Looking Beyond Treatment to Understand Relapse

Treatment for problematic behaviors like drug and alcohol addiction, self-injury, and childhood aggression costs individuals and society millions of dollars a year. Well-designed treatments often work in the short term, but relapse is common. Understanding the reasons why is critical, because when people take up their old bad habits, it causes distress for patients, families, and community members. But one significant factor is rarely considered by clinicians, because it isn’t about the treatment, but about what happens after the treatment, says Chris Podlesnik, Associate Professor of Psychology and Behavior Analysis at the Florida Institute of Technology. His research finds that people are more likely to relapse after they transition to a new setting, for example from a treatment center to home, or from one city to another.

People with serious addictions and other severe behaviors often need to be treated in a clinic or hospital to keep them out of danger. Therapists there typically use methods to both discourage the problematic behavior and reinforce alternative ones. That process often works, and people stop their dangerous behaviors. But when they go home, even the positive reinforcements for the alternative behaviors, like praise from family or the ability to hold down a job, might not be enough to prevent relapse.

Why does going home increase their risk? Is it because home reminds them of the habit? That may be a part of it. But there seems to be more to it, because a context change of any kind can increase the chance of relapse. Podlesnik’s studies with both animals and humans show that even when treatment is given in the home setting, moving to a new context can trigger the old behavior to reemerge. He thinks this might happen because ambiguous situations can cause people to fall back on old habits. He gives the example of intervening with a child who throws frequent temper tantrums: even if you successfully help her change her behavior at home by taking away the extra attention she was ‘rewarded with’ when she threw tantrums, she may still have a tantrum at the grocery store. Similarly, an addict who moves from a treatment center to a shelter or to be with family in a new city might be at risk for relapse.

So what are clinicians, patients, and families to do? Podlesnik, who conducts research and supervises clinicians who treat problem behaviors, says the first thing they can do is pay more attention to environments. “Usually clinicians are focused on treatment fidelity,” or whether the treatment is provided the way it was intended, and on whether the rewards for alternative behaviors are consistently provided. “We’re saying that you need to pay attention to context, too.” For example, clinicians can help patients’ families be aware that a behavior eliminated in a clinic could return once the person goes home, possibly even getting worse before it gets better.

Podlesnik hypothesizes that it may be possible to apply his findings to modifying treatments. For example, teaching desirable alternatives in a range of contexts the patient doesn’t associate with the problem behavior could be effective.  But we need more research on this and other applications, he cautions. He is optimistic about the chances of that research to improve the long-term effectiveness of treatments. His research, he explains, highlights that “it’s about behavioral flexibility. Problem behaviors can come back, but that flexibility also means we have the ability to learn a new response.”

Christopher Podlesnik was recently honored with the Federation of Associations in Behavioral & Brain Sciences (FABBS) Foundation Early Career Impact Award during the annual meeting of the Association for Behavior Analysis International in Chicago, IL.