Relapse Prevention: A Critical Aspect of Treatment Planning

In the treatment of eating disorders, relapses occur so frequently that it makes sense to incorporate prevention strategies right from the beginning. The goal is to teach a person to take more responsibility for his or her behaviors, and also to be prepared ahead of time to cope with stressful situations that might trigger a relapse into eating disordered behaviors.

First, let's look at the difference between a lapse and a relapse. A lapse occurs when a person temporarily falls back on former eating disorder behaviors as a means of coping with the stress of a particular situation, but is then able to recognize the self-destructive behavior, analyze it with a therapist, and use it to modify subsequent behavior. If, on the other hand, the person continues the eating disordered behaviors rather than confronting and dealing with the stress, the result is predictable: a complete relapse and surrender to the illness.

Causes for Relapses

Relapses usually involve a complex interaction of many factors. These may include:

• Emotional stimuli
• Interpersonal relationships
• Actions of others (family members, friends, people at school or work)
• Actions and behaviors of the patient
• Thoughts and interpretations about an event or interaction
• Environmental circumstances
• Physical state (the person's experience of his or her body and its responses to the stressful event)
• Spiritual issues
• Treatment issues

In this article, we will discuss the prevention strategies outlined in the book Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors by Alan Marlatt (1985). The role of the therapist in preventing relapse is to work with the patient to analyze and understand the contributing factors and then learn more adaptive, healthy coping responses for handling similar stressful situations in the future.

Critical to this process is understanding the relationship between triggering events or factors, the person's thoughts, and subsequent behavior. The therapy may focus on ways in which the person interprets and reacts to a difficult situation, and it may involve developing alternatives and practicing new problem-solving skills and behaviors. It may also focus on examining the relationship between the person's emotions and behaviors. In this case, it may involve learning to regulate and release emotions in healthy ways.

The ABC's of Behavior Chain Analysis

One particularly useful therapeutic tool is behavior chain analysis. It consists of three parts, which Marlatt breaks down as the "ABCs." "A" stands for the antecedents, or the events, thoughts, and emotions leading to a relapse. "B" refers to the relapse behavior, which the person wants to avoid. "C" refers to the positive and negative consequences of the decision to use the relapse behavior.

To use behavior chain analysis, it's important to focus on just one relapse behavior at a time. The therapist will ask the person to recall the antecedents of the relapse: all the interpersonal, intrapersonal, and environmental factors that preceded it. Second, the person is asked to identify an automatic thought that he or she associates with each antecedent. Third, the person looks at his or her emotional response to each antecedent and automatic thought. Finally, the person considers the positive and negative consequences of using the relapse behavior. Understanding the positive consequences helps the patient see the function of the eating disorder behavior—why it has been chosen as a means of coping. Understanding the negative consequences and long-term effects can help the person resolve to change.

Effective behavior chain analysis focuses on solutions. Once the person understands the relationships between the antecedent factors, the therapist and client can follow a defined series of steps to prevent relapse in the future: 1) They must identify changes that can be made in the client's life to interrupt the complex process of relapse. For example, in the future, can the client find ways to avoid situations that are likely to provoke the urge to relapse? 2) The client needs to develop challenges to each of the automatic thoughts identified in the behavior chain analysis. He or she can then commit to using these challenges in place of the old automatic thoughts whenever triggering situations occur. For instance, if a client's automatic thought after having an argument with a loved one is, "I'm a failure and am unloved," then he or she may challenge this thought by saying, "Someone can be angry at me and still love me." 3) The therapist can help the client manage and regulate emotions so that they no longer take control and determine the client's actions. 4) Adaptive coping mechanisms must be identified that will provide the same desired reinforcements as the eating disordered behavior has been.

It is important to realize that learning relapse prevention strategies will involve mistakes, lapses, and trial and error. But ultimately it can be the key treatment in preventing a return to the eating disorder.