Relapse prevention has been a major part of the mental health policy agenda since the advent of the National Mental Health Strategy in 1992, but it is now time for it to receive specific emphasis. This paper considers the role of relapse prevention within the recovery process for people who have been seriously affected by a mental illness. It has been developed to inform several different audiences for whom this issue is central to continuing care: people of all ages who have experienced mental illness and their families and carers; primary care services, including general practitioners; case managers; providers of non-clinical support services; providers of clinical services; service managers, workforce planners, and policy makers; as well as the whole community.
The methodology used to develop the paper comprised five major components: liaison with Auseinet and the Auseinet Consumer and Carer Consultative Committee; national consultation with consumers and carers; stakeholder consultation; review of the national and international literatures; and a review of current State/Territory initiatives in relapse prevention.
The paper considers definitions of the terms 'relapse' and 'relapse prevention' and discusses the place of relapse prevention within the spectrum of interventions for mental health. Relapse prevention and the related concept of rehabilitation are placed under the umbrella of recovery, which comprises treatment and continuing care.
Specifically, relapse prevention is defined as:
- a specific component of the recovery process. It entails maximising wellness for people with mental illness by reducing the likelihood and impact of relapse. It involves empowering people with mental illness to recognise early warning signs of relapse and develop appropriate response plans. It requires identifying risk and protective factors for mental health, and implementing interventions that enhance protective factors and eliminate or reduce the impact of risk factors. Relapse prevention is based on communication and understanding between the person experiencing mental illness, their family and carers, primary health care, the specialist mental health system, and community support services about access to support or treatment if there are early signs of relapse. Relapse prevention is an essential, but not sufficient, component of the recovery process for people with mental illness.
A review of the literature shows that relapse prevention involves both illness self-management and illness management with the support of professional-based interventions. It has been categorised as including the following types of approaches: training in recognition of early warning signs; programs that encourage effective use of medication; coping skills training; and broad-based psycho-education programs. The evidence generally supports the effectiveness of these interventions, however, it is argued that a more comprehensive and holistic approach is required to fully realise relapse prevention within the spectrum of interventions for mental health adopted by Australian mental health policy.Top of page
Consultations with people of all ages who have experienced mental illness and their families and carers, other stakeholders, and wider review revealed the following essential elements of relapse prevention:
- Awareness - Awareness is the first component of effective relapse prevention, and is made up of acceptance and recognition. Acceptance means acknowledging and coming to terms with having an ongoing mental health condition. Positive attitudes toward people with mental illness within all sectors of the community facilitate the process of self-acceptance while maintaining a sense of self-worth. Recognition of early warning signs of illness and awareness of personal risk and protective factors are core components of relapse prevention. Acceptance and recognition determine whether people at risk of further episodes of mental illness, and the people and services that they are in contact with, are aware of and able to respond to changing mental health needs.
- Anticipation and planning - Anticipation of potential future episodes of illness and appropriate planning are fundamental to relapse prevention. Planning is what empowers people with mental illness to make the decisions they choose, rather than have decisions made for them. Planning needs to be undertaken on many levels: daily plans, crisis plans and longer-term wellness and relapse prevention plans. Planning is based on the development of trusting relationships and good communication, and places the consumer at the centre of their continuing care. All those involved in the ongoing support of someone with a mental illness need to be involved in planning: the consumer, their family and carers, clinical service providers, and providers of psychosocial and psychiatric rehabilitation services. Relapse prevention plans need to be regularly reviewed and revised and effective plans tailored to each person's unique needs, taking into account their age, personal circumstances, cultural background, and experience of mental illness. Relapse prevention planning needs to become a routine component of continuing care for people who have experienced mental illness: a component that commences at the first point of contact with mental health services, that is ongoing and responsive to changing circumstances, and supported by effective self-management approaches.
- Alternatives and opportunities - Support services need to be available to target all the environmental, physical, social and emotional stressors and supports that comprise the risk and protective factors for mental health. The provision of all these service alternatives needs to be integrated, through planning, partnerships and effective communication strategies, to provide a comprehensive approach to relapse prevention within continuing care. Importantly, there must be a range of supported accommodation options and follow-up services within the community, both clinical and psychosocial. These must be suitable to the age, cultural background and personal circumstances of individual consumers and their families and carers. Provision of community support services must be adequate to meet population needs.
- Access and early intervention - Effective relapse prevention requires early intervention through access to appropriate supports and services. This means, firstly, the development of effective personal coping skills in response to early warning signs. Secondly, it requires a service system that responds to early warning signs, not just acute crises. Step-up and step-down facilities are needed to respond quickly and effectively to changing mental health needs as recognised by consumers and their families and carers.
There are several population groups within Australia that are of special significance and have additional needs in relation to relapse prevention. These groups are: children and adolescents, older adults, Aboriginal peoples and Torres Strait Islanders, people from culturally and linguistically diverse backgrounds, and people living in rural and remote communities. While the issues covered throughout the paper also apply, the unique features of relapse prevention in terms of awareness, anticipation, alternatives and access for these population groups are highlighted.
It is argued that the actions required to implement relapse prevention have already been identified and are listed as outcomes in the National Mental Health Plan 2003- 2008. These include: real participation and partnerships with consumers and their families and carers; access to services and service responsiveness; workforce development; and ongoing monitoring, evaluation and research. How these apply specifically in the context of relapse prevention is described.
Relapse prevention must become standard practice within mental health care. This requires specific emphasis on awareness, anticipation and planning, the availability of alternatives and opportunities, and access and early intervention. Underpinning relapse prevention is the need for effective communication that places the person with mental illness at the centre of their continuing care and self-management. The roles of families and carers, primary care, specialist mental health services, rehabilitation services, and allied health need to be negotiated and responsive to the changing needs of consumers. Approaches must be appropriate to people's age, cultural background, personal circumstances, and experience of mental illness, and be supportive of families and carers.