A relapse occurs when a person in recovery re-experiences problems or
symptoms associated with his or her disorders. With substance use
disorders, a relapse means a return to problem substance use after a
period of abstinence or controlled use. With mental health disorders,
a relapse is a flare-up of symptoms that are associated with the
disorder. A relapse of one disorder can sometimes trigger relapse of
There are many contributing factors and warning signs that indicate
that a person may be in danger of returning to substance use or
redeveloping symptoms related to mental health problems.
A relapse is an expected part of the recovery process in substance use
treatment. Usually there are warning signs that start long before the
relapse. It is possible to identify these warning signs and take
action to prevent a relapse.
If a relapse does occur, it is not a sign that treatment has failed,
or that a person has a weak character, or that the caregiver is at
fault in any way. A person with a substance use problem needs to learn
and practise a variety of skills to prevent relapses. A relapse should
be seen as an opportunity for the person to think about how to manage
similar situations in the future. However, if someone relapses over
and over again, it may be a sign of a more serious, undiagnosed
disorder, such as posttraumatic stress disorder.
It’s common for people to have ongoing urges and cravings that they
must deal with to prevent a relapse.
People may experience situations or feelings that put them at greater
risk of relapsing. A person who has a stressful, demanding life may
see substance use as the only way to get pleasure or escape stress.
The following factors can increase the chances that a person will
• negative emotional states, such as anger, anxiety, depression,
frustration or boredom
• conflict with others that leads to negative emotions
• social pressure from peers who use substances.
Positive occasions, such as birthdays, anniversaries or reunions may
also increase the chances of a relapse if alcohol is part of the
celebration. Any intense feelings, even happy ones, can be
uncomfortable for some people. As a result, they may use substances to
try and reduce the emotional intensity. Other people may use
substances to try and intensify positive emotions.
Preventing substance use relapse
A person who copes effectively with high-risk situations is less
likely to relapse. Also, a person who recognizes that substance use
can lead to negative consequences, despite the fact that it may bring
temporary pleasure, is less likely to relapse than a person who only
acknowledges the pleasure.
When people have one relapse, their reaction to this “slip” can affect
whether they go back to a pattern of heavy use. People who feel that
they have no control over their use are more likely to use substances
again. Those who see the relapse as a single event in which they
didn’t cope effectively, and as an opportunity to develop more
effective ways to deal with similar triggers, are more likely to avoid
using substances again.
Relapse prevention strategies for substance use problems
The following strategies can help your family member prevent a relapse:
• Become familiar with a return, or worsening, of symptoms of the
person’s mental health problems (such as manic behaviour, worsening
of depression, self-harm behaviour) that have, in the past, frequently
been associated with a substance use relapse.
• Identify situations in which the person may have problems coping
(e.g., for many people, it is risky to be in places where they used
substances before—such as in a bar—and to be around people they used
to drink or use with).
• Develop strategies to deal with these high-risk situations. For
example, a person could be prepared to refuse drinks in social
situations by going to an establishment that offers interesting
non-alcoholic drinks or going with friends who will support their
decision not to drink and who do not drink to excess themselves.
• Remove items that might trigger use (e.g., someone who has a problem
with alcohol could remove all alcohol, favourite drinking glasses,
corkscrews and bottle openers, at least temporarily, from the house).
• Practise techniques to deal with stressful situations (e.g.,
meditation, anger management, positive thinking and withdrawal from
• Pursue activities that increase a sense of balance in life, such as
relaxation training, stress management, time management, pet
ownership, exercise and yoga.
• Make a “relapse road map” that outlines and emphasizes choices
available to cope with or avoid high-risk situations.
Be prepared for relapse. Try to understand what triggered it. Think of
a relapse as an opportunity to plan for similar situations in the
future, not as a mistake.
As people learn new skills and use them to avoid relapse and deal with
stress, they develop a sense of mastery, which, in turn, decreases the
risk of relapse.
Some people only have one episode of mental illness, but many people
have more than one episode. In some cases, the mental health problem
is expected to recur.
Studies have shown that people can learn to recognize and manage their
symptoms and reduce the chances that they will relapse. If they do
relapse, the symptoms may be less severe.
There are some common factors that may contribute to relapse for many
mental health disorders. However, sometimes there is no obvious
People may experience situations or feelings that put them at greater
risk of relapsing. A person who has a stressful, demanding life can
be more vulnerable to relapse. Lack of regular routines and a poor
diet and sleeping habits can also have a negative impact. A lack of
social, family and community support may be a factor. Some common
• substance use or abuse
• medication use problems—medication is stopped, taken irregularly or
the dose is too low
• high levels of criticism, hostility or too much emotional
involvement from family members (high emotional expression)
• conflicts with others
• severe mental stress, such as the death of a loved one
• condition-specific triggers—for example, the anniversary of a
traumatic event could be a trigger for someone with posttraumatic
stress disorder (PTSD)
• feelings, thoughts or situations that have come before a previous
episode of illness
• other medical or physical problems.
Relapse Prevention Strategies for Mental Health Problems
The following strategies can help your family member prevent a relapse:
• Identify signs of relapse and work with a professional to develop a
relapse prevention plan.
• Take medication as prescribed, and speak to the doctor if it is not
working or if side-effects are too unpleasant.
• Recognize situations that may trigger symptoms, and try to avoid
them or reduce exposure to them.
• Learn about the disorders. Psychoeducation—formal learning about
mental illness by the individual and family members—reduces the rate
• Apply skills learned in treatment to deal with symptoms.
• Practise techniques to deal with stressful situations. Examples
include meditation, anger management and positive thinking.
• Develop a structured routine. Pursue lifestyle choices and
activities that increase a sense of balance in life, such as
relaxation training, stress management, assertiveness training and
Understanding Crises and Emergencies
Even the best planning can’t always prevent a relapse. Sometimes a
relapse develops into a crisis. A crisis may also occur with little or
A crisis is any serious deterioration of a person’s ability to cope
with everyday life. It can be a turning point—for better or worse. It
does not necessarily involve a danger of serious physical harm. A
crisis develops when people feel they cannot control their feelings
and behaviour and have trouble coping with the demands of day-to-day
life. People in crisis may experience extreme despair, sorrow or
anger. They may not be able to sleep, they may hear voices or they may
believe that they have superhuman powers. Although people in crisis
are not necessarily a danger to themselves or anyone else, in many
crisis situations, outside help (the person’s doctor or therapist, a
mobile crisis service or crisis line) is needed.
An emergency is a situation in which there is an immediate danger that
the person will harm either him- or herself or someone else (Chan &
Examples of emergencies:
• threats of suicide
• threats of physical violence
• extreme impaired judgment caused by problems such as psychosis or
Sometimes issues related to concurrent disorders happen suddenly. The
symptoms, problems and needs of the person affected create a crisis
that galvanizes all members of the family into action. At other times,
issues can unfold slowly, and may build until someone in the family
decides that it’s time to take action. For example, a behaviour that
has become quite regular, such as an adolescent son coming home
intoxicated, can suddenly become a heated issue because a parent
decides that it is finally time to address this behaviour. Another
example is a person who skips one session in his or her treatment
program because of feeling down, but is confident that he or she will
go back the next day. Family members may react strongly because they
are worried that the person might be backsliding, missing needed care
and risking relapse.
In both of these examples, how family members will perceive the
situation will vary. One person might feel that things are at a point
where immediate action is necessary—that things are in crisis; another
might not see why today has to be treated differently than any other
day. Sometimes the person with the co-occurring problems feels that
something has suddenly gone seriously wrong and needs immediate
attention, while family members aren’t as concerned. In other
situations, family members are convinced that action needs to be
taken, but the person with the problems may not agree, or may be
afraid of what taking action will mean for them.
So you need to ask yourself: Whose crisis is it? The answer will help
you understand who is really asking for help—your relative, the family
Setting limits can help to prevent conflicts from turning into crises.
Conflicts can result from interpersonal problems between the person
who is ill and his or her family members, or between the ill
individual and other people. The family member with concurrent
disorders may also experience conflict for other reasons, such as
changes in his or her daily routine, difficulties with finances or
loss of housing.
Family members may feel guilty when they set limits on their ill loved
one’s behaviours or insist that he or she follow the rules and
guidelines that everyone else in the family is expected to follow.
By refusing to set limits, families may believe that they are being
helpful in preventing their relative from becoming unnecessarily upset
or angry. Consistent rules and boundaries can help to create a sense
of predictability and security.
It is usually best to avoid:
• making excuses (e.g., “He’s just upset today.” “She’ll go to her day
program tomorrow.” “A few drinks won’t hurt him and it may help him
calm down.” “It’s okay if she comes home late. She has such a hard
• paying their bills
• giving extra money, often over and over again, and being surprised
when it’s used to buy more alcohol or other drugs
• bailing the person out of jail
• making excuses for irresponsible behaviour
• ignoring problems (e.g., mental, emotional, financial, employment,
legal) caused by the person’s substance use
• accepting excuses or believing lies.
• yelling, swearing or other forms of emotional aggression
• physical aggression
• dangerous behaviour such as smoking in bed
• stealing from family members or friends
• misuse of money that is intended for rent or other basic needs.
Although it may be difficult when your loved one suffers from
concurrent disorders, it can be helpful to set limits on his or her
use of alcohol and/or other drugs in your home.
When objecting to unacceptable behaviour, be clear and request
specific changes in the person’s behaviour. For instance:
• Identify problems (e.g., spending weekly allowance on alcohol rather
than on bus fare, or coming home late intoxicated and disturbing other
• Work on one problem at a time.
• Avoid making demands or becoming confrontational.
• Clearly state your expectations for the future in a positive,
non-judgmental, non-threatening manner. For example, try saying “I
would like you to —————— .” or “We would really appreciate it if you
would —————— .” or “It is important to me (and/or other members of the
family) that you help us by—————— .”
• Help the person to understand the consequences of ignoring a
boundary or limit on a particular behaviour (e.g., no additional money
will be given that week; you will buy bus tickets and give them to
your relative rather than giving him or her the money, which could be
spent on alcohol).
• Be consistent in both limit-setting and following through with consequences.
• Review the limits set on particular behaviours and redesign the plan
Sometimes a sudden change in daily routine triggers a crisis that
escalates into an emergency. Sometimes there is nothing that family
members can do to prevent a crisis. Other times family members can
prevent—or trigger—a crisis.
If your relative threatens to harm him- or herself or you, or to
seriously damage property, you must do whatever is necessary to
protect yourself and others (including your relative) from harm. You
may need to leave and call for help. This is advisable only under
extreme circumstances, and only for very short periods of time. If
possible, remove objects that your relative could use to harm him- or
• argue with others about what to do.
One of the most terrifying aspects of a serious mental health disorder
is talk of suicide. Any talk—or even joking—about suicide must be
Most people do not want to end their lives. Suicidal thinking or
attempts typically occur during a serious episode of mental illness
when the person feels helpless, hopeless and in a state of despair.
Although the feelings are often temporary, at the time, people do not
believe that the feelings will pass. You can help by acknowledging
your relative’s feelings while offering to help him or her find other
solutions. However, it is also important to recognize your own
limitations. Family members must realize that they do not have
absolute control to change things and cannot be responsible for all of
their relative’s actions.
Warning signs of suicide
There are several warning signs that a person is considering suicide.
He or she may:
• discuss suicide and what it would be like to have things end
• be concerned with providing for children, other family members or pets
• give away possessions
• express feelings of worthlessness, such as, “I’m no good to anybody”
• feel hopeless about the future, reflected in comments such as,
“What’s the use?”
• talk about voices that tell him or her to do something dangerous.
What to do if you find someone after a suicide attempt:
• Phone 911 immediately.
• If you know first aid, administer it immediately.
• Phone someone to accompany you to the hospital or to stay with you at home.
Do not try to handle the crisis alone; contact a support group to help
you with your immediate reactions and long-term feelings.
Getting Treatment in an Emergency
It’s best if you can get your relative to go to the hospital
voluntarily. If he or she won’t listen to you, ask someone your
relative trusts to convince him or her to go to the hospital. This
should be part of your prearranged action plan (see “Creating an
Emergency Plan,” p. 174. Try to offer your relative a choice. For
example, John’s mother might have asked him: “Will you go to the
hospital with me, or would you prefer to go with your father or Anna?”
This reduces a person’s fear that he or she is being coerced.
Calling the police
If your relative appears likely to endanger him- or herself or someone
else, and refuses to see a doctor, you can get a judge or justice of
the peace (depending on the province or territory in which you live)
to issue a document that authorizes the police to take your relative
to a hospital for an assessment. But if you’re in a crisis or
emergency situation (the danger is immediate), just call 911.
Sometimes you have to phone the police, and the first time is really
tough. I remember the first time we had to phone 911, and the
ambulance came, and the police—and then my neighbour who’s a doctor
came over and said, “Is there anything I can do?” And I had to say,
and I remember I actually got it out, “My daughter is having a
psychotic episode. And she’s been using crack.” And once I got that
out, he was very supportive—and I was fine. I thought, OK, you know,
that’s behind me. So I told him, and he was very kind. So once you put
it out there, and nothing terrible happens, you’re OK.
It’s understandable that families are reluctant to call the police,
but extreme circumstances may leave you no other choice. Often, merely
telling the ill person that you are calling the police will calm him
or her down.
When you call 911, tell the emergency operator that your relative
needs emergency medical assistance and give the operator your
relative’s diagnosis. Say you need help getting him or her to the
In some communities, the police are given training in crisis
intervention. It’s helpful to find out what kind of training, if any,
the police in your community have so you’ll know in advance how much
advocating you might have to do when and if you need to call on them.
If you find yourself in a situation where you need to call the police,
write down the officers’ names, badge numbers and response time in
case you later need to report any concerns about how the problem was
handled. While the police are present, you may have time to call the
doctor or any other emergency contact.
Even when your relative has been destructive or physically abusive,
you may be reluctant to involve the police. Family members sometimes
fear that their relative will be put in custody where they may be
victimized and treated inappropriately.
But failing to take seriously the risk of violence and physical harm
can have its own consequences. You should take care to recognize the
signs of escalating threats and violence, and the presence of extra
stress and triggers that could set your relative off, and know when
things are beyond your control. Don’t be afraid to call a crisis team
in to your home or the police. In many cases that is the safest,
kindest thing you can do for an ill family member.
Involvement with the forensic mental health system
Ironically, if a person with serious mental health conditions comes
before a judge because he or she has been charged with doing something
illegal, it may be more likely that person will be remanded for a full
assessment and possibly treatment. Forensic psychiatry is a branch of
mental health that works with people who have become involved with the
law. For some individuals with mental health problems who have become
involved with the law, being directed to a forensic facility allows
them to receive the care that they have not been able to receive in
the community system.
Working with Emergency Room Staff
If possible, go to the emergency department with your relative. The
staff should interview you because you have information that they need
to decide how to treat your relative. If the emergency room staff
don’t ask to talk to you, you should insist that you get a chance to
talk to them.
Try to provide an organized account of the events leading up to the
hospital visit. If you are worried about your safety should your
relative be released, let the staff know.
In some cases, your relative may not want to get treatment after a
crisis, or even after having serious symptoms. In Canada, people can’t
be forced to get treatment for a mental health disorder unless they
are a threat to themselves or others. While this approach does
acknowledge the rights of the individual, it has created complex
problems for families. If a person who doesn’t want to be admitted to
hospital is admitted, he or she is considered an involuntary patient.
The specific criteria used to decide whether a person can be admitted
to the hospital without his or her consent vary from province to
province. The basic principles are:
• The person is believed to be a danger to him- or herself (e.g., is
suicidal or self-harming).
• The person is believed to be a danger to others (e.g., is violent).
• The person is unable to care for him- or herself and is at immediate
risk as a result (e.g., because he or she is not eating or drinking).
If the person meets the provincial criteria for involuntary admission,
a physician can issue a document that authorizes a short stay in the
hospital (in most provinces, one to three days) for emergency
treatment. In some provinces, another document must be issued if
longer-term treatment is needed.
Consenting to Treatment
People who have been admitted to hospital involuntarily still have the
right to make decisions about their treatment if they are mentally
capable to do so. This includes refusing treatment.
To be considered capable, a person must:
• be competent to give consent
• have the intellectual capacity to make the decision
• give the consent voluntarily
• have enough information to make an informed decision, including
information on potential risks or side-effects of treatment.
If the person is not able to give informed consent, then he or she
must be declared incompetent. Someone is appointed to make decisions
on the person’s behalf. In some provinces, the decision-maker is a
family member while others use people appointed by the state.
Before a situation turns into a crisis or an emergency, it may help to
sit down with your family and discuss what you would do in an
emergency. Don’t try to deal with your family member when he or she
appears to be under the influence of alcohol or other drugs, or when
family members are extremely upset. You may say things under the
stress of the situation that you don’t mean, or take action that just
makes things worse.
When everyone is calm, you can focus on planning what to do if:
• the family notices that some of the symptoms of the substance use or
mental health problem are reoccurring
• the situation has already become a crisis.
Developing a plan together ensures that your relative is an active
participant in his or her own care. Planning all of this before a
crisis happens can sometimes help avoid a crisis altogether. However,
there are times when a crisis may not be preventable.
The following guidelines will help you create a crisis action plan
that is tailored to the needs of your ill family member:
• Make sure that your relative is actively involved and participates
in the discussion and in all decisions, and that his or her
preferences are heard and respected.
• Involve as many members of your family as deemed appropriate and
develop an approach that all can agree on.
• Generate a number of possible crisis plans and act on the ones that
everyone, especially your ill loved one, agrees are the best ones.
• Develop specific steps for carrying out your plans. Decide what role
each member will have in implementing the plan. For example, decide
who is the best person to accompany your loved one to the hospital,
should this become necessary, who should stay on at the hospital, and
who should make phone calls from home.
• Decide who will speak to the treatment team or, in extreme
situations, to the police, if your relative is unable to speak for
him- or herself.
• Make sure to get your relative’s permission to relate particular
information to hospital staff or to the police.
People with concurrent disorders and their family members have found
it extremely helpful to write important information on a card or a
piece of paper folded small enough so that it can be carried with them
wherever they go. For example, the card or paper may be placed in a
visible part of the person’s wallet.
A crisis card usually contains information important for others (e.g.,
friends, health care workers, police, strangers) to have in the event
that your relative experiences a mental health or substance
use–related crisis while away from home. It contains information such
• important phone numbers—who to call in the event of a crisis or an
emergency, including who to call first and who to call as a back-up
• the person’s mental health or addiction professional (e.g.,
psychiatrist, therapist or worker)
• the person’s family doctor
• the hospital or treatment centre at which the person has currently
or previously been involved in inpatient or outpatient care
• a list of the person’s current medications, the proper dosage for
each, and the times of day or night that they are to be taken (you may
also wish to include the name and number of the pharmacy at which the
prescriptions are usually filled)
• a list of medications to which the person is allergic
• any medications used in the past for either the mental health or the
substance use problem that did not work, or that the person would not
take due to side-effects (you may list such medications in one column
and list the side-effects in a second column)
• tips for effectively talking to and working with the person when he
or she is in crisis
• neutral topics of interest to them
• comforting foods
• self-calming measures, such as music or video games.