Relapse dynamics during smoking cessation: recurrent abstinence violation effects and lapse-relapse progression

Smoking cessation is a process that unfolds over time and is characterized by intermittent lapses. We used parametric recurrent event survival analyses to better understand the dynamic relationship between a set of Abstinence Violation Effect (AVE, Marlatt & Gordon, 1985) responses to lapsing and subsequent lapse-relapse progression. Participants were 203 smokers who achieved abstinence and responded to items assessing three core components of the AVE (internal attribution, abstinence self-efficacy and guilt) following a total of 1,001 lapse episodes in near real time. Neither self-blame, self-efficacy, nor guilt following participants' first lapse predicted relapse. Controlling for responses to their first lapse, responses to each additional lapse did prospectively predict lapse progression, such that drops in self-efficacy were associated with accelerated progression to a subsequent lapse (HR = 1.09, CI = 1.02-1.15), while increases in internal attributions of blame actually protected against lapsing (HR = 0.98, CI = 0.97-0.99). Treatment with nicotine patches slowed recurrent lapse progression (HR = 0.58, CI = 0.48-0.70), but this effect dissipated over multiple lapses, and was moderated by elevated ratings of postlapse guilt (HR = 1.08, CI = 1.01-1.18), which predicted accelerated progression within the active patch group, while protecting against lapse in the placebo group. Results highlight the dynamic nature of lapse responses during smoking cessation, indicating that self-efficacy predicts progression from one lapse to the next, while attributions of self-blame and guilt influenced progression in unexpected ways.     

Using Multiple Contexts and Retrieval Cues in Exposure-Based Therapy to Prevent Relapse in Anxiety Disorders

The benefits of exposure-based interventions for anxiety disorders are substantial but not stable for everyone, given that these interventions are often followed by relapse of symptoms. A body of research provides a background on how to add certain strategies in exposure-based therapy to prevent relapse in anxiety disorders. This review summarizes some of these strategies and provides clear-cut clinical implications. Studies that provide support for two types of strategies to prevent relapse have been reviewed—the use of multiple contexts and the use of retrieval cues. The use of multiple contexts reduces context and stimulus specificity of extinction learning during exposure, while the use of retrieval cues enhances memory (re)consolidation and retrieval after exposure. The described strategies to enhance the accessibility and therefore the retrievability of exposure-based learning to prevent relapse in anxiety disorders can be summarized as advice to conduct exposure under variable conditions. This way, the generalizability of what is learned during exposure to the patients’ daily life after treatment improves. Therefore, adding these strategies in the course of exposure-based treatment of anxiety disorders seems beneficial. However, future replications and translational studies are needed to verify ecological validity.     

Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth

Relapse rates for children and adolescents with major depressive disorder (MDD) range from 30% to 40% within 1 to 2 years after acute treatment. Although relapse rates are high, there have been relatively few studies on the prevention of relapse in youth. While acute phase pharmacotherapy has been shown to reduce symptoms rapidly in depressed youth, children and adolescents frequently report ongoing residual symptoms and often relapse following acute treatment. Recent adult trials have begun examining augmentation with psychosocial treatment after successful medication treatment to enhance medication response and prevent future relapse. This strategy has not yet been examined in youth with depression. Here we present initial efforts to develop a sequential, combination treatment strategy to promote rapid remission and to prevent relapse in depressed youth. We describe efforts to adapt CBT to prevent relapse (RP-CBT) in youth who respond to pharmacotherapy. The goals of RP-CBT include: preventing relapse, increasing wellness, and developing skills to promote and sustain well-being. We describe the rationale for, components of, and methods used to develop RP-CBT. The results from a small open series sample demonstrate feasibility and indicate that youth appear to tolerate RP-CBT well. A future test of the treatment in a randomized controlled trial is described.     

Individual and Family Growth: A Gestalt Approach

Gestalt therapy is described as a comprehensive framework of theory and techniques for experiential family therapy. Like other experientially oriented therapies, it is systems-oriented, immediate-experience-oriented, and affect-oriented. Unlike others, this method regards the client system's emergent processes as the central focus, and it emphasizes that growth occurs as the family and its members are helped to greater self-awareness and responsibility for their own functioning.     

A new visual illusion: neonlike color spreading and complementary color induction between subjective contours.

A new visual illusion is described as a neonlike spreading of color between subjective contours. Spreading of an actually present color as well as spreading of a complementary color appear to be possible. Spreading of brightness can be demonstrated also.Two related classes of illusions are mentioned and some indications of central factors involved in the effect are discussed.     

Internalized homophobia in men: wanting in the first person singular, hating in the first person plural

This paper focuses on the expression of internalized homophobia in men, arguing that the most powerful clinical use of this term depends upon its applicability to any man, without limitation to those whose primary object choice is homosexual. A number of dynamic situations are described to which the term might apply, elaborated by examples from contemporary culture and clinical practice. A central dynamic elucidated here is the move from an anxiety-ridden, first person singular voice to the promised safety of a first person plural voice--that is, from the dangerous position of "I want" to the more protected "we hate."     

Self-Psychology,Shame, and Adolescent Suicide: Theoretical and Practical Considerations

Using the psychoanalytic self-psychology of Heinz Kohut as the theoretical foundation of this article, the authors discuss the role of shame in adolescent suicidal behaviors. Shame is described as a central component of suicidal behavior within the context of adolescence, a fundamental stage in the development of the healthy self. Normal and pathological self-development are described and important issues pertaining to the development of the self during adolescence are explored. A theoretical explanation of adolescent suicidal behavior from a self-psychology perspective is offered. Finally, suggestions for treatment of the suicidal adolescent and an illustrative clinical vignette are presented.     

Cognitive Antecedents and Sequelae of Smoking Relapse Crises1

This study examines Marlatt's account of the cognitions surrounding relapse episodes. Interviews with 143 ex-smokers who called a relapse prevention hotline provided mixed support for this account. Most subjects, especially those who smoked, stated that they had expected smoking to result in reduced tension. Subjects who were motivated by reduction of craving were unlikely to smoke. Contrary to expectations, all subjects experienced significant drops in self-efficacy as a result of the relapse crisis, regardless of whether or not they smoked. Subjects who did not smoke worried about future crises, while those who did felt guilty about their transgression. Both groups reported feelings of failure, which were related to the absence of coping. These unexpected results, though based on a limited sample, suggest that many subjects' experience of relapses and near-relapses are not well described by current theory.     

Evolution,depression and counselling

In this paper a framework of evolutionary psychology is used to develop a model of depression. In this model depression is seen as not normally a biochemical illness or disorder, but instead as usually due to the person becoming trapped within a psychologically activated but unwanted and inappropriate suite of natural emotions, with the activation coming from a perception of a major decline in personal usefulness that can include failure, guilt, shame or perceived rejection. A neuropsychological observation that supports this model is described. The implications of the model for counselling with depressed clients are outlined in terms of a multi-dimensional approach, oriented around perceived usefulness. It is predicted that clients receiving such counselling will recover more rapidly and be less likely to suffer a relapse than those receiving just drugs or a form of counselling that covers fewer dimensions.     

Towards a relational framework for pathological gambling (Part I): Five circuits

Relationship patterns before and after pathological gambling were investigated qualitatively using eight in‐depth clinical case studies in which one partner met Diagnostic and Statistical Manual of Mental Disorders‐IV pathological gambling criteria. Five circuits of couple interactions are described: (i) fault‐lines; (ii) pressure points; (iii) escalation; (iv) relapse and (v) congruence. The exploration of these circuits is developed in two complementary articles. This first article delineates the first four circuits as recursive self‐perpetuating cycles of couple distress in systemic interaction with pathological gambling development and relapse. The second article delineates how a couple can be helped to extricate themselves from these recursive circuits through ‘congruence’. Implications of this relational formulation of pathological gambling for conceptualization, assessment and treatment are discussed.     

Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder

Cognitive-behavioral therapy can be effective for many clients who have obsessive-compulsive disorder. Despite its effectiveness, many treatment guidelines fail to describe cognitive-behavioral therapy procedures in adequate detail. The present paper will review the literature on cognitive-behavioral therapy for OCD in an attempt to provide concise, meaningful guidelines for the psychological treatment of this disorder. Cognitive-behavioral therapy includes four general components: initial preparation for therapy, development of applied coping skills, exposure with ritual prevention, and relapse prevention. The four general treatment components are described, and clinical examples are provided.     

Emptiness in agoraphobia patients

In light of new research findings about the efficacy of psychodynamic treatment for panic disorder and agoraphobia, it seems a prudent time to carefully address psychoanalytic thinking about the treatment of agoraphobia. The literature has highlighted oedipal contributions to its genesis and clinical unraveling in psychoanalysis. While those contributions are indeed central to the disorder, structural deficits in the self-representation often become a central focus of treatment once symptomatic remission has been achieved in psychoanalytic treatment. This aspect of the clinical presentation of agoraphobia has not yet been specifically addressed in the psychiatric literature. Some aspects of the phenomenon have been described by psychoanalysts. It is more difficult to treat this "emptiness" than the overt symptoms of agoraphobia, as described in DSM-IV. Nonetheless, this phenomenon may be one of the contributors to the chronicity of the disorder. Two clinical cases illustrate these points.     

Implications of a Relapse Prevention Model for the Treatment of Sexual Offenders

This article presents the rationale for applying a relapse prevention model in the treatment of sexual offenders. First, a general model formulated from the cognitive/behavioral treatment of addictive behaviors is described and then guidelines are provided for the application of this model to the treatment of sexual offenders.     

Psychotherapie für Straftäter

The legal and administrative framework for psychotherapy of offenders in prisons and secure forensic hospitals is outlined. Established treatment programs for offenders are presented including different variations of standardized cognitive behavioral approaches, e. g. relapse prevention programs (RP), dialectic behavioral therapy (DBT), transference-focused psychotherapy (TFP), and mentalization-based treatment (MBT). The foci of the individual programs as well as their integrative tendencies are described. In psychodynamic therapies cognitive processes are taken into consideration and, vice versa, cognitive-behavioral therapists discover the significance of the therapeutic relationship.     

The Role of Sexual Trauma in the Treatment of Chemically Dependent Women: Addressing the Relapse Issue

A review of the literature indicates a high incidence of sexual trauma among women who seek treatment for substance abuse. Additionally, clients who have experienced sexual trauma appear to be more susceptible to relapse, the return to substance abuse. This article explores issues surrounding sexual trauma and chemical dependency. It aims to provide direction for relapse prevention with a relapse-prone population. Application of traditional milieu substance abuse treatment for sexual trauma survivors is explored. Recommendations for working with sexual trauma survivors who are also substance abusers are presented, as are suggestions for research.     

Psychophysiological correlates of long-term attention to complex tasks

An ongoing investigation of the psychophysiological nature of attention is described. Problems associated with the measurement of long-term human attention to complex tasks are discussed. A multivariate, hierarchical regression approach is described for the inference, from the non-in vasive measurement of surface neuroelectrical activities, of central nervous system operations associated with the maintenance and failure of long-term attention. The neuroelectrical signals used include the EEG, EOG, EGG, and impedance cardiogram. Psychophysiological measurement, data reduction, and analysis techniques are described.     

A neural mechanism for discrimination

A mechanism for localizing different stimulus intensities within the nervous system, essentially as described by Rashevsky, is considered in first approximation. The mechanism is central, and therefore general. There results a one-parameter family of theoretical curves, graphs of the Weber (discriminal) ratio against stimulus intensity. Comparisons are made with experimental visual, acoustical, and tactual data.     

Philosophy of medicine and other humanities: Toward a wholistic view

A less analytic and more wholistic approach to philosophy, described as ‘best overall fit’ or ‘seeing how things all hang together,’ is defended in recent works by John Rawls and Richard Rorty and can usefully be applied to problems in philosophy of medicine. Looking at sickness and its impact upon the person as a central problem for philosophy of medicine, this approach discourages a search for necessary and sufficient conditions for being sick, and instead encourages a listing of “true and interesting observations” about sickness which reflect the convergence of a number of different viewpoints. Among the relevant viewpoints are other humanities disciplines besides philosophy and the social sciences. Literature, in particular, provides insights into the meaning and the uniqueness of episodes of sickness in a way that philosophers may otherwise fail to grasp.