DESCRIPTION OF THE STRATEGY

Behavior therapists and clinical researchers have long recognized relapse prevention as an
essential area of focus in the treatment of clinical problems. Relapse prevention strategies are
defined as treatment procedures that aim to protect patients from the realistic threat that their
clinical problems will recur or return to pretreatment levels. Behavior therapists historically
have used the term relapse prevention vis--vis treatment of substance use problems, although
this term also applies to a wide range of clinical problems, such as eating disorders, anxiety,
depression, disruptive behavior, and sexual offending with some terminological
modifications. For example, interventions for anxiety disorders include relapse prevention
strategies that are designed to prevent what is frequently called renewal, reinstatement, or
return of fear. Also, procedures described as addressing the generalization or maintenance of
outcomes across time and settings relate to relapse prevention in important ways.
Behavioral interventions have been developed to treat children with a broad range of clinical
problems, and many of these interventions commonly are delivered effectively in outpatient
therapy settings. Despite the success of such interventions, however, risk of relapse may
remain high when a child's experience with the natural environment does not change in
meaningful ways throughout the course of treatment. For example, parents may learn and
successfully role-play behavior management strategies for disruptive behavior in the clinic
setting, but if parents fail to use such strategies reliably at home, it is unlikely that any
shortterm improvements in the child's disruptive behavior will be maintained over time. For a
more traditional example, consider a substance-abusing adolescent who is temporarily placed
in a restrictive environment, successfully treated, and then returned to an environment that
might include permissive caretakers and regular contact with peers who use and encourage
use of substances. Unless efforts are made to facilitate changes within the peer network, and
unless parents learn strategies that enable them to exercise greater control over the
adolescent's behavior, risk of relapse for this adolescent is likely to be high.
Behavior therapists use a variety of clinical techniques that can reduce risk of relapse.
Techniques discussed here include functional assessment, identification of risk factors,
psychoeducation, skills training, and behavioral rehearsal. Functional assessment helps
clinicians identify the wide range of contextual cues or antecedents (e.g., situations, events,
people) that are associated with the targeted behavior, as well as reinforcing or punishing
consequences that typically follow such behavior. Identifying the antecedents and
consequences for targeted behavior across multiple settings and contexts prepares clinicians to
guide changes in the way the child relates to and experiences the natural environment. With
such changes in effect, the natural environment is more likely to sustain improvements in
behavior that occur as a function of treatment.
The identification of risk factors can occur in the context of functional assessment and entails
the identification of factors that are associated with risk for returning to pretreatment behavior
patterns. Factors are identified in collaboration with the child and family and may include risk
factors that are present in the external environment (e.g., socializing with unsafe people)
and/or correlates at the level of the individual (e.g., increased heart rate, muscle tension).
Coping skills are developed to promote functional and safe ways of responding when these
factors are recognized in the natural environment.
Psychoeducation refers to a range of techniques that therapists use throughout treatment to
educate children and parents about the problem behavior and correct inaccurate interpretations

(e.g., of events, situations, or behavior) that may be associated with relapse. For example,
educating parents about relatively normal artifacts of behavior management strategies (e.g.,
extinction bursts, spontaneous recovery) can promote adherence to such strategies. Relapse
prevention also is promoted by providing realistic interpretations of problem behavior after
treatment has been completed. For example, helping substanceabusing children and parents
distinguish between a lapse (a brief return to use) and relapse (a return to pretreatment
use patterns) can foster a rapid return to nonproblem behavior patterns after short-term errors
in judgment. Likewise, educating parents and children about the accurate appraisal of danger
(e.g., the probability of harm) and the relation between avoidance and other forms of fearful
responding can help prevent a return of fear.
Skills training involves teaching children and parents skills that are designed to alleviate
behavioral, verbal-cognitive, or affective deficits that are associated with the targeted
problem. Common skills training components include emotion identification (e.g., teaching
the child to identify various physiological reactions that relate to fearful responding, such as
rapid heart rate and sweating), coping skills (e.g., relaxation training), problem-solving skills,
and communication/social skills, among others. Skills training is particularly important for
relapse prevention because augmentation of general and broad-based skills can provide
children with tools to cope with various circumstances that occur outside the therapy context
and after therapy has ended. Parent-focused strategies typically entail behavior management
exercises that reduce the frequency of the child's problematic behavior and increase the
frequency of alternative, more desirable forms of behavior.
Behavioral rehearsal refers to the practicing of skills (e.g., coping skills, social skills) in
situations that resemble those in the natural environment but where the clinician can provide
feedback to enhance skill acquisition. For example, clinicians often provide opportunities to
practice assertiveness and social skills by role-playing these skills during the session. The
probability of relapse is decreased particularly when behavioral rehearsal is repetitive and
closely mimics situations that the child encounters in the natural environment.
The extent to which sessions are arranged and spaced apart may also have important effects
on relapse prevention. For some clinical problems, research has shown that long-term
treatment effects can be improved in part by using a stepped approach to treatment
termination in which more intense or restrictive treatments are followed by less intense
methods. In this way, treatment is faded out gradually, thereby gradually transferring the
responsibility for treatment maintenance from the clinician to the family and other sources of
support. For example, common approaches in inpatient settings are to graduate children first
to a day program and then to an outpatient program. In outpatient programs, relapse
prevention can be affected by gradually spacing sessions from weekly to biweekly meetings
and, finally, to monthly (i.e., booster or follow-up) sessions.

RESEARCH BASIS
The effectiveness of various relapse prevention techniques has not been widely researched
among children. However, data from clinical research and human and animal laboratory
experiments provide suggestions regarding the use of specific treatment procedures that are
likely to reduce relapse. Taken together, these substantive literatures point to both patient and
treatment factors that can influence the probability of relapse following treatment, and
therefore deserve attention from clinicians.

Among patient factors, individuals with especially severe and/or chronic behavior problems
are at increased risk for relapse. For example, studies have found that when anxiety-related
(especially phobic) problems are targeted in treatment, individuals with particularly high
physiological reactivity during fearcue exposure prior to the start of treatment are more likely
to exhibit a return of fear following treatment. Children and adolescents with weak social and
family support networks are also at risk for a return of clinical problems following treatment.
Several treatment factors are also associated with relapse prevention following treatment.
Inconsistent treatment attendance and adherence, which hinders the effectiveness of the
treatment itself, is associated with a return of clinical problems following treatment. Relapse
prevention is enhanced when interventions are delivered across multiple settings and
situations, when there is repeated practice, and when treatments are conducted using in vivo
situations that closely approximate high-risk situations in the environment. Moreover, when
exposurebased treatments for anxiety are used, relapse prevention is enhanced for cases in
which fear habituation occurs within each session, the individual is not distracted during
exposure, and fear intensity is not too high or too low.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
Relapse prevention efforts are applicable to virtually any clinical population, and
comprehensive treatment for any clinical problem should incorporate strategies that guard
against the recurrence of presenting problems. However, whereas the research literature in
relapse prevention is fairly well developed in the area of substance use problems, relatively
less research is available concerning relapse prevention for other clinical problems.
Furthermore, the literature presently offers insufficient guidance in the use of evidencebased
strategies for relapse prevention with children and adolescents.
It is important to note also that, particularly for young children, relapse prevention efforts do
not necessitate the full understanding, awareness, or involvement of the child. Because the
primary focus is on the child's natural environment, strategies to prevent relapse frequently
emphasize the social environment of the child (e.g., parents, teachers, siblings) rather than the
child specifically. This emphasis on the social network enhances the likelihood that the child's
natural environment will sustain improvements in clinical problems that initially brought him
or her into treatment.

COMPLICATIONS
A variety of complications can arise when behavior therapists attempt to prevent relapses of
clinical problems. An adolescent who responds well to substance abuse treatment may
encounter social circumstances or stressful events that were unanticipated by the clinician or
adolescent, which may put the adolescent at risk for relapse. A child who is provided with
successful treatment following a serious car accident may later be involved in a second
accident that produces a return to pretreatment levels of accident-related anxiety and distress.
Comorbidity also may be associated with increased likelihood of relapse. For example, a rapevictimized adolescent with comorbid substance abuse and posttraumatic stress disorder
(PTSD) may be successfully treated for substance abuse, but unless successful treatment also
is provided for PTSD, risk for substance abuse relapse may be high when the adolescent
encounters strong reminders of his or her victimization.

Clearly, it would be inefficient and unproductive for clinicians to attempt to address all of the
many ways in which clinical problems can reemerge following successful treatment. For this
reason, relapse prevention efforts frequently focus on the most common and preventable
circumstances under which relapse can occur. However, behavior therapists also use
psychoeducation and related techniques to teach children and their caretakers to manage
situations in which clinical problems appear to have reemerged. For instance, when clinicians
predict potential complications, such as a child's disruptive behavior potentially reemerging in
a new situation or that a child may attempt new forms of disruptive behavior while the parent
works to extinguish other forms, parents are better prepared to manage these situations when
they arise. Clinicians' anticipation of complications also is likely to have the effect of building
the parents' confidence in the clinician's knowledge and also may improve their willingness to
adhere to treatment recommendations. Furthermore, behavior therapists often provide parents
with an understanding of the principles supporting the treatment procedures they are using,
which allows parents to apply these principles to new forms of problem behavior and across
multiple settings.

CASE ILLUSTRATION
Kelly was a 16-year-old girl who was raped and physically assaulted by a coworker several
weeks before presenting for treatment. In the weeks leading up to treatment, she regularly
experienced nightmares about her victimization, had difficulty falling and staying asleep
nearly every evening, and experienced intense fear, panic, and distress in the presence of
victimization-related cues. She engaged in various patterns of victimization-related avoidance
in an attempt to control these reactions, such as avoiding people, places, situations, and
conversations that reminded her of the assault. In addition, Kelly reported having frequent
suicidal thoughts, was having considerable difficulty concentrating in school, and recently had
discontinued her involvement in various social and extracurricular activities.
In the context of the clinical interview, a comprehensive functional assessment was conducted
to identify the range of antecedents (setting events, discriminative stimuli) and consequences
associated with the clinical problems Kelly reported. Assessment of antecedents led to an
enhanced awareness of the range and nature of conditioned stimuli that produced Kelly's
fearful responding. Such information, in turn, was used to develop a fear hierarchy that guided
the exposure-based component of treatment. Initially, exposure-based treatment was
conducted in an outpatient therapy setting on a weekly basis, with Kelly recounting her
victimization in considerable detail. After a handful of these sessions, Kelly reported
significant decreases in her frequency and intensity of nightmares, sleep difficulties, and fear
in the presence of assault-relevant cues.
Despite the significant gains Kelly had made in treatment, the clinician recognized that she
might experience a return of fear upon encountering a particularly salient cue or set of cues in
the natural environment. For this reason, the clinician extended exposure exercises outside the
therapy setting. Specifically, in vivo exposure to realistically nondangerous settings and cues
was used to increase the likelihood that Kelly's gains would be maintained in the natural
environment. In addition, the clinician provided education with regard to the adaptive nature
of fear, the protective functions it serves, and the distinction between fearful responding to
dangerous versus nondangerous situations. It was communicated to Kelly that, following the
completion of treatment, she might encounter nondangerous situations in the future that lead
her to respond fearfully. The clinician described that this is common among victims of
traumatic events and explained how Kelly could respond effectively to future fear-eliciting

(but nondangerous) situations by applying her knowledge about reducing fear through
exposure (or approach/acceptance). Examples were used to ensure that Kelly could
differentiate realistically dangerous from nondangerous situations.
At this point in treatment, assessment results revealed sustained improvements in the area of
fearful responding and general distress. However, Kelly continued to spend little time outside
the classroom with peers and doing extracurricular activities that she previously enjoyed.
These observations raised questions about the heightened risk of relapse that may coincide
with elevations in depressed mood. To address this issue, the clinician discussed with Kelly
and her parents ways in which they might ensure that Kelly had increased contact with peers
outside the classroom setting. Once Kelly reestablished regular contact with her peers outside
the classroom setting, she elected also to reenroll in two extracurricular activities. This
increased engagement in pleasurable activities coincided with further reductions in depressed
mood. At this stage of treatment, improvements in fearful responding had been maintained,
and Kelly reported significant reductions in depressed mood while denying suicidal thoughts.
By targeting fearful responding and comorbid clinical problems through psychoeducation and
at the level of the natural environment, the clinician had made efforts to reduce risk of relapse
following treatment.
Kenneth J. Ruggiero and Steven R. Lawyer
Further Reading

Entry Citation:
Ruggiero, Kenneth J., and Steven R. Lawyer. "Relapse Prevention." Encyclopedia of
Behavior Modification and Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr.
2008. <http://sage-ereference.com/cbt/Article_n2102.html>.