Guest Post: Relapse Prevention



Every year around this time, I have a few patients who graduate from high school with plans to go away to college. I also have patients who are preparing to go away to summer camp, take a vacation without their parents, or study abroad. At this time of year, kids are usually relieved that school is ending and excited about the experiences that wait for them just over the horizon. But for parents, this can be a time of trepidation and uncertainty.

Most children, teenagers, and young adults with eating disorders are able to recover successfully with
the help of their families and guidance from skilled clinicians. Once recovered, most of these young
people can maintain their wellness while living at home with the protection of their families. But when
they are removed from their parents’ watchful eyes and their treatment team’s steady support, relapse
is more likely to occur.

Let’s face it: relapse happens. Parents must remain mindful of this possibility forever. The child’s
genetic susceptibility to eating disorders - the unique biology that makes her more prone to getting
trapped in the claws of this vicious illness – is there for life. That being said, I have treated many
individuals who have recovered from eating disorders and successfully made the transition to college
or other independent living situations without relapse. I have also worked with many younger children
who have recovered fully and gone on to lead full, active, independent teenage lives. It can be done!

A written relapse prevention plan serves multiple functions. First, it provides patients and their families with both objective and subjective means to assess how the patient is doing. Second, it helps families determine when and how to intervene when their child is struggling. Finally, it spells out the expectations and responsibilities of the patient as well as the family.

I believe it is helpful for patients, parents, and clinicians to work together on a written relapse
prevention plan under the following circumstances:

• The patient’s illness is in remission and he/she is preparing to be discharged from treatment

• The patient is preparing to go away to college or another independent living situation

• The patient would like to begin playing sports, taking dance classes, or participating in another
type of physical activity

• The patient would like to do something that requires a greater level of independence (e.g., going away to summer camp, taking a trip without parental supervision, getting a job)

I work with patients and their families to construct a relapse prevention plan which includes an
assessment checklist as well as interventions tailored to the patient’s particular level of recovery or relapse.

Part 1: Assessment Checklist

The assessment checklist includes subjective items that the patient may recognize in himself or herself, as well as objective signs that are observable to others. I use the following categories:

• Green light signs – these are indications that the patient is in remission from the eating disorder as well as any other comorbid conditions.

• Yellow light signs – these are signs that suggest that the patient is struggling. In other words, early signs that a relapse may be around the corner. For patients in remission from restrictive eating disorders, I generally consider any weight up to 5 pounds below the bottom of their target weight range to be a yellow light sign. For patients whose symptoms have included bingeing and purging, I generally consider one episode of bingeing or one episode of purging to be a yellow light sign.

• Red light signs – these signal that a relapse has occurred. For patients who have restrictive eating disorders, I generally consider it a red light sign when a patient’s weight drops more than five pounds below the bottom of her target range. For those whose eating disorders have included binge/purge symptoms, I typically consider two or more episodes of bingeing and/or purging to be a red light sign.

Part 2: Interventions

The interventions are tailored specifically to the green, yellow, and red light categories listed above.

• Green light interventions are basic preventative wellness behaviors to help patients maintain their remission. For a college student, green light interventions may include weigh-ins at the health center every two weeks and maintaining a structured eating schedule of three meals and two snacks per day.

• Yellow light interventions are designed to provide patients with extra support when they are struggling in attempt to prevent relapse. This typically involves more frequent weigh-ins, more meal support, and more contact with clinicians. For example, yellow light interventions for a college student may involve coming home every weekend for supervised meals.

• Red light interventions are designed to stop a relapse as soon as possible and generally involve a return home to the safety of regular family meals and parental support. For a college student, red light interventions often involve taking a medical leave of absence for the rest of the semester. For a high school athlete, a red light intervention may involve quitting sports for the rest of the season.

Part 3: Signatures

The signatures of each family member, including the patient, represent an understanding of the plan
and an agreement to abide by it. Any clinicians involved in the execution of this plan should also sign it and keep a copy in the patient’s file.

Here is an example of a relapse prevention plan for a recovered patient who is preparing to go away
to college. This plan helped my patient, whom I will call Jane Doe, make a successful transition to the
university of her dreams in another state while maintaining excellent physical and mental health.




Dr. Sarah K. Ravin Ph.D., is a licensed psychologist and trained scientist-practitioner.  She specializes in treating pre-teens, adolescents, and young adults with eating disorders, depression, anxiety, and related issues.  Dr. Ravin believes parents are a child’s greatest resource in recovery and works to keep parents fully informed and actively involved in each step of the process, from initial evaluation to relapse prevention. She views parents as the leaders of their child’s treatment team, and provides parents with the latest scientific information on their child’s illness, empowering them to make decisions about their child’s care and supporting them through the process. 

Comments

  1. This is really, really valuable information. Thank you so much for posting. I was frustrated because my daughter's original "followup" team, which I fired, gave me really bad advice which landed my daughter back in another recovery facility. Confidence in the parents to do right by their child is a rare and wonderful treasure.

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  2. Dr. Ravin, thank you for outlining the preventative steps we parents can take to hold on to hard-fought progress in treating our child's eating disorder. Re-feeding and eradicating ED behaviors is tiring work. By agreeing to a plan like the sample you outlined, it appears we can agree up front when we need to step back in an nudge (yellow) or bail out (red) the sufferer. This is another tool that empowers parents to be an integral part of the treatment process.

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  3. This is great. It helps create clarity from what can seem like a lot of grey areas. I love how you posted a real example.

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  4. We've been using this since you posted it! Thanks -

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