities. A diagnosis of mental
illness is generally made according to the classification systems of the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-IVR) (APA 1994) or the
International Classification of Diseases, Tenth Edition (ICD-10) (WHO 1992). These
classification systems apply to a wide range of mental disorders (for the DSM-IV) and mental
and physical disorders (for the ICD-10).” (p5).
In the context of this paper, a more narrow view of mental illness is adopted, with mental
illness comprising psychotic and major mood disorders: primarily psychosis, schizophrenia,
bipolar affective disorder, major depression, anxiety disorders and eating disorders. Imposing
Page 4
these boundaries around the definition of mental illness was necessary to contain the scope to
be more manageable. These particular disorders were selected as the primary focus because
they are of major concern to consumers and their families and carers as they seriously impact
on current and future wellbeing. They also tend to be the mental illnesses that have received
the most attention in the literature and are the core business of many specialist mental health
services. Nevertheless, it is expected that the issues covered in the paper will be relevant
more generally to other mental illness and mental health problems, as well as other long-term
health conditions.
Methodology
It was imperative that this paper be based on and guided by the experiences of people with
mental illness and their families and carers. It was also important that the views of service
providers, who have the responsibility of providing clinical and non-clinical support to
people with mental illness, be incorporated. Consequently, the methodology used to develop
the paper was based on ensuring that the views of all these people were presented.
There were five main components to the methodology, as shown in Figure 1. These
components were undertaken in late 2003 and comprised:
• Liaison with Auseinet and Auseinet Consumer and Carer Consultative Committee — The
Australian Network for Promotion, Prevention and Early Intervention for Mental Health
and Suicide Prevention (Auseinet) was an important resource, providing networks and
information. Of particular note, Auseinet’s Consumer and Carer Consultative Committee
provided essential guidance. This Committee comprised consumer and carer
representatives invited from all States and Territories, with New South Wales, Victoria,
South Australia, Western Australia, Tasmania and the Northern Territory represented at
the time of developing this paper. These people helped to access consumer and carer
networks within each of the jurisdictions. Their personal experiences were also an
invaluable resource, and a focus group was undertaken with the members of the
Consultative Committee prior to the other consultations to develop a discussion
framework.
• National consultation with consumers and carers — Focus groups and interviews were
conducted across Australia with male and female consumers of all ages and representing
a cross-section of the community in terms of social, economic and cultural backgrounds,
as well as their families and carers. Focus groups and interviews were generally taped and
transcribed (after which the original tapes were erased) and direct quotes from these
conversations are anonymously presented throughout the document. Focus groups and
interviews were undertaken according to the principles outlined in the National Statement
on Ethical Conduct in Research Involving Humans (NHMRC 1999). Furthermore,
specific ethical issues related to undertaking research with mental health consumers were
also taken into consideration (see Peterson 1999).
• National consultation with service providers and stakeholders — The views of service
providers, from both clinical and community support services, and representatives from
peak mental health organisations were also obtained through focus groups and interviews
conducted across Australia. Direct quotes from these conversations also are anonymously
presented throughout the document.
• Review of the national and international literatures — A review of the national and
international literatures related to relapse prevention was undertaken. This involved a
search of relevant computerised databases, as well as resources provided by Auseinet and
some of the stakeholders contacted during the national consultations. The literature
Page 5
review was not intended to be exhaustive, but rather was used to provide a summary of
the main issues that have been researched relevant to relapse prevention for mental
illness.
• Review of current State/Territory initiatives in relapse prevention — Each State and
Territory nominated a representative from the government mental health sector to provide
information on current State/Territory initiatives related to relapse prevention. These
representatives were personally contacted by phone and email to elicit information around
current initiatives in each of the jurisdictions. This process aimed to develop an
understanding of some of the major initiatives being undertaken that related to relapse
prevention in each of the States and Territories, to provide a current Australian context to
the discussion paper.
Figure 1. Methodology used to develop the paper
Please note that this monograph is an up-dated version of the discussion paper developed
through this methodology. The original discussion paper was entitled, Pathways of Recovery:
Preventing Relapse. A discussion paper on the role of relapse prevention in the recovery
process for people who have been seriously affected by mental illness. This discussion paper
formed the basis of a further national consultation around the issue of relapse prevention,
undertaken in late 2004. Consultations were held in all States and Territories and submissions
were invited from over 50 relevant organisations. The methodology and major findings of
this national consultation are documented in a separate report, and an implementation
Framework was developed as an outcome of the further consultation. These supporting
documents are:
• Pathways of Recovery: 4As Framework for Preventing Further Episodes of Mental
Illness
• Pathways of Recovery: Report of the National Consultation on Preventing Further
Episodes of Mental Illness
National consultation with service
providers and stakeholders
National
consultation with
consumers and
their families and
carers
Review of the
national and
international
literatures
Review of current
State/Territory
initiatives in relapse
prevention
Liaison with Auseinet
and Auseinet
Consumer and Carer
Consultative
Committee
METHODOLOGY
Page 6
Policy background
Relapse prevention has been a major part of the policy agenda since the advent of the
National Mental Health Strategy in 1992. It was fundamental to many of the priority areas for
reform and especially pertinent in the move from institutional to community-based mental
health care. In the First Plan, which applied from 1992-1998, relapse prevention was evident
in the prioritising of community care options following deinstitutionalisation. In the Second
Plan, which covered the period from 1998-2003, relapse prevention was made more explicit
with greater emphasis placed on promotion and prevention at that time.
In response to the higher priority afforded promotion and prevention in the Second Plan, a
National Action Plan for Promotion, Prevention and Early Intervention for Mental Health
[Action Plan 2000] was developed and published in 2000 by the National Mental Health
Promotion and Prevention Working Party, which is auspiced by the Australian Health
Ministers’ Advisory Council National Mental Health Working Group and the National Public
Health Partnership Group. This document, and its accompanying Monograph 2000, presented
a rationale and framework for intervening earlier in the developmental trajectory of mental
health problems and mental illnesses, based on a growing body of evidence demonstrating
that more could be done to reduce the impact of mental illness by widening the spectrum of
interventions beyond a treatment approach. Interventions to promote mental health for all
Australians regardless of their current mental health status, to prevent the development of
mental health problems and mental illnesses for those at risk, and to intervene early for those
people showing signs of mental illness, were advocated in order to invest in the longer-term
to improve the mental health and wellbeing of Australians.
Action Plan 2000 and Monograph 2000 describe a spectrum of interventions for mental
health, arguing that a balance of interventions across the entire spectrum is required to
effectively meet challenges in mental health care (see Figure 2). These documents
concentrated on the first half of the spectrum and did not consider issues of promotion,
prevention and early intervention in terms of continuing care for people with mental illness. It
was acknowledged, however, that many of the issues relevant to promotion, prevention and
early intervention for mental health were also likely to be pertinent to relapse prevention, but
that there were sufficient distinctions to warrant the separate consideration of relapse
prevention within another document.
In Action Plan 2000, relapse prevention was included in the spectrum of interventions under
the sections termed ‘Continuing Care’, which was defined as:
Continuing care comprises interventions for individuals whose disorders continue or recur.
The aim is to provide optimal clinical treatment and the necessary rehabilitation and support
services in order to prevent relapse or the recurrence of symptoms, and to maintain optimal
functioning to promote recovery. Rehabilitation may focus on vocational, educational, social,
and cognitive functioning. Ongoing mental health promotion and the reduction of risk factors
and enhancement of protective factors are still relevant at this end of the spectrum to
facilitate and support recovery and ongoing wellbeing. (Monograph 2000 p33)
Monograph 2000 defined relapse prevention as:
Relapse prevention refers to interventions in response to the early signs of recurring mental
disorder for people who have already experienced a mental disorder. Relapse prevention is a
critical issue for this group of people, their families, mental health services and the wider
community. Recognition of the early signs of recurrent disorder and the appropriate
treatment responses comprise a unique area of investigation. (p33)
Page 7
Universal
Selective
Indicated
Symptom
identification
Early
treatment
Standard
treatment
Engagement
with longer-term
treatment and
support
Long-term care
Mental Health Promotion
(including relapse
prevention)
Figure 2. Spectrum of interventions for mental health
Source: Adapted from Action Plan 2000 and Mrazek & Haggerty 1994.
Note: This Figure shows the spectrum as amended to include recovery as in the National Mental Health Plan 2003-2008.
Since publication of Action Plan 2000 and Monograph 2000 there has been increased
emphasis on continuing care pathways for people who have experience mental illness. The
Evaluation of the Second National Mental Health Plan (2003) reported that continuity of care
“remains an elusive goal for the complex systems that deliver mental health care. In
particular, follow-up care into the community after hospitalisation for an acute episode is
often lacking and puts consumers at risk.” (p2). Relapse prevention and early intervention, for
first and recurrent episodes of mental illness, were identified as areas where there remains
considerable need for improvement in terms of Australia’s mental health care system.
Continuity of care, in all its forms—across the course of an episode of illness, across the
lifespan, and across service sectors—urgently required action and innovation.
The importance of applying a recovery orientation within mental health services was also
identified in the Evaluation of the Second National Mental Health Plan. The concept of
recovery has emerged as a central issue and is strongly advocated by many people who have
been affected by mental illness. As a consequence, providing services to people with mental
illness within a recovery orientation is a fundamental principle of the National Mental Health
Plan 2003-2008, in which recovery is defined as:
a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills
and/or roles. It is a way of living a satisfying, hopeful and contributing life. Recovery involves
the development of new meaning and purpose in one’s life as one grows beyond the
catastrophic effects of psychiatric disability. (adapted from Anthony 2000 p11)
A growing body of clinical evidence reveals that the long-term prognoses of people with
mental illness are more hopeful than previously realised (Anthony 2000). Outdated beliefs of
the inevitable adverse impact of mental illness should no longer be perpetuated, and instead,
an atmosphere of hope and a belief in human potential must pervade mental health service
delivery. Implementing a recovery orientation requires an attitude shift for many service
Page 8
providers in order to support consumer rights and provide the types of services that maximise
wellbeing for people with mental illness. Specific approaches and plans aimed at reducing the
likelihood and impact of relapse are an important component of this approach to continuing
care.
Page 9
WHAT IS RELAPSE PREVENTION?
In the National Mental Health Plan 2003-2008, relapse prevention is defined as “reducing
recurrence of illness and strengthening functional capacity” (p37). This minimal definition
does not, however, adequately account for the diversity of views regarding relapse prevention
nor its conceptual richness, and it is timely to more fully develop this definition.
Defining relapse
‘Relapse’ is a word that is used in many different ways in a variety of contexts. It is defined
in the Macquarie Dictionary as “to fall or slip back into a former state, practice, etc”. In the
Australian Concise Oxford Dictionary, it is defined as “deterioration in a patient’s condition
after a partial recovery”.
It is used most commonly within a medical context, where it is a word that is clearly
understood by health practitioners to mean returning to a diagnosable state of mental illness:
a mental state that has previously been diagnosed and the symptoms of which have returned
to the point where the threshold has again been reached for diagnosis. Relapse is evident by
recontact with services in the form of another acute episode of illness that requires service
intervention, often hospitalisation. Most acute service providers within the mental health care
system use the word relapse and believe that it is a useful and commonly understood term.
We all understand, clinicians that is, what we mean by relapse in a mental health context. It’s
another acute episode that requires intervention, often hospitalisation. —Clinician
Relapse is a term that is less well accepted and less clearly applied within the more personal
context of the experience of people with mental illness. It is seen as a “clinical term”, “not the
usual language” and “not used in everyday language”. In general, most people who have
experienced mental illness do not use the term relapse at all and are more likely to talk in
terms of being “well” or “unwell”. For many people who have experienced mental illness,
relapse has an underlying negative sentiment; it implies “going backwards”, “failing” and
“back to square one”.
Relapse is a sense of failure. Relapse means this kind of concept of falling right back into it,
back where you were. When what’s really happening is that I’m moving on all the time;
sometimes it’s two steps forward one step back, but I’m always learning and moving on.
Relapse means going right back to the start and nobody can stand to think like that.
—Consumer
The negative connotations of the term ‘relapse’ are evident in that it is a term used primarily
in the context of mental illness and substance use disorders; it is not generally applied to
other illness conditions. As one consumer noted:
If you have had a heart attack and have another heart attack, no-one says you have relapsed;
they say you had another heart attack. —Consumer
Furthermore, some consumers seriously affected by mental illness argue that the notion of
relapse is irrelevant to them because they “have not really been well since the first time”. The
chronic nature of their illness has meant that while they have periods of being more or less
well, they do not think that they have been well enough to have been able to ‘relapse’.
Page 10
I’ve never been to hospital myself and my episode has lasted 17 years. I’ve never had a
relapse because I’ve been there ever since. I mean I go up and down but I don’t think I’ve ever
been well. —Consumer
There are also degrees of relapse, and what one person defines as a relapse, another may not.
In contrast, the medical diagnosis of relapse depends on meeting specific thresholds that
dichotomise experiences into either illness or health.
I sometimes think about it in terms of if someone’s got a problem with their knee and they
limp, some days they’ll be better than others and they might still limp all the time but they’ll
still be able to do the things that they want to do. So, in terms of having a mental limp is a
way of looking at the extent of mental illness: some days it might be crutches, some days it
might be the wheelchair, some days you might be fine. —Consumer
It depends whether relapse means a complete hospital experience — whether you come back
to the very, very lowest of low or just not being as well as you want. —Consumer
Most people with mental illness do not think of their life course in terms of relapses.
Generally, the reality of experiencing mental illness is a process of change and development:
the same process experienced by all people as they age and mature. Few people think in
terms of going backwards to a previous state as implied by the term ‘relapse’.
The negative associations of the word ‘relapse’ are not congruent with a recovery orientation
to mental illness. Consequently, some consumers argue that relapse is a “non-word” and that
“it doesn’t exist”. When consumers were asked during the consultations what would be a
better word, they had difficulty coming up with a preferred term, but generally agreed that
they tended to use the term ‘episode’ rather than ‘relapse’. The experience of recurrent
symptoms of mental illness is perceived as a continuous move forward through the life
course. This is consistent with a recovery orientation, where people with mental illness are
acknowledged to change and mature, as all people do.
I see episodes – it’s just a pattern of life – this is part of my life. Relapse is a sense of failure.
Episodes is a more neutral term. It’s just the reality of certain people in our community. To
relapse means a sense of it’s our fault when the reality often is that we have done an amazing
job to stay calm and healthy for such a long time. —Consumer
Families and carers are also aware that “illnesses fluctuate”. They can become aware of
“something happening”, “all’s not well”, “a feeling” and the “need to do something”. They
agree that the term ‘relapse’ is generally applied within the context of medical intervention; it
is when an acute episode of illness occurs that requires medical intervention. However, it is
also applied by family members to acknowledge the change from when the person is
“coping” to when they are “not coping and need help”. Relapse implies upheaval and
disruption for families and carers and for some it implies a constant process of monitoring
and source of distress.
I’m always watching for the signs. I’m horribly fearful of a really bad patch starting all over
again. —Family member
Differences of opinion sometimes occur between the person with a mental illness and their
family members regarding whether a relapse may be occurring, but there is also frequently
agreement.
I can always tell when another episode is on the way, it’s so clear to me, but he can
sometimes get really angry and accuse me of being smothering and hypervigilant. —Carer
Page 11
It might take my mum to say you really don’t seem to be feeling very well and then I’ll realise
and it will all click into place. It does creep up sometimes. —Consumer
The concept of relapse is also less clear for providers of psychiatric disability support and
rehabilitation services compared with acute and clinical services. While a “full-blown relapse
that requires hospital admission” is clearly understood as a relapse, providers of support
services are also aware of periods of more or less “wellness” as experienced by their clients.
Periods of being “unwell” can affect clients’ ability to cope with their lives, and it is this level
of complexity that is evident to non-clinical and non-acute service providers who argue that
they are in a position to recognise variations in wellness.
We see them when they’re well, sometimes when they’re really unwell, and everyplace in
between. —Rehabilitation services provider
Finally, it is important to note that there does not need to be an agreed definition of the term
‘relapse’ in order to consider ways to prevent relapse. There are no generally accepted criteria
for relapse; it is a relative term and must take into account: the person’s condition before the
original onset of illness; his/her level of functioning before the present episode; and the
severity of the relapse in terms of symptom severity, duration and interference with personal
functioning. Relapse needs to be evaluated at the symptomatic, phenomenological and
behavioural levels (Lader 1995). It impacts on interpersonal, social and occupational
activities and has wider implications for the family in general, the provision of medical and
social services, and for health economics.
Regardless of lack of total agreement on what comprises relapse, maximising wellness by
reducing the recurrence or exacerbation of symptoms was universally acknowledged in the
consultations as an important goal for people who have experienced mental illness, their
families and carers, and mental health and community support services.
Defining relapse prevention
The term ‘relapse prevention’ also prompted considerable debate and elicited a wide range of
views during the consultations. Again, negative connotations and a strong perceived
association with medical terminology were commonly reported.
Relapse prevention implies a medical perspective and a definition that is one of control and
one-sided. —Carer
Within the medical literature, relapse prevention generally refers to illness management
through compliance with medication regimes. It is widely accepted that people who have
been seriously affected by mental illness are at risk of relapse if they do not take their
medication as prescribed. Consequently, much of the relevant literature focuses on
encouraging compliance with medication regimes through psycho-education and cognitive
behavioural techniques (see Mueser et al 2002).
Relapse prevention is also generally acknowledged to involve recognising early warning
signs of relapse and responding quickly and effectively. Awareness of early warning signs
and planning around how to respond to these were seen as key tools for preventing relapse.
I’ve had eight relapses and I recognise that if I start hearing voices or hallucinations or
visualisations and if that increases a couple of days in a row, and I start isolating myself and
not eating properly – that’s a clear sign that I’m getting unwell again. Then I’ll do less work
or study and activities for awhile and when I get over it I’ll build them up again. If it goes on
for awhile I might have to change my medication or increase it. —Consumer
Page 12
I notice him start to isolate himself. He stays in his room, won’t come out for meals. The best
thing to do to start with is get one of his friends in touch. Getting him up and out and about
can stop it progressing. —Family member
He [flatmate] knows if I’m staying in bed too long he’ll knock on my door and say “Get up!
Come on mate, get up, get out of bed” He’ll be a bit like a parent, but you need that every
now and again. —Consumer
Beyond awareness of early warning signs and complying with medication there was,
however, no clear view regarding what else relapse prevention might entail. Many people in
the consultations initially had a negative reaction to the term ‘relapse prevention’, which they
thought comprised only medication compliance. However, when they began to think of what
they actually did to reduce the recurrence of symptoms, they realised that they did undertake
many actions that would be defined as relapse prevention, and that these were important and
empowering for them.
Most people recognised that relapse prevention means putting in place supports to stay as
well as possible and to reduce the likelihood and strength of future illness symptoms. This
was seen as a process of “illness management” in the context of a chronic illness rather than
‘relapse prevention’ per se. It was understood to be a learning process that takes time and is
constantly evolving. It is a process that “is a continuum” and “occurs in a context”.
Many people reported that they did not have much insight into preventing relapse after their
first episode, but learned with repeat episodes what their triggers and wellness needs were.
Relapse prevention is seen as part of the process of self-discovery. It involves developing
“personal strategies” to cope with symptoms and stressors and to maintain wellness.
Families and carers similarly regard relapse prevention as a learning process of coming to
understand “how and if to act”. Relapse prevention was highlighted as “happening on an
interpersonal level” and “being part of the education process”.
Providers of non-clinical and non-acute services also emphasised evolving learning about the
individual at risk and their environment and the importance of developing trusting
relationships to facilitate this learning.
Planning was viewed as fundamental to relapse prevention. Many people who had
experienced mental illness and their families and carers had, either explicitly or implicitly, a
plan to attempt to reduce the likelihood of relapse when the early warning signs commenced.
Many services also had relapse or recovery plans for clients.
I used to have a list of things to check that I put on my fridge with basic things like to ring
someone and ask, ‘ How do you think I’m sounding?’ or ‘When was the last time you saw
your psychiatrist?’ and ‘Have you taken your medication?’, ‘How many coffees have you had
today?’. If you get to the end of the list maybe there are some other things you need to do
because you’re going to need some help. —Consumer
It’s all about planning and knowing what to do and making sure you’ve checked everything.
You have to get together and agree on it all and then have it all there in front of you ready to
go through. —Carer
Lists are important in terms of what do I have to do today. Do I have to go and have a coffee
with someone or do I have to go and exercise. Just like everybody else does, it’s just that the
consequences of what can happen if you don’t maintain your mental health can be a lot more
severe. —Consumer
Page 13
Identifying stressors and ways to deal with them was another common element. Repeatedly,
people who had experienced mental illness and their families and carers emphasised the
importance of minimising stress and reducing stressful activities when early warning signs
began to emerge.
Just not stressing myself out. Not do too much. —Consumer
One clear one was cutting down stress levels. —Carer
Finally, fundamental to attempts to prevent relapse was an emphasis on building
relationships, communication and trust. Recognition of early warning signs and developing
effective responses to them was invariably based on having trusting relationships and good
communication with other people, preferably with a whole range of people involved in the
ongoing support of a person with mental illness.
My case manager can tell when I’m listening to voices – she’s really good. That’s someone
I’ve been with for three years. I’ve had three or four doctors in that time, but she’s good. You
need to build the trust with someone. You need to build a stable relationship with someone –
it doesn’t matter if it’s a doctor or a mate – someone who recognises what’s going on, will get
you out of bed, motivate you, know you can look after yourself and they can look after you.
That’s a big part of stopping relapses getting extremely dramatic. —Consumer
The consultations revealed that relapse prevention is not a concept that is explicitly well
understood, but it became evident after prompting that people were, in fact, implementing
elements of relapse prevention. While in the research literature relapse prevention has a
narrow definition and is usually applied in the context of medication compliance and
recognition of early warning signs, there is clearly much more to preventing relapse that has
not been explored. It is a construct that needs to be more fully understood and its role and
functions, within a recovery orientation, clarified.
The post Preventing Further Episodes of Mental Illness (Monograph) appeared first on My Assignment Online.