Relapse Prevention: What Do We Know and What Do We Need to Do More Of

In psychotherapy research in general, not a lot of attention has been paid to the problems of relapse which is common after therapy in substance abuse, recurrent depression, anxiety and more chronic conditions but there are some recent developments in this field which are to be welcomed. 

CBT has been found to be an effective treatment for a number of psychological disorders in both research trials and in clinical practice. It is now first line treatment for disorders such as depression, panic disorder, social anxiety and OCD. Short-term outcomes have been consistently demonstrated to be positive and CBT packages have in some cases demonstrated durability in that recovery is sustained over time. However, an important need remains in CBT implementation, which is how to go beyond basic methods to enhance and optimize long term outcome and prevent relapse. This is a significant challenge for CBT moving forward but there are encouraging signs of progress on this front.

The CBT model of relapse posits that relapse is a process not an event. Following the important contribution made by Alan Marlatt in the field of substance abuse and relapse (Marlatt, 2007), the model suggests that there is an initial first stage where lapse or setback occurs and subsequently there is the possibility of either prolapse (moving forward) or relapse (further slipping back into a full- blown return of problems\symptoms). For example; a client with a history of depression who start to feel a bit “blue” one day might have negative cognitions concerning this ‘setback’ (“It will progress to severe depression”) or themselves for having the setback (“I am weak for letting this happen”) which exacerbates the situation and leads to relapse. This model has important treatment practice implications. Instead of viewing the setback as irreparable failure, clients (and therapists) can see these slips as learning experiences which are expected and can ultimately improve their maintenance efforts and outcomes. In addition, staying in the present using some mindfulness skills may also be preventive, as will be described later.

In terms of comprehensive CBT treatment which targets both symptom remission and relapse prevention, one of the most important issues before treatment begins is having a good conceptualization of the case. Risk factors which are known to be predictive of relapse can be evaluated which means that clinicians can then establish the risk of relapse in a particular client similar to the important therapeutic task of establishing suicide risk. These factors can be grouped into;

• enduring personal characteristics (coping style, personality)
• background variables (life events)
• precipitants (thoughts and feelings related to a particular relapse episode).

At the onset of therapy the clinician might assess

• The number of previous episodes
• Self-efficacy
• Coping skills
• Enduring dysfunctional beliefs
• Life stressors

• All of the above have been found to be predictive of higher relapse risk. For example, a depressed client who has (1) a history of many previous depressive episodes,(2) a coping style that involves avoidance or dependence on others,(3) a belief that he/she is not capable of change or solving problems,(4) dysfunctional attitudes such as “I must be perfect” and (5) numerous life stressors such as marital problems or unemployment is at high risk of being depressed again even if he/she is now in remission as regards depressive symptoms as a result of short -treatment or medication.

Once the risk of relapse is established a treatment plan based on this can be arrived at. Decisions can be made regarding;

• the length and frequency of treatment
• the need for maintenance or continuation therapy after the client is no longer depressed.
• the need for motivational interviewing to increase motivation
• the content of therapy (targeting enduring dysfunctional beliefs, poor self-efficacy, life stressors)

With CBT it is considered important to give the client an expectation from the first session that through therapy clients can “become their own therapist” in that they will have learned and practiced skills which will help them deal with setbacks after therapy ends. Throughout therapy this idea will be fostered by asking clients what they have learned, what they did to make change possible and what they can do to keep up their skills.

Importantly in the later stages of therapy before discharge the following strategies will be very important:

• Identifying and preparing for the management of high-risk situations (a predicted upcoming life stressor or times when their symptoms historically get worse)
• Recognizing and managing early warning signals of lapse/relapse
• Rehearsing and practicing an emergency plan for when these occur
• Working on vulnerability factors (dysfunctional attitudes and maladaptive behaviors) *
• Managing life- style imbalance and dealing with ongoing or predicted stressors
• Making sure the client has a good support system and is comfortable using this

A few additional strategies which the literature has shown to reduce relapse risk are:

• Utilizing Maintenance sessions: A series of studies have shown that engaging a CBT client in some follow up maintenance sessions after they are ‘well’ can prevent relapse. For example, one study found that adding ten sessions of Continuation Cognitive Therapy, with a focus on generalization of skills and relapse prevention over an eight-month period after remission reduced relapse rates from 31% to 18% over a two year follow-up.This may be good clinical practice particularly for clients at high risk of rlapse.
• Implementing Mindfulness Based Cognitive Therapy for depression (MBCT; Segal et al, 2018).

This treatment combines Mindfulness-Based Stress Reduction (MBSR: Kabat Zinn,2003) with standard CBT treatment for depression. The results found in outcome studies have indicated a significant effect on relapse using this approach. One study showed that MBCT reduced the relapse risk by half compared to treatment as usual. It was particularly striking in this study that the difference in the risk of relapse risk was 36-37% for the MBCT group versus 67-78% for the treatment as usual group in patients with three or more previous episodes of depression. It can be concluded that MBCT may confers a particular benefit over time, as regards relapse-prevention/sustained recovery. There are also number of other studies showing the MBCT approach can reduce relapse in anxiety disorders.

In conclusion, it is evident that while cognitive-behavioral approaches with or without specific relapse prevention focus appear to have reduced the relapse rates in emotional disorders, substance abuse and other disorders, studies have shown that a significant percentage of patients (approximately 20% to 35% ) with depression and anxiety still experience a recurrence of symptoms and in the field of addictive behaviors including substance abuse, smoking and alcohol misuse more than 50% of these clients do not maintain behavior change over time. This may be an even more significant problem in clinical practice, as usually clients treated in clinical practice will have more severe psychopathology than patients meeting the inclusionary criteria for research studies. Thus, it behoves clinicians to educate themselves on methods to further reduce the significant problem of relapse in patients successfully treated in the short term with CBT and other effective therapies. “Staying well” should be prioritized as much as “getting well” has been within the field of Cognitive Behavior Therapy and psychotherapy in general.

Helpful resources

Ludgate, J.W. (2009) Relapse Prevention for Depression and Anxiety. Professional Resources Exchange.

Marlatt, A. & Donovan, D. (2015) Relapse Prevention Counseling. PESI Publishing.

Segal Z et al (2^nd Ed) (2018) Mindfulness-Based Cognitive Therapy for Depression. Guilford Press.