Relapse and relapse prevention
In the course of illness, relapse is a return of symptoms after a period of time when no symptoms are present. Any strategies or treatments applied in advance to prevent future symptoms are known as relapse prevention.
When people seek help for mental disorders, they receive treatment that, hopefully, reduces or eliminates symptoms. However, once they leave treatment, they may gradually revert to old habits and ways of living. This results in a return of symptoms known as relapse. Relapse prevention aims to teach people strategies that will maintain the wellness skills they learned while in treatment.
Prevention of relapse in mental disorders is crucial—not only because symptoms are detrimental to quality of life but also because the occurrence of relapse increases chances for future relapses. In addition, with each relapse, symptoms tend to be more severe and have more serious consequences.
Relapse is a concern with any disorder, whether physical or psychological. Cancer is a prime example of a physical condition where relapse is common, either after a short period or many years of remission (being symptom-free). Psychological disorders can follow a similar pattern, and certain psychological disorders tend to have a higher rate of relapse than others. Addictive disorders, such as alcohol and drug abuse, smoking, overeating, and pathological gambling , are well known for high levels of relapse. Many addictions involve a lifestyle centered around the addictive behavior. In such cases, individuals must not only discontinue the addictive habit, they must also restructure their entire lives in order for changes to last. Such vast changes are difficult at best, approaching impossible in the worst scenarios. For example, an individual with a drug addiction may live in a neighborhood where drugs are prevalent but may lack the resources to move. According to recent statistics, relapse rates are approximately 33% for people who gamble pathologically (within three months of treatment), 90% for people who quit smoking, and 50% for people who abuse alcohol. Within one year of treatment, people struggling with obesity typically regain 30% to 50% of the weight they lost.
Affective disorders, such as depression and anxiety, also have high rates of relapse. People with affective disorders are thought to engage in self-defeating, negative thought patterns that occur more or less automatically. These thought patterns affect behavior, resulting in unproductive or negative consequences. Negative consequences are regarded by such individuals as proof that their original self-defeating thoughts must be correct. The thought-behavior pattern becomes a repetitive cycle, with negative thoughts resulting in negative behavioral outcomes, and consequences of negative behavior encouraging more self-defeating thoughts. This cycle is extremely difficult to break because it becomes a habitual way of responding to the world that occurs almost without awareness. Relapse rates for depression are reportedly as high as 80%.
Relapse among people who commit sex offenses is a constant safety concern for those in the community. However, some statistics show that this population has a very low rate of relapse. A recent report by Robin J. Wilson and colleagues indicated rates as low as 3.7% to 6.3%. This same report stated that, among various criminal offenses, those who commit sex offenses relapse at lower rates than those who commit general offenses. Other professionals may not necessarily agree with this study, however. Those who commit sex offenses are considered at a higher risk for relapse if they display little insight into the impact of their crime. Those at high risk of committing a sex offense are not typically released back into the community.
For many types of disorders, initial treatment is often effective at eliminating the unwanted behavior. However, these effects are rarely maintained long-term without some type of preventive planning. Results of medications are similar; symptoms are alleviated, but once the medication is discontinued, symptoms return unless the individual has had some type of training in coping with his or her disorder and that training has been effective. There are various forms of relapse prevention training. Most follow a similar pattern with and employ the following common elements:
- Identifying high-risk situations: Symptoms are often initiated by particular times, places, people, or events. For example, a person with agoraphobia is more likely to experience symptoms of panic in a crowded building. An essential key to preventing relapse is to be aware of the specific situations where one feels vulnerable. These situations are called "triggers," because they trigger the onset of symptoms. While people with the same mental disorder may share similar triggers, triggers can also be highly individual. People tend to react—sometimes unknowingly—to negative experiences in their past. For example, a woman who was sexually abused as a child may have negative emotions when in the presence of men who resemble her abuser. Because some triggers occur without conscious awareness, individuals may not know all their triggers. Many prevention programs encourage individuals to monitor their behavior closely, reflecting on situations where symptoms occurred and determining what was happening immediately before the onset of symptoms. With this kind of analysis, a pattern often emerges that gives clues about the trigger.
- Learning alternate ways to respond to high-risk situations: Once triggers have been identified, one must find new ways of coping with those situations. The easiest coping mechanism for high-risk situations is to avoid them altogether. This may include avoiding certain people who have a negative influence or avoiding locations where the symptom is likely to occur. In some instances, avoidance is a good strategy. For example, individuals who abuse alcohol may successfully reduce their risk by avoiding bars or parties. In other instances, avoidance is not possible or advisable. For example, individuals attempting to lose weight may notice that they are more likely to binge at certain times during the day. One cannot avoid a time of day. Rather, by being aware of this trigger, one can purposely engage in alternate activities during that time. Strategies for coping with unavoidable triggers are generally skills that need to be learned and practiced in order to be effective. Strategies include—but are not limited to—discussion of feelings, whether with a friend, counselor, or via a hotline; distraction, such as music, exercise, or engaging in a hobby; refocusing techniques, such as meditation , deep-breathing exercises, progressive muscle relaxation (focusing on each muscle group separately, and routinely tensing then relaxing that muscle), prayer, or journaling; and cognitive restructuring, such as positive affirmation statements (such as, "I am worthwhile"), active problem solving (defining the problem, generating possible solutions, identifying the consequences of those solutions, choosing the best solution), challenging the validity of negative thoughts, or guided imagery (imagining oneself in a different place or handling a situation appropriately).
- Creating a plan for healthy living: Besides being prepared for high-risk situations, relapse prevention also focuses on general principles of mental health that, if followed, greatly reduce the likelihood of symptoms. These include factors such as balanced nutrition, regular exercise, sufficient sleep, health education, reciprocally caring relationships, productive and recreational interests, and spiritual development.
- Developing a support system: Many research studies have demonstrated the importance of social support in maintaining a healthy lifestyle. Individuals who are socially isolated tend to display more symptoms of mental disorders. Conversely, individuals with mental disorders tend to have more difficultly initiating and maintaining relationships due to inappropriate social behavior. For such people, a support system may be nonexistent. Research suggests that support systems are most effective when they are naturally occurring—in other words, when a circle of family and friends who genuinely care about the individual is already in place. However, artificially created support systems are certainly better than none at all. For this reason, relapse prevention programs strive to involve family members and other significant persons in the treatment program. Everyone in the support system should be knowledgeable about the person's goals, what that person is like when he or she is doing well, and warning signs that the person may be on a path toward relapse. The support system agrees on who will take what role in encouraging, confronting, or otherwise caring for that person. Self-help groups such as Alcoholics Anonymous or Moderation Management are often examples of artificially created support systems.
- Preparing for possible relapse: Although the ultimate goal of relapse prevention is to avoid relapse altogether, statistics demonstrate that relapse potential is very real. Individuals need to be aware that, even when exerting their best efforts, they may occasionally experience lapses (one occurrence of a symptom or behavior) or relapses (return to a previous, undesirable level of symptoms or behavior). Acknowledging the potential for relapse is important, because many people consider a lapse or relapse as evidence of personal failure and give up completely. In their widely acclaimed book for professionals, Motivational Interviewing , William R. Miller and Stephen Rollnick cite a study by Prochaska and DiClemente that found that smokers typically relapse between three and seven times before quitting for good. From the perspective of Miller and Rollnick, each relapse can be a step closer to full recovery if relapse is used as a learning experience to improve prevention strategies. Although some argue that such a tolerant attitude invites relapse, general consensus is that individuals need to forgive themselves if relapse occurs and then move on. Some prevention programs include designing a crisis plan to be put into effect if a relapse occurs. The crisis plan involves specific actions to be taken by the individual or members of the support system.
These elements are common to all relapse prevention programs, but programs can be further customized to meet the particular characteristics of a disorder. For example, prevention of depression or anxiety may focus on becoming aware of thoughts as passing mental events rather than facts about self or reality. Learning to identify bodily sensations that accompany maladaptive thoughts is also important for preventing depression and anxiety. Addictive disorders concentrate on reactions to social pressure, interpersonal conflicts, and negative emotional states as part of a relapse prevention plan.
As with any type of therapeutic treatment, success of relapse prevention programs depend heavily on motivation. If an individual is not interested in making life changes, he or she is not likely to follow a prevention plan. Individuals low in motivation may need to participate in group or individual psychotherapy before deciding whether to enter a relapse prevention program.
Aftercare typically consists of participation in support groups . For addictions, 12-step groups (such as Alcoholics Anonymous) are most commonly recommended. These types of groups can be attended daily. Support groups exist for other types of mental disorders, and may be run by peers or a professional facilitator. Aftercare groups, usually run in treatment facilities by professional staff, may be used to continue practicing skills and to trouble-shoot problems individuals are experiencing with their prevention plans in everyday life. Aftercare groups usually meet less frequently (once a week or month) and may gradually taper off. Some relapse-prevention programs may use telephone contacts or individual therapy sessions to help individuals continue to use prevention skills effectively.
Successful relapse prevention programs will empower individuals to make choices about how they respond in stressful, high-risk situations (triggers) rather than responding in habitual, unhealthy ways. Individuals should be aware of their personal triggers, use positive strategies for coping with stress , practice healthy lifestyle choices, involve others in their efforts, and have a realistic attitude regarding relapse. Use of these prevention skills should reduce symptoms and increase the time span between occurrences of lapses or relapses.
If an individual is unmotivated to make life changes, or a relapse prevention program has been ineffective, that individual will demonstrate few (if any) of the prevention skills learned. The individual will show little improvement in symptomatic or problematic behavior. Periods of remission (symptom-free behavior) will be short and relapses will occur frequently.
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National Institute on Alcohol Abuse and Alcoholism.6000 Executive Boulevard, Willco Building, Bethesda, Maryland 20892-7003. <http://www.niaaa.nih.gov> .
National Institute on Drug Abuse, National Institutes of Health. 6001 Executive Boulevard, Room 5213, Bethesda, Maryland 20892-9561. (301) 443-1124. <http://www.nida.nih.gov> .
National Institute of Mental Health. 6001 Executive Boulevard, Room 8194, MSC 9663, Bethesda, Maryland 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov> .
Sandra L. Friedrich, M.A.