by John Ludgate, Ph.D.
There is a good deal of support in the literature (see a review by Hollon et al; 2006 ) for the idea that cognitive-behavioral approaches appear to reduce relapse rates in some emotional disorders, especially depression and anxiety. While this might be a reason for some pride and self-congratulation amongst CBT researchers and practitioners, there is really little room for complacency since a significant percentage of patients (approximately 20% to 35%) still experience a recurrence of symptoms (Ludgate, 1994). This may be an even more significant problem for clinicians because it is usually the case that patients treated in clinical practice will have more severe psychopathology than patients meeting the inclusionary criteria for research studies and so the relapse rates may actually be higher.
Therefore, despite lower relapse rates compared to other treatment modalities, relapse is still a significant problem in CBT. As a consequence, it behooves clinicians to refine and evaluate relapse-prevention methods to counter this problem. In the field of cognitive behavioral treatment of depression and anxiety, we have lagged behind in the development of CBT for addictions where there has been a great deal of research and clinical emphasis on relapse-prevention beginning several decades ago (Marlatt & Gordon, 1985). A number of writers in the field of CBT with emotional disorders have more recently described how maintenance and relapse-prevention can be built into a comprehensive treatment of depression and other disorders. (Wilson, 1992; Anthony et al, 2005; Ludgate, 2009). Some concrete suggestions for improving longer term outcome may involve incorporating mindfulness into cognitive therapy (Segal et al, 2002) or including a continuation or a maintenance version of cognitive therapy (CT) after remission. (Jarrett et al, 2001)
Some studies that have looked at the effectiveness of adding a continuation phase following acute CT treatment or incorporating mindfulness into cognitive therapy practice have shown very encouraging results in the treatment of depression. For example; Hollon et al (2005) conducted a study in which acute phase CT was followed by three booster sessions during a 12 month follow up. This treatment had enduring effects at 2 year follow up with 30% of these patients relapsing versus 76.2% of clients who received medication continuation. Similarly, Bockingetal (2005) found that treating depressed clients in remission who were at high risk for relapse with continuation pharmacotherapy plus CT reduced the risk of relapse compared to continuation pharmacotherapy alone. This effect was even more pronounced when the number of previous depressive episodes was 5 or more, where the risk was reduced from 72% down to 42% at 2 year follow up.
With patients who are in partial remission following pharmacotherapy and have some residual symptoms Paykel et al, (1999) found that adding CT significantly reduces their relapse probability relative to standard clinical management (29% versus 47%). Similarly, Fava and colleagues (1998) found that treating residual symptoms of depression and anxiety with CT following successful pharmacotherapy greatly reduced the risk of relapse compared to clinical management at three different follow up points: 2nd ,4th, and 6th year. They reported that the average number of relapses/recurrences per patient was 0.8 in the CT treated patients versus 1.7 in the clinical management group. In a study where the continuation version of CT was significantly different from the acute phase of CT, with more of an emphasis on generalization of skills and relapse prevention and maintenance, Jarrett et al (2001) found that adding 10 sessions of Continuation CT over an eight months period after remission resulted in a 10% relapse rate at 2 year follow up compared to 31% with acute phase CT only.mindfulness based cognitive therapy (MBCT) reduced relapse by about half compared to treatment as usual. It was found to be especially effective in reducing relapse in patients with three or more previous episodes (36 and 37% versus 67 and 78%).
Knowledge of predictors of relapse or sustained recovery can guide good clinical practice in terms of relapse-prevention. For example, studies done on dysfunctional attitudes and relapse (Eaves & Rush, 1984; Ludgate, Reinecke, & A. T. Beck, 1987) suggest that, unless maladaptive attitudes or beliefs are identified and modified in therapy, patients who have improved symptomatically may still be at risk for relapse after treatment. Some research shows that psychotherapy that produces symptom relief only rather than also targeting belief-change may be a less than adequate treatment in terms of long term outcome (Ludgate, 1991). Again, in the same vein of incomplete or less than adequate treatment, the study mentioned earlier by Paykel and colleagues (1999) attests to the importance of dealing with residual depressive symptoms in ensuring good long term outcome.
Although no studies have addressed this issue empirically, it seems likely that inadequate conceptualization and the application of CBT in a rigid, over-technical manner is associated with a higher risk of relapse because core and idiosyncratic problems are not identified and addressed. Consequently, there is a need for a comprehensive case assessment based on a biopsychosocial risk analysis to ensure well planned and appropriate treatment. The importance of sophisticated case conceptualization as a means of maximizing treatment gains and preventing relapse needs to be underscored (Ludgate, 1994).
Research in depression treatment outcome has consistently found that adverse life events effect longer-term outcome negatively (Ludgate, 1991). Subsequently effective CBT should target skills for dealing with adverse life events and facilitating the setting up of a good resource system, including having emotional and social support available from others, which has also been found to act as a buffer to stress and relapse in these clients.
Finally, the focus on a skills training approach with the patient to become his or her own therapist would appear to be important in guiding clinical practice. This emphasis is consistent with self efficacy research (Bandura, 1977) and with process research in CT (Barber & DeRubeis, 1989). This research suggests that compensatory skills (i.e., skills to curtail negative thinking) are the process by which patients both overcome problems and prevent relapse. Also, in keeping with this model, Ludgate (1991) found that patients' perception of their skill in using CT strategies on their own after therapy was the most powerful predictor of positive outcome over a 5-year period.
In summary, some of the following factors, which are considered important in the relapse process, can be targeted for intervention in a comprehensive cognitive behavioral treatment approach:
- The patient's personal resources and skills and his or her perception of these variables.
- External resources including support systems such as family, friends, community, and professional help, and the perception of these resources after treatment.
- Life events/stressors and the patient's perceptions of these events
- Residual symptoms that exist at the end of treatment
- Residual or continuing cognitive deficits or distortions such as dysfunctional beliefs or biased information processing
Although many writers in the CBT field stress the importance of building maintenance and relapse prevention into treatment, little specific information exists as to how this can be achieved in routine clinical practice. From a number of sources outlined earlier, the following appear to be the most promising strategies:
- Beginning early in therapy, stress the goal of making the client his/her own therapist
- Promote internal attributions of change
- Increase client activity level and responsibility more and more as therapy proceeds
- Place greater emphasis on between session activity as therapy enters middle and later stages
- Work on a variety of targets
- Train in general skills and in vivo where possible
- Get the client to practice skills beyond criterion/overlearn
- Enlist significant others in therapy where possible and feasible
- Fade frequency of sessions later in therapy
- Help client plan a self-therapy program to be pursued after termination
- Educate regarding relapse and create realistic expectations regarding the future course of the disorder
- Discuss the need for and benefits of maintenance efforts
- Anticipate and plan for high risk situations
- Help client recognize early warning signals of possible relapse
- Generate and rehearse an emergency plan in the event of future setbacks
- Modify the environment, if possible to support new behaviors and set up a support system to buffer future adverse life events if they occur
- Use booster sessions
These and other therapeutic interventions aimed at relapse prevention are more fully described in Ludgate (2009) Cognitive-Behavioral Therapy and Relapse Prevention for Depression and Anxiety, published by Professional Resources Exchange.
If you would like to learn more about these topics, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.
John Ludgate is a licensed psychologist who has practiced psychotherapy for over 30 years. He was trained by and subsequently worked with Aaron Beck and has been an author on a number of books and peer-reviewed journal articles. You can learn more about Dr.Ludgate and his North Carolina-based practice at his website: www.behaviortherapist.com.