Relapse Prevention

As indicated in our summaries of the treatment results for DSM disorders last chapter, in several instances (e.g., autism, depression, addictive disorders, etc.) successful results were not maintained. This is often the result of issues other than the failure to generalize beyond the training environment(s). In Chapter 5, we saw that the extinction process does not “undo” prior learning. Rather, an inhibitory response is acquired that counteracts the previously learned behavior. Adaptive learning procedures have been successful in addressing a wide range of behavioral problems. Successful treatments rely upon the establishment of new behaviors to counteract behavioral excesses and eliminate behavioral deficits. Unfortunately, successful treatment may still be subject to relapse. G. Alan Marlatt has published extensively on the conditions likely to result in relapse and developed a strategy for reducing the risk (Marlatt, 1978; Marlatt & Gordon, 1980, 1985; Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Marlatt & Donovan, 2005). Much of this research relates to addictive disorders that have been shown to undergo remarkably similar relapse patterns. Unless provided with additional training, 70 percent of successfully treated smokers, excessive drinkers, and heroin addicts are likely to relapse within six months (Hunt, Arnett, & Branch, 1971). Marlatt conducted follow-up interviews to track the incidence of relapses and attain information regarding the circumstances (e.g., time of day, activity, location, presence of others, associated thoughts and feelings). Approximately 75 percent of the relapses were precipitated by negative emotional states (e.g., frustration, anger, anxiety, depression), social pressure, and interpersonal conflict (e.g., with spouse, family member, friend, employer/employee). Marlatt also described the “ abstinence violation effect ” in which a minor lapse was followed by a full-blown binge.

Relapse prevention methods involve identifying personal high-risk situations, acquiring, and practicing coping skills. For example, depending upon one’s environmental demands, any combination of the following treatments may be appropriate: relaxation exercises; desensitization for specific fears or sources of anxiety; anger management; time management; assertiveness training; social-skills training; conflict resolution training; training in self-assessment and self-control. A review of research applying relapse prevention methods to difficult recalcitrant substance abuse problems concluded that it was quite successful (Irvin, Bowers, Dunn, & Wang, 1999). It is likely that targeted use of such procedures (e.g., assertiveness training to resist the effects of peer pressure) would improve upon the effectiveness of MST with conduct disorder.

An adaptive learning perspective requires an extensive analysis of an individual’s environmental demands and coping strategies. Whether in the home, the school, or a free-living environment, there may be a mismatch between the demands and the person’s current skill set. Successful treatment provides the necessary skills to not only cope with the current demands, but also to prepare the individual for predictable stressors and setbacks.

Binge drinking and excessive alcohol consumption pose substantial health risks and negatively impact upon class attendance and the academic performance of college students (https://www.alcohol.org/teens/college-campuses/). Based upon his extensive research addressing substance-abuse interventions and relapse prevention, Marlatt developed a comprehensive assessment and intervention program called Brief Alcohol Screening and Intervention for College Students (BASICS) : A Harm Reduction Approach (Denerin & Spear, 2012; Dimeff, Baer, Kivlahan, & Marlatt, 1998; Marlatt, 1996; Marlatt, Baer, & Larimer, 1995). The program consists of two 1-hour interviews presented in an empathic, non-judgmental manner.  The first interview is followed by an on-line assessment survey designed to enable the prescription of specific behavioral recommendations based on each student’s responses. In order to reduce the likelihood of relapse, the program provides information and develops skills to counter peer pressure, negative emotions, and other triggers for excessive and binge drinking. A review of randomized controlled trials concluded that the BASICS program resulted in a significant reduction of approximately two drinks per week in college students (Fachini, Aliane, Martinez, & Furtado, 2012).

Prevention of Maladaptive Behavior

An ounce of prevention is worth a pound of cure

The Early Risers

The current state of the art in treating conduct disorder appears to be a long-term recidivism rate of 50%. Hopefully, implementation of relapse prevention techniques and forthcoming research will enable us to improve upon this result. Ideally, we would be able to prevent the problematic behavioral excesses and deficits which comprise the disorder from developing in the first place. The Early Risers “Skills for Success” Conduct Problems Prevention Program attempted to achieve this by working with kindergarten children exhibiting high incidences of aggression (August, Realmuto, Hektner, & Bloomquist, 2001). Similar to MST, Early Risers (ER) focuses upon parent training, peer relations, and school performance: parents are instructed in effective disciplining techniques; children meet with “friendship groups” on a weekly basis during the school year and during a six-week summer session; and a family advocate will work with parents on their child’s academic needs with an emphasis on reading. A 10-year follow-up of the results for high-risk children receiving three intensive years of ER training followed by two booster years found fewer symptoms of conduct, oppositional defiant, or major depressive disorders than a randomized control condition. Behavioral and academic improvements were evident in the ER condition as early as the first two years, even for the most aggressive children. The authors concluded that the Early Risers program was effective in interrupting the “maladaptive developmental cascade” in which aggressive children “turn off” parents, peers, and teachers, resulting in a spiraling down of social and academic performance (Hektner, August, Bloomquist, Lee, & Klimes-Dougan, 2014).

The Good Behavior Game

Children arrive at school with different levels of preparedness and skills. This often results in classroom management challenges for the teacher. Many different adaptive learning procedures have been implemented successfully to address such problems. The Good Behavior Game (GBG) is a comprehensive program recommended by the Coalition for Evidence-Based Policy (www.evidencebasedprograms.org), a member of the Council for Excellence in Government. The GBG was developed by two teachers and Montrose Wolf (Barrish, Saunders, & Wolf, 1969), one of the founders of the Journal of Applied Behavior Analysis, a very readable and practical publication. In order to play the game, the teacher divides the class into two or three teams of students (it has been implemented as early as pre-school). The GBG is usually introduced for 10-minute sessions, 3 days a week. Gradually, the session times are increased to a maximum of an hour. A chart is posted in front of the room listing and providing concrete examples of inappropriate behaviors such as leaving one’s seat, talking out, or causing disruptions. Any instance of such a behavior is described by the teacher (e.g., “Team 1 gets a check because Mary just talked out without raising her hand”) and a check mark is placed on the chart under the team’s name. The teacher also praises the other groups for behaving (e.g., “Teams 2 and 3 are working very nicely”). At the end of the day, the members of the team with the fewest check marks receive school-related rewards such as free time, lining up first for lunch, or stars on a “winner’s chart. Usually, it is possible for all groups to receive rewards if they remain below a specified number of inappropriate behaviors. This number may then be reduced over sessions.

The Good Behavior Game has been tested in two major randomized controlled studies in an urban environment. It was demonstrated to reduce aggression (Dolan, Kellam, Brown, Werthamer-Larson, Rebok, & Mayer, 1993) and increase on-task behavior (Brown, 1993) in 1st-graders, and reduce aggression (Kellam, Rebok, Ialongo, & Mayer, 1994) and the initiation of smoking (Kellam & Anthony (1998) in middle school students. A follow-up after the 6th-grade, found that students experiencing the GBG in the 1st-grade had a 60% lower incidence of conduct disorder, 35% lower likelihood of suspension, and 29% lower likelihood of requiring mental health services. Perhaps most impressively, 14 years after implementation, the GBG was found to result in a 50% lower rate of lifetime illicit drug abuse, a 59% lower likelihood of smoking 10 or more cigarettes a day, and a 35% lower rate of lifetime alcohol abuse for 19-21 year-old males (Kellam, Brown, Poduska, Ialongo, Petras, Wang, Toyinbo, Wilcox, Ford, & Windham, 2008)! The GBG has been found to significantly reduce disruptive behavior as early as kindergarten (Donaldson, Vollmer, Krous, Downs, & Beard, 2011). Tingstrom and colleagues reviewed more than 30 years of research evaluating variations of the GBG (Tingstrom, Sterling-Turner, and Wilczynski, 2006). The experimental findings for the effectiveness of the Good Behavior Game have been so consistent and powerful that it has been recommended as an extremely cost-efficient “universal behavioral vaccine” (Embry, 2002).

Health Psychology

It is health that is real wealth and not pieces of gold and silver.

Mahatma Gandhi

We can make a commitment to promote vegetables and fruits and whole grains on every part of every menu. We can make portion sizes smaller and emphasize quality over quantity. And we can help create a culture – imagine this – where our kids ask for healthy options instead of resisting them.

Michelle Obama

It is a truism, consistent with Maslow’s pyramid, that one’s health overrides all other factors in one’s life. If one is not healthy it can be impossible to enjoy any of life’s social and vocational pleasures or achieve one’s potential. For practically all of our time on this planet, by today’s standards, humans had relatively brief lifespans. As shown in Kurzweil’s (2001) graph (see Figure 7.7), human life expectancy has doubled from approximately 39 to 78 years since 1850! The major causes of this increase are improved sanitary conditions and inoculations against infectious diseases. We now live at a time where the major causes of death in industrialized countries relate to our health practices. Our nutrition, as implied by our first lady, exercise routines, sleep habits, protective sex practices, use of seat belts, tooth brushing and flossing, adherence to medical regimens, and avoidance of tobacco and excessive alcohol, all impact upon the quality as well as longevity of our lives (Belloc & Breslow, 1972). A preventive approach emphasizing a prudent lifestyle is the most likely path to continued improvements.

Health psychology has emerged as a sub-discipline of psychology dedicated to “the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of health, illness and related dysfunction” (Matarazzo, 1980). It is hoped that the knowledge acquired through this discipline will enable the development of lifestyle-related technologies essential to the continuation of the upward trend in human life expectancy. Equally important, it is hoped that the quality of life can be improved, resulting in a greater percentage of individuals realizing their potentials. Health psychologist positions exist for those with master’s as well as doctoral degrees. Often training is linked with other specializations in academic/research (e.g., behavioral neuroscience) or practice (e.g., clinical psychology), or attained after earning the doctorate. Sub-specializations include clinical health psychology, community health psychology, occupational health psychology, and public health psychology.

As mentioned in the previous chapter, it has been found that inclusion and completion of homework assignments is essential to the success of cognitive-behavioral procedures (Burns & Spangler, 2000; Garland & Scott, 2002; Ilardi & Craighead, 1994; Kazantzis, Deane, & Ronan, 2000). Albert Bandura (1977b; 1982; 1986, chapter 9; 1997; Bandura & Adams, 1977; Bandura, Adams, Hardy, & Howells, 1980) coined the term “ self-efficacy ” to refer to an individual’s expectancy that they are able to perform a specific task. Presumably, successful completion of a homework assignment develops this expectancy. Once acquired, the individual is less prone to discouragement and more likely to act upon the desire to change. In the previous chapter, we observed that in several instances (e.g., depression), even though pharmacological treatment was initially as effective as cognitive-behavioral treatment, the benefits were more likely to be sustained with the learning-based treatment. This can be attributed to the self-efficacy beliefs likely to result from the different approaches. In one instance, the person is likely to attribute success to the effects of the drug. Once it is withdrawn, the person may no longer believe that they can cope. In contrast, after cognitive-behavioral therapy, the person is more likely to believe they have acquired the knowledge and skill to address their problem.

The Health Action Process Approach (see Figure 12.8) emphasizes the importance of different types of self-efficacy in the development of the intent and ability to change health-related behavior (Schwarzer, 2008). We will use smoking as an example. During the motivational stage, even if a smoker perceives it as a problem and expects health to improve as the outcome of quitting, the intent to act requires believing that success is possible. During the volitional stage, even if the smoker formulates an effective plan, success requires believing that quitting can be maintained for an extended period of time and that recovery from any lapses is likely. Relapse prevention techniques should result in increased maintenance and recovery self-efficacy.

“I think I can, I think I can”

The Little Engine that Could by Watty Piper (1930)

Nothing succeeds like success.

Oscar Wilde

There is an extensive research literature documenting the relationship between self-efficacy and successful change in health habits including: smoking (Dijkstra & De Vries, 2000); dietary changes (Gutiérrez-Doña, Lippke, Renner, Kwon, & Scwarzer, 2009) including Michelle Obama’s desired increase in fruit and vegetable consumption (Luszczynska, Tryburcy, & Schwarzer, 2007); and exercise (Luszczynska, Schwarzer, Lippke, & Mazurkiewicz, 2011). For decades, it was believed that improving students’ self-esteem , as opposed to self-efficacy, would improve their school performance. A comprehensive review of the research literature concluded that the relationship was the result of better school performance improving self-esteem rather than the other way around (Baumeister, Campbell, Krueger, & Vohs, 2003). Despite this strong relationship between self-efficacy and successful behavior change, one needs to be careful about concluding cause-and –effect. Self-efficacy can be a seductive pseudo-explanation. Does increased self-efficacy lead to improvement or is it the other way around?

Multisystemic Therapy for Conduct Disorder

It takes a village to raise a child.

African proverb

I chaired the Department of Psychology for 24 years, an unusually long stretch. Often, less-experienced chairs from other departments would ask me about my “administrative style.” Eventually I arrived at the term humanistic ecology to describe my interpretation of the chair’s role (Levy, 2013, pp. 231-232). The same term could be applied to the roles of parent, friend, teacher, mentor, administrator, clergy member, coach, or helping professional. One is even being a “humanistic ecologist” when engaged in a self-control project. From Maslow’s perspective, humanism requires supporting others in their quests to self-actualize. An ecologist studies the relationships between organisms and their environments. Humanistic ecology involves the attempt to identify and create niches in which individuals are able to achieve their self-defined goals and realize their potential while serving the needs of a social group (e.g., family, work colleagues, team, community, nation, etc.).

Sometimes effective treatment for an individual requires coordination between professional psychologists, family, and appropriate community members. We saw that the gains made by autistic children in institutionalized settings could be lost when they returned to their homes. In order to maintain and build upon previously acquired skills, it was necessary to teach family members and significant others to implement direct and indirect learning procedures. In treating conduct disorder, it has been found that successful treatment in one context (e.g., at home) will not necessarily generalize to another context, such as school (Scott, 2002). In Chapter 11, multisystemic therapy (MST) was mentioned as a promising approach to treating severe, intractable cases of conduct disorder. As described, children and adolescents diagnosed with conduct disorder must frequently cope with economic, interpersonal, substance abuse, and criminal justice issues confronting their families and friends. In the same way that treating an individual for malaria would not protect them from contracting the disease when they returned to a mosquito-infested environment, treating a child for conduct disorder would not provide protection from the difficult and discouraging realities they face on a day-to-day basis. Effective long-range treatment requires altering the environmental conditions in order to encourage and sustain desired behavioral changes.

MST is a comprehensive treatment approach to conduct disorder incorporating evidence-based practices in the child’s home, school, and community (Henggeler & Scaeffer, 2010; Scott, 2008; Weiss, Han, Harris, Catron, Ngo, Caron, Gallop, & Guth, 2013). MST targets such serious behavioral excesses as fighting, destroying property, substance abuse, truancy, and running away. Targeted behavioral deficits may include communication (e.g., initiating and sustaining a conversation), social (e.g., sharing and cooperating), and academic (e.g., reading and math) skills. Services are provided in the natural environment as opposed to an office. MST is intense, usually consisting of direct contact for about five hours per week for up to six months. Staff members are continuously available at other times to provide assistance and address emergencies.

The treatment objective of MST is to transform the child’s environment from one that fosters and sustains the behavioral excesses to one that discourages and eliminates them. This requires a comprehensive, detailed analysis of the antecedents, behaviors, and consequences (i.e., the “ABC”s) within the specific environmental circumstances. Vygotsky’s developmental principles of incorporating zones of proximal development and scaffolding are implemented through the use of prompting, fading, and shaping procedures. A problem-solving process is followed, incorporating the results of continual assessment into an evolving intervention strategy in the different contexts.

MST includes training family members to systematically monitor the child’s (or adolescent’s) behavior and provide appropriate consequences, including explanations. Communication between parents and consistency in their enforcement of rules is encouraged to prevent a “good cop, bad cop” pattern from emerging. Attempts may be made to monitor and influence choice of friends, encouraging the development of a peer group of positive role models. Regular meetings are scheduled between parents and teachers to discuss the behavioral and academic performance of the child. After-school time is monitored and structured carefully to promote studying and decrease the likelihood of engaging in anti-social activities. Role-playing exercises are designed to prepare the child to resist peer pressure to use drugs or engage in delinquent behavior (Henggeler, Melton, & Smith, 1998; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009). It may not require a village, but MST typically includes a doctoral-level psychologist supervising three or four master’s-level psychologists, each with a caseload of four to six families. Therapists may initially meet with the family on a daily basis, gradually reducing the frequency to once a week (Henggeler & Schaeffer, 2010).

Several randomized outcome studies have found MST effective in reducing rearrests and improving behavioral functioning with youth and adolescents diagnosed with conduct disorder (Butler, Baruch, Hickey, & Fonagy, 2011; Timmons-Mitchell, Bender, Kishna, & Mitchell, 2006; Weiss, et al., 2013). Follow-up studies ranging from two (Ogden & Hagen, 2006) to 14 years (Schaeffer & Borduin, 2005) have found the effects to be long-lasting. Recidivism rates were 50% for individuals receiving MST in comparison to 81% for those receiving standard care. MST treated adults (an average of almost 29 years old at follow-up) were arrested 54% less frequently and confined for 57% fewer days (Schaeffer & Borduin, 2005). Meta-analysis is a statistical procedure used to combine the results of several different research studies to determine patterns of findings and estimates of the size of the effect of independent variables. Meta-analyses have confirmed the short- and long-term effectiveness of MST in treating conduct disorder (Curtis, Ronan, & Borduin, 2004; Woolfenden, Williams, & Peat, 2002).

The proverbial “round peg in a square hole” is a useful metaphor for the human condition and for humanistic ecology. We are all “pegs” doing our best to fit our current environmental circumstances (“holes”). We are born essentially “shapeless”, requiring parents and significant others do their best to “shape us up.” Sometimes, those who care require professional assistance to get us to fit comfortably. Usually, professional assistance consists exclusively of trying to change the shape of the peg to conform to the hole. As we saw with autism spectrum and conduct disorders, this approach can be insufficient. Sometimes it is necessary to also change the shape of the hole. Parent training and the more comprehensive multisystemic therapy are examples of this strategy.

Psychology and Human Potential

Upon completing the discussion of psychological approaches to treating and preventing maladaptive behavior, we have reached the end of our story. We can now consider the implications of what we have learned about the discipline of psychology and human potential. Theoretically, the multi-systemic approach to treatment of conduct disorders could be expanded to achieve al least the first 3 (of 30) articles of the Universal Declaration of Human Rights (https://www.un.org/en/universal-declaration-human-rights/) listed in Chapter 7 (repeated below). Our homes, schools, communities, and nations could collaborate to realize the following:

Article 1.

All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2.

Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3.

Everyone has the right to life, liberty and security of person.

Article 1 implies all humans are born with the same genome. In chapter 1, we saw how the combination of our large frontal cortex and physical features permitting speech and use of tools enabled us to transform the world and human condition. Our imagination combined with communication, collaboration, and manipulation seem unlimited in their application. They could be directed toward achieving the goals of the first three articles. As described in the first article, this requires communicating, collaborating, and manipulating in a spirit of brotherhood. Tragically, human pyramids of hate interfere with climbing Maslow’s human needs pyramid. By emphasizing the article 2 differences of race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status, we fail to recognize and fulfill the potential of our common humanity. Fulfilling our potential will only be achieved when we insure the opportunity for everyone to satisfy the Article 3 human survival, interpersonal, self-esteem, and self-actualization needs. Then “What a wonderful world it would be!”

Attributions

Figure 12.1 “Health Action Process Approach” by R.Schwarzer is in the Public Domain, CC0