RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
Recovery is a Process; Not an Event
Recovery has a beginning but no ending because it is an ongoing process. Relapse prevention planning
needs to also be an ongoing process and the sooner it is discussed and begun, the better. It begins with
the development of a core plan that is revised and enhanced over time.
You are either moving forward in recovery or backwards towards relapse
Where are you on the continuum?
RELAPSE --------Æ-------Æ-------Æ--------Æ--------Æ--------Æ-------ÆRECOVERY
Understanding the Relapse Process
Relapse refers to the process of returning to eating disorder symptoms and behaviors after a period of
abstinence. Relapse is always a possibility. Every treatment program and approach needs to integrate
relapse prevention planning. It is essential to learn how to recognize signs of slipping and relapse and to
devise a plan for effectively coping with warning signs to prevent relapse.
The relapse process can start with a thought and can take place prior to ever acting on urges. A relapse
can build up over a period of hours, days, weeks or even months. When it takes place you can learn from
it and identify clues (signs/indicators) that preceded and triggered the relapse.
Relapse triggers, cues, or warning signs, may relate to changes in your behavior, attitudes, feelings,
thoughts, or a combination of these. The first step is identifying your individual triggers and then
identifying & utilizing skills, support and a plan of action to promote progress in recovery and prevent
moving backwards towards relapse. Triggers can either be avoided or need to be neutralized. The
attached document includes a list of relapse warning signs that are broken down into categories under
“ED’s ineffective means of coping.” Please take time to identify the ones that pertain to you.
Relapse Prevention Planning
Relapse prevention planning is a process of learning about the tools needed for recovery and developing
a plan to minimize the likelihood of engaging in old behaviors, and maximize the likelihood of
succeeding in developing a healthy recovery and a life you enjoy living! Having a well-developed plan
to prevent a full-blown relapse is an integral part of treatment and recovery from an eating disorder.
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
A slip in your recovery isn’t the same thing as a relapse. A SLIP is a backwards step in
recovery. Recovery is not about perfection. A slip is one incident, one behavior, one event, or even one
day. It is a short period of time or an isolated occurrence. When a slip occurs, it is important to have a
relapse prevention plan in place in order to prevent a full-blown relapse. Sometimes, a slip is a signal to
you that parts of your relapse prevention plan may need to be changed to better meet your needs.
A RELAPSE is a continued pattern of behaviors (i.e. a series of slips/lapses) that signal you or others
that you are struggling in your recovery and may require help from others to get back on track.
Sometimes, that may mean returning to a more structured level of treatment. While this may not be your
ideal situation, sometimes a brief “tune-up” can get someone who has already completed treatment back
on the road to recovery.
A number of specific skill areas are important for establishing a solid relapse prevention plan. These
areas are identified in the attached plan under the heading of “Effective coping skills for patients and
family members.” Please check the ones that you have developed and can integrate into your recovery
and work with your treatment team on expanding your recovery tools, skills and support network.
Support Network
Your support network consists of those people around you that you rely on for support in a variety of
situations. Many people with eating disorders isolate themselves from other people, especially those
that care and seek to support recovery and not enable the eating disorder. A support network can consist
of family members, friends, neighbors, co-workers, professionals, clergy and other people who are
involved in our lives on a regular basis as well as treatment team providers. Take some time to identify
the members of your recovery support network.
Relapse Prevention Contract
Please take time to review and complete the attached relapse prevention contract. It was developed to be
utilized as a guideline to aid you in developing a comprehensive plan for recovery and to be enhanced
and revised over time. Please share it with your family members, current treatment providers and
support network as well as all future providers.
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
RELAPSE PREVENTION CONTRACT
Fundamentals
• Full recovery is possible and you deserve it.
• The overall goal is to try to decrease
ineffective coping strategies while increasing
effective coping skills and enhance empowerment and self-esteem.
• My recovery weight range as established with my treatment team is from _____ to
_____ pounds at the height of ______ inches and ______ years old.
BEHAVIORS: Ineffective/Unhealthy Behaviors to Focus on Decreasing
□ Restriction of Intake
Identify typical pattern and progression: _________________________________
Specific triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Consuming a limited variety of food/exchanges or limiting certain groups of food
previously consumed (i.e. fat, desserts, protein)
Identify specific patterns: _____________________________________________
Specific Triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Purging after eating snacks/meals without
binge eating
Identify patterns & high-risk places/foods/signs/indicators: __________________
Specific Triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Over Eating or Mindless Eating: either binge eating or emotional pattern of eating
(eating when not hungry and to the point of being uncomfortably full)
□ Followed by purging in some form
□ NO engagement in purging
Identify typical pattern: ______________________________________________
Specific Triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Use of laxatives or diuretics
Identify signs & indicators of use: _____________________________________
Specific Triggers: __________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Taking diet pills, stimulants or other non-prescribed drugs.
Identify signs & indicators of use: _____________________________________
Specific Triggers: __________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Engaging in excessive/compulsive exercise or exercising in a manner that is against
treatment team’s advice.
Identify signs & indicators: ___________________________________________
Specific Triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
□ Engaging in self-injurious behaviors i.e. cutting
Identify signs & indicators: ___________________________________________
Specific Triggers: ___________________________________________________
Action plan for relapse:_______________________________________________
Signs/Indicators: ___________________________________________________
ED’S INEFFECTIVE MEANS OF COPING: Behavioral Risk Signs/Indicators
Weight/Dietary/Nutritional Risk Signs/Indicators
□ Weight loss or frequent/rapid fluctuations in weight
□ Weighing self or increased use of scale.
□ Demonstrating bizarre eating habits
(i.e. food rituals, extremely fast or slow pace or
eating, excessive cutting, chopping or chewing of food, etc.)
□ Mindless eating and grazing instead of eating structures and planned meals/snacks
□ Hiding or discarding of food.
□ Not eating unless prompted or monitored.
□ Dieting or engaging in diet-like behaviors.
□ Avoidance of social eating situations and/or increased anxiety around meals/snacks.
□ Missing/skipping/forgetting meals or snacks
(intentional or unintentional)
□ Intentionally not responding to physical hunger/satiety cues.
□ Increase in food preoccupation
(time spent thinking about food, cooking for others, thinking
about eating)
□ Calorie counting, looking up calories on the Internet, label reading
□ Weighing/measuring food
□ More arguments surrounding food/eating/negotiating treatment/recovery.
□ Consuming diet/low calorie foods
□ Increased caffeine intake
□ Increased consumption of carbonated diet/no calorie/low-calorie beverages
□ Increased gum chewing
□ Binge eating
(objective or subjective)
□ Purging.
□ _________________________________________________
Behavioral Risk Signs/Indicators
□ Increased rigidity in behaviors, thinking, etc.
□ Engaging in “body-checking” behaviors.
□ Engagement in rituals, obsessive and/or compulsive behaviors.
□ Increased secrecy, dishonesty and incongruence between actions and behaviors.
□ More frequent showers/baths/use of bathroom especially following eating.
□ Change in attire (more or less revealing clothing)
□ Change in self-care and/or hygiene.
□ Canceling/avoiding appointments with treatment providers
□ Change in degree of engagement in treatment sessions.
□ Expression of sudden desire to make change in treatment plan
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Seeking to discontinue taking prescribed medications w/o any justified reason.
□ Change in sleep schedule/patterns; staying up later at night, sleeping longer, etc.
□ Reading triggering magazines, articles, books, online information.
□ Exercising in a manner incongruent with recovery plan and/or exercising as a means of
weight control verses activity.
□ Symptom substitution pattern; replacing one behavior/symptom with another.
□ _________________________________________________
Emotional Risk Signs/Indicators:
□ Increase in “harm avoidance”: inhibited behavior, pessimistic worry in anticipation of
problems, fear of uncertainty & negative forecasting of outcome
□ Change from approaching fearful situations/uncomfortable emotions to avoidance
□ Increase in argumentativeness, moodiness, irritability.
□ Increased depression.
□ Negative emotions surrounding body image
□ Self Esteem unduly based on weight, shape and appearance
□ Ineffective expression of negative emotions (either too much or not at all
□ Feeling overwhelmed by stress, emotions, or the responsibility of recovery.
□ Anger, towards self or others, hostility, pessimistic outlook especially re: recovery
□ Increased feelings of hopelessness and helplessness.
□ Feeling numb.
□ Increase in anger, sadness, anxiety and/or fear.
□ Guilt/shame and/or sense of worthlessness
□ Guilt and shame which leads to more negative emotions and symptoms.
□ More rigid and/or obsessive about food, exercise, eating and/or in general
□ Feeling “Fat” more often
□ Anhedonia
□ Self-pity i.e. “why me” or “poor me”.
□ Resentment.
□ Repressing thoughts, feelings and needs.
□ _________________________________________________
Cognitive Risk Signs/Indicators:
□ Increase in self criticism; negative comments about physical appearance & weight
□ Defensiveness when support people seek to talk about recovery.
□ Feeling over confident, asserting need for space, trust, freedom, no longer needing
support, accountability, etc.
□ Disregard for relapse warning signs and triggers, minimizing risks or rationalization
□ Dwelling on the past, resentments, negativity and things that cannot be changed.
□ Self doubt regarding ability to recover
□ Feeling sick & tired of working so hard every day at recovery.
□ Need for instant results, increased impatience.
□ Increased drive towards perfectionism.
□ Self doubt, self-invalidation & increase in comparisons to others.
□ Increase in thoughts about food, weight, eating and premeditation about eating or
engaging in symptoms.
□ Maintaining dichotomous thinking, black and white or all or none thinking
□
Increased difficulties with set-shifting (cognitive flexibility) and avoidance.
□ Ruminating about calories, food consumed, food, etc.
□ Attention/Concentration difficulties
□ Messianic or sense of destiny
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Increase in urges, pre-meditation of acting on urges and “euphoric recall”: glamorization
of how good the good ole days were with disregard of the consequences
□ _________________________________________________
Physical Risk Signs/Indicators:
□ Changes in weight: gain/loss or frequent shifts & fluctuations
□ Frequent complaints about tiredness, weakness, loss of energy.
□ Scars, scratches, marks on body either unexplainable or justified.
□ Changes in appearance/texture of hair/skin/nails/teeth
□ Changes in grooming, attire, appearance
□ Cold intolerance
□ Inability to fall/stay asleep or fitful sleep
□ Loss of menstrual cycle or menstrual irregularities after being consistent.
□ Frequently sick or not feeling well.
□ Excessive bruising, physical aches and pains
□ Loss of hair, thinning of hair, brittle texture and/or growth of lanugos
□ _________________________________________________
Interpersonal/Social/Relationship Risk Signs/Indicators:
□ Change from trusting others to increased mistrust, paranoia & fear.
□ The eating disorder seems to be running/controlling the individual/home/family.
□ More arguments surrounding food/eating/negotiating treatment/recovery.
□ Increase in social withdrawal/isolation/avoidance of previously enjoyed activities.
□ Avoidance of seeking out help and of recovery support network
□ Treatment appointments used as a place to complain and vent but lack of following
through to make changes
□ Relationship conflicts: dishonesty, deceit, avoidance
□ Boundary/Limit issues in relationships.
□ Competition with other sufferers or comparisons of symptoms
□ Problems setting boundaries & limits (i.e. involved in too many activities, spending too
much time tending to others not allowing time for self care)
□ Imbalance between leisure/work/school and self-care
□ Maintaining unrealistic demands on self with disregard of consequences
□ Passivity: appears to go along with what others are doing instead of actively expressing
thoughts, feelings or opinions
□ Misdirecting anger and negative emotions onto family and support people
□ _________________________________________________
EFFECTIVE COPING SKILLS FOR PATIENTS & FAMILY MEMBERS
□ Use Dialectical Behavior Therapy (DBT) Skills
□ Interpersonal Effectiveness Skills
□ Expression of thoughts, opinions & emotions (i.e. anger, sadness, anxiety, or
fear) in an interpersonally effective manner
□ Active Listening
□ Effective use of support including asking for help without shame/guilt
□ Demonstrating respect towards others, their opinions and differences (even
when I might not agree with them)
□ Development of increased respect/tolerance of family members limits
□ Development of confidence to form and express thoughts, feelings and
opinions and tolerate disagreement with others
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Emotion Regulation Skills
□ Identify emotions & use skills instead of symptoms to effectively cope
□ Do something fun/enjoyable on a daily basis to increase positive emotions.
□ Reduce vulnerability to negative emotions by maintaining overall balance in
sleep, eating, self-care, and use of skills/support.
□ Use my gratitude list as a way to focus on the positives.
□ “Opposite Action” skill to approach instead of avoid.
□ Release emotions by writing in a diary or talking about them instead of using
symptoms
□ Distress Tolerance Skills
□ Use of “Self-Soothing” skill
□ Use of distractions as a skill.
□ Use of “Radical Acceptance” skill to accept what I cannot change.
□ Make a pros verses cons list to aid in decision-making.
□ Use skills/support to turn willfulness into willingness.
□ Use relaxation techniques and/or mindful breathing to get grounded.
□ “Stop & Think” before acting
□ Delay acting on urges by using skills/support/planning
□ Urge Surfing Skill: observe & describe the urge & use skills to see it through
□ Mindfulness Skills
□ Use of “conveyer belt” to increase awareness & focus on observing and
describing without judgment
□ Use of “Wise Mind” to counteract emotional mind
□ Focus on doing what is effective in the moment.
□ Mindful breathing
□ Use of therapeutic mantra i.e. breath in, breath out
□ Use
Self Care Skills
□ Establishing & maintaining healthy boundaries & limits
□ Establishing/maintaining healthy boundaries and limits for myself that balance
work, leisure, self-care and family time.
□ Get adequate sleep on nightly basis
□ Make and take time for myself.
□ Regularly engage in leisure activities
□ Take pride in how I act, look and feel
□ Do something nice for myself.
□ Take a personal day or vacation (i.e. 2 hours off work for “me-time”
□ Spend time alone with my spouse/significant other/________.
□ Utilize and increase my social support network.
□ Learn and practice new coping skills and strategies.
□ Time management planning to add structure/accountability to my day/week
especially during high-risk times
□ Optimism.
□ Confidence.
□ Balanced/Mindful Eating
□ Maintain a non-diet approach towards eating, weight and body image
□ Prioritize regular mealtimes and having family meals.
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Eat foods/meals that I enjoy.
□ Mindful eating.
□ Follow my meal plan or individual dietary recommendations.
□ Engage in activity for enjoyment not exercise
□ Use of meal buddies for accountability/support
□ Planning meals/snacks in advance as needed to promote effectiveness
□ Use of accountability following meals.
□ Avoid or neutralize high-risk places/situations/times/events.
□ Use Cognitive Behavior Therapy (CBT) Skills
□ Use of cognitive restructuring to work through urges and not act on them.
□ Confront/combat cognitive distortions
□ Replace negative/self-defeating thoughts with empowering ones.
□ Develop the ability to see and experience the shades of gray
□ Role modeling confidence in my self and not solely evaluating self -esteem &
self worth based on physical appearances
□ Utilization of self-validation and positive affirmations to combat negative body
image and ED thoughts
□ Focus on the positives as a skill to stay in the moment.
□ Separation of self from ED/illness: I am not my eating disorder, I have choices.
□ Development of multi-faceted nature of Self-Esteem not based just on weight,
shape and appearance
□ Use of mantras in the moment to manage urges
□ Goal Setting
□ Setting realistic & attainable goals with specific objectives
□ Celebrate goal attainment and progress.
□ Use Other Coping Skills
□ Humor
□ Effective utilization of therapy & provider appointments to work through issues
□ Openly discuss thoughts, feelings & urges and any engagement in symptoms/behaviors
□ Identification of personal & recovery strengths
GRATITUDE LIST: ED is always willing to point out the down sides of recovery therefore it’s
important to take time to focus on the upsides of recovery. What are you grateful for? Despite the
low points of your day what were the high points?
I am grateful for……
□ My friends and family and their ongoing support
□ the unconditional love that my cat/dog/pet provides.
□ the fact that today is almost over and I didn’t act on urges.
□ the support of my treatment team.
□ getting through a very challenging day.
□ having a job and a consistent paycheck.
□ my health.
□ my iPod and the hours of distraction that it provides after days like today
□ the beautiful sunshine
□ the smell of coffee that started my morning
□ what my body is able to do for me when well-nourished
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ having my parents/grandparents in my life.
□ my new electric toothbrush.
□ the fact that my car is still drivable and takes me where I need to go
□ the wonderful support community that I have
□ defying the ED voice and eating a little extra dinner tonight
□ free applications on iTunes.
□ technology, especially my laptop
□ ending my day with a mindful browsing trip at Target!
□ today being payday!
□ being able to get lost for a while in a good book!
□ Frivolous fun
□ Lighthearted vanity
□ Quirky relatives
□ Silly YouTube videos
□ Online blogs that are conducive towards recovery
MY SUPPORT NETWORK: List the names, numbers, & contact information for the members
of your recovery support network as well as their role in your recovery
My Treatment Team Members
□ Individual Therapist Name _____________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
□ Family/Marital/Group Therapist Name___________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
□ Primary Care Physician Name ___________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
□ Dietitian Name ________________________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
□ Psychiatrist Name _____________________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
□ Other Team Member’s Name ___________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
RELAPSE PREVENTION CONTRACT
Stephanie B. Milstein, Ph.D. @ Dennis & Moye & Associates, P.C.
(248) 451-9085 x25 [email protected]
□ Other Team Member’s Name ___________________________________________
Address __________________________________________________________
Phone #:_______________ Fax #: _______________ Email _______________
Dates of Treatment _______________ Frequency of Appointments ___________
My Recovery Support Network
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □ Socialization □ Processing Issues □ Other
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □ Socialization □ Processing Issues □ Other
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □ Socialization □ Processing Issues □ Other
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □ Socialization □ Processing Issues □ Other
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □
Socialization □ Processing Issues □ Other
□ Support Person Name/Relationship ______________________________________
Address __________________________________________________________
Phone #:_______________ Cell #: _______________ Email _______________
Role/Type of Support: _______________________________________________
□ Skills Coaching □ Distraction □ Socialization □ Processing Issues □ Other
