By Beau Black

It’s possible to plan ahead to decrease the chances of relapse after you leave treatment. Therapist and author Lisa Ferentz discusses this challenging part of treatment and offers a realistic and proactive process that helps patients prevent a relapse before it begins.

Ferentz’s “Creatively and Compassionately Addressing the Impulse to Self-Harm and Relapse” explains the process she uses to help patients head off the urge to relapse when it begins. She uses the acronym CARESS (or simply, ‘“CARES” if the word “caress” evokes a negative response) to describe the three steps:

• Communicate Alternatively
• Release Endorphins
• Self-Soothe

To provide some context for these steps, Ferentz says that her approach to treating trauma and the coping strategies that flow from traumatic experience is to “de-pathologize” them. She says, “I remind myself, This person is cutting; this person is picking up and using; this person is bingeing and purging because, this is their way of attempting to navigate their thoughts, feelings, and interpersonal dynamics that feel challenging, stressful, or overwhelming.”

Ferentz says that it’s important to give the client some alternatives early on in the process. “Unless we’ve given our clients other ways to [regulate their emotions], the soothing — unless we’ve given them other tools — they’re going to get dysregulated again.” This is why, she says, relapse is such a common occurrence.

“Rather than jumping to, We’ve got to get rid of this behavior, I began to get curious about what purposes the behavior was serving, why it felt necessary to hold onto the behavior. What did they think they were going to lose if they gave up the behavior?” Instead of focusing on what you gain, Ferentz says it’s important to identify what you will lose so you can understand the purpose these harmful behaviors are serving.

Ferentz sees the CARESS process as a way to give patients the ability to self-regulate, become more self-reliant, and to “avoid treatment becoming a game of whack-a-mole.”

Understanding Self-Harm and Relapse

The National Center for PTSD defines self-harm as the act of harming your body on purpose, usually as a result of past trauma. Those susceptible to self-harm may struggle with frequent feelings of worry, depression, low self-esteem, or impulsive aggressiveness. Relapse, on the other hand, refers to returning to a prior habit you have not participated in for some time. These two definitions are often synonymous with each other, as someone experiencing a relapse may reengage in self-harming behaviors like cutting, burning, hair-pulling, choking, or resuming addictions like drugs or alcohol. 

Usually someone engaging in self-harm or experiencing a relapse is doing so to cope with emotional distress or other triggers, such as increased anxiety, traumatic flashbacks, and even recent abuse. As a result, you may pursue harmful behaviors as a cry for help to get others to notice your struggles. Some may relapse to punish themselves or try to feel more in control of their lives. 

Once you act out with self-harm, you may feel guilt or shame, leading to a damaging cycle of even more self-harm, says the National Alliance on Mental Illness (NAMI). However, there are healthier, more productive support systems for managing urges and overcoming triggers. When faced with difficult times, it’s important to seek guidance from a trusted adult — such as a professional therapist — to get the help needed to cope. 

Recognizing the Warning Signs of Relapse

If you have a history of self-harm or relapse, there are key emotional and behavioral warning signs that can indicate it could happen again. Personally, you may be struggling with loneliness or experiencing social isolation. You may begin to lose interest in the activities you once enjoyed. You may start having consistent feelings of worthlessness or hopelessness about your future circumstances, leading to increased anxiety or depression. Or you may even experience invasive thoughts about self-harm or begin to romanticize your former addictions. 

Families with loved ones who’ve dealt with self-harm can also be on the lookout for specific behavioral signs that they may start or have already begun to relapse. These can include:

• Wearing long-sleeved clothing when it’s warm to hide injuries
• Prolonged time alone in their room
• Neglecting physical appearance 

Self-awareness is important to cultivate for anyone struggling with the thought of self-harm, so you can take steps to prevent a future relapse. When triggers arise, having a plan to overcome them through healthy recovery techniques and strong support systems with others can make a difference. Self-care activities and personal reflection can also be vital tools to help you understand the source of your emotional distress and improve your physical and mental wellness.

Using the CARESS Process as a Coping Strategy for Self-Harm and Relapse Prevention

When you feel triggered or on the verge of acting out/relapsing, you can use the CARESS process to short-circuit an old, destructive pattern and pursue healthy alternatives. Ferentz suggests setting a timer for 10 to 15 minutes for each of the three steps of the process. She also encourages patients to fill a box with all the materials you’ll need so it’s all in one place and ready to go when you start. Here are some ways to follow through on the three steps:

1. Communicate Alternatively

Draw, make a collage, sculpt clay, write in a journal, create a poem, or record thoughts/feelings. Traumatic experience is encoded on our bodies and minds in ways that can make it difficult to put into words. This step gives you room to experiment with different ways of expressing feelings and helps you articulate what is often difficult to say.

2. Release Endorphins

Engaging in physical activity like exercise, hugging, and laughter all trigger the body to release endorphins. Endorphins dull the brain’s pain receptors and create a feeling of euphoria. Ferentz suggests using YouTube as an easy source for funny videos; watching a favorite comedy is another option.

3. Self-Soothe

Taking a warm bath, singing, meditating, playing music, using aromatherapy, and coloring something intricate are all ways to comfort and calm ourselves.

Why Use a Timer for the CARESS Steps?

“Many people who engage in [self-harm and addiction] behaviors are dissociative,” Ferentz says. “Drinking, getting high,  bingeing, all have elements of dissociation.” They trade one behavior in which to zone out for another, Ferentz says. That’s why she advises allowing 10 to 15 minutes per step because it buys you 30 to 45 minutes of something constructive that will meet the same needs as your old self-destructive coping strategies. Because the self-destructive impulse often lasts about 20 minutes, the process can help pass that time productively.

Ferentz says it’s important to use the process before “I do X” and not instead of. It gives you ways to achieve what you get from that behavior so that it becomes moot. It also helps to release endorphins in ways that do not exacerbate the feelings you’re trying to move away from.

For many, self-harming is a form of communication. “When a client is in a form of self-harm, they are showing me their pain. There’s a narrative there,” she says. Giving them a safe space to communicate what’s happening to them and why they feel the need to give into that impulse is crucial.

Celebrating Progress

Every recovery takes time. If you’ve experienced a relapse in your journey to overcome habits of self-harm and addiction, don’t lose heart. Setbacks, though unwelcome, are a natural part of the process, so don’t let them derail the work you’ve already done. Instead, continue to apply healthy coping strategies like the CARESS process and be accountable to your support systems.  

At the same time, make it a priority to reflect on the progress you’ve made and the emotional regulation victories you’ve achieved along the way. Write these milestones down in a journal to remember them later. As you celebrate your accomplishments, it only becomes more evident that long-term healing is attainable. 

Reach Out for Help with Self-Harm and Relapse Prevention

The CARESS process offers a positive, practical way to sidestep old destructive patterns and create new, productive ones that actually help manage trauma and addiction.

If you or someone you love needs treatment for self-harm or addiction, please contact our team today. We would be glad to help you find the path to healing and mental wellness.