Lapses—failing to implement an acquired skill—occur in all areas of behavior change. A particularly apt example can be seen in parent training. After a teach- ing intervention, parents will be much better equipped with simple, basic child discipline strategies. Sometimes, however, these take time or need to be practiced in a refl ective manner. Th ere will be many occasions in normal family life in which there is little time (sending children off the school, grocery shopping) and parents are pressured (have brought work home) and distracted (on the phone, bathing the new baby). Sanders (1982) defi ned these as hectic times in which proper program implementation was at risk, so that parents needed to be alerted to these critical periods and to have deliberate strategies for dealing with them.
Many of the changes people hope to accomplish involve stopping current activities that are inappropriate, harmful, illegal, or all three. Th ese are behav- iors that are strongly habitual, that are driven by powerful urges, and that have to be actively inhibited. Common clinical examples are consuming alcohol, binge eating, smoking cigarettes, and sexual paraphilias such as exhibitionism or watching child pornography. Given that many treatments teach clients to control these undesirable behaviors but may not eliminate the urge to perform them, it should not be surprising that “relapse” is quite likely. Slipping back into an old pattern of behavior—having a cigarette after quitting smoking, or fi nish- ing off a box of chocolates when trying to consume fewer carbohydrates—is a common enough experience for most of us to realize that it presents a challenge to permanent change.
Th ere are two fundamental principles in the many strategies known collectively as relapse prevention (Marlatt & Gordon, 1985). Th e fi rst is the “what the heck” principle: we need to ensure that one slip-up or violation of a rule for abstaining from a behavior does not indicate to the individual that control is impossible. We know most about this eff ect from the studies of treating alcoholism. Within the culture of many alcoholism treatment services is a belief that if someone were to violate an abstinence rule, they would then, because of their “illness,” be prone, driven in some internal way, to drink more. Th is is the “one drink then drunk” myth that becomes for vulnerable people a self-fulfi lling prophecy.
Th e second principle is that habits, with their associated urges when prevented, are highly controlled by eliciting stimuli that trigger the undesired response the client is attempting to inhibit. It is harder to control sexual behavior when in the
presence of highly arousing erotic cues; the sight and smell of alcoholic bever- ages trigger the urge to have a drink. One solution, therefore, is to avoid being exposed to these stimuli, as they make desistance so much harder. To this we can add another fundamental principle, confi rmed in hundreds of experimental studies: stimuli tend to control behaviors in the contexts in which those behav- iors were learned (see Chapter 5). If learning new habits, unlearning old ones, or learning to resist temptations occurs in only one context or setting, a change in that context will result in the person reverting to former ways of behaving (Laborda, McConnell, & Miller, 2011).
Relapse prevention strategies, which were developed around drinking behav- ior and rapidly adopted by clinicians treating all the urge-based habits, make good use of these two principles. Th e Alcoholics Anonymous depiction of there being no half way behavior between total abstinence and inebriation is chal- lenged, partly by education and persuasive communication, but even more so by normalizing the idea of relapse so that clients are led to expect that relapse is the norm and if they do break down and engage in the prohibited behavior it is not a disaster but an opportunity to learn where their vulnerabilities lie and to be better able to prepare in the future.
Th e other principle involves variations of the theme of not being exposed to triggers, which can include rules such as not living next to an elementary school if the client is a child sex off ender being released from prison. It also includes more formal eff orts to decrease the triggering properties of certain cues. Here the strategy is exposing the client to typical eliciting stimuli in a controlled setting, such as the sight, smell, and taste of alcoholic drinks in the clinic or laboratory where actually drinking them is not possible. Th e conditioning rationale for this is essentially that of extinction or habituation—the urge should decrease with unreinforced exposure to the stimuli. A third variant is to erode the power of these cues by altering their valence so that they no longer have positive aff ec- tive value for the individual—we might try to make the sight of someone smok- ing nearby evoke disgust (yellow teeth and bad breath) and fear (of lung cancer) rather than the urge to light up a cigarette. When this is done verbally it seems like verbal conditioning, if it is done using imagined scenes to create an aversive association it is called covert sensitization, if negative consequences are imag- ined it is called covert punishment, and if the client is encouraged to think of these negative images when in the actual situation and feeling an urge it is called a self-control strategy (all of which are mentioned again in Chapter 9). A fourth idea is to uncouple the automatic connection between a trigger and an impulsive act (the sequence being experience distress, feel the urge to drink, see a bar, order a drink). It has been proposed that this can be accomplished by intensely shifting attention from that sequence to distracting internal and external cues (Hsu, Grow, & Marlatt, 2008).
Although these are clinically all very useful strategies for ensuring longer term maintenance of change, they do not illuminate the underlying processes of
change. Instead they tell us something important about the way change can be sustained. Given that all change is by degrees over some span of time, it might be that so-called relapse prevention strategies are simply a special case of a more general process in which any temporary or transitional change becomes more permanent. Th is is a very subtle distinction, so it can be made a little more con- crete by considering a clinical phenomenon. Let us use bedwetting. Children with a diagnosis of enuresis wet the bed at night outside expected patterns of normative development. Volume of urine is not an important dimension in this phenomenon—we do not look for change being smaller and smaller amounts of wetting each night. We just have a clear goal: dry nights. So as the treatment begins to show an eff ect, what is the change actually seen? It is more and more regular dry nights. Th e child does not show slight improvements each night. After X number of dry nights in a row, the child, the parents, and the clinician will start to feel change has been achieved. But lapses are common and after a few dry nights the child might have an accident and wet the bed; then there will be a few more dry nights, then maybe another lapse, and then a long period of dry nights, and so on, until eventually 99% dry nights can be expected. What has changed here is the pattern of dry nights or the ratio of wet to dry nights, and that ratio can be plotted as a cumulative moving average, showing steady change. But what has actually changed is only the probability that any given night will be dry—this should go from zero before treatment to 100% posttreat- ment. Relapses are not always a failure of change but are integral to the change process. In other words, whether a lapse is judged to be a new state of aff airs (a reversal) or simply a further step in the variable change sequence depends entirely on the time frame selected. If you have a 4-month frame for treatment and its follow-up, a reversal (an accident) after 6 months is a relapse; if you have a 24-month time frame for treatment and follow-up, a reversal after 6 months is merely noise in the change cycle.