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Identifying and Managing Relapse Risk

Buckworth, Janet, Ph.D., FACSM

doi: 10.1249/FIT.0000000000000367
Columns: Enhancing Your Behavioral Toolkit
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Janet Buckworth, Ph.D., FACSM,has spent more than 25 years studying exercise adherence and theory-based behavior change interventions. She has master’s degrees in clinical social work and health education and a Ph.D. in exercise psychology, with work experiences in medical and college settings. Dr. Buckworth is a fellow of the American College of Sports Medicine, serving on the Behavioral Strategies Special Interest Group. Dr. Buckworth is a department head in Kinesiology at the University of Georgia.

Disclosure:The author declares no conflict of interest and does not have any financial disclosures.

A central step in relapse prevention is identifying high-risk situations. These are internal and external events that challenge a client’s confidence in sustaining the target behavior. Having a plan B to manage disruptions to an exercise routine is an important skill for decreasing the risk of stopping a program; this was covered in the last Enhancing Your Behavioral Toolkit column. This time, we’ll consider other things that increase the risk of stopping a healthy routine and how to help someone prevent or cope with them. These concepts and strategies are based on the relapse prevention model, which was developed to improve the chances that someone would remain abstinent from unhealthy behaviors, such as smoking cigarettes. Useful strategies to sustain healthy lifestyle behaviors have emerged from using several key psychological elements of this model.

Certain characteristics of a person can put him at greater risk of stopping a healthy habit, especially in the early period after adopting a new behavior. First, fitness professionals should watch out for signs of all-or-none thinking. Clients who exercise only on a certain cycle or backtrack at the end of each run to make it exactly 3 miles, for example, may not respond well when their routine must be adjusted. A good illustration from weight management is a client who is very strict about not snacking after supper but “gives in” and eats one cookie. All-or-none thinking would be, “I’ve blown it by eating that cookie! I might as well eat the whole box.” For physical activity, think about someone who skips a workout because he or she only has 30 minutes and not the 60 minutes necessary for his or her routine. He or she has acted on his or her all-or-none thinking. When a client chooses with growing frequency to do nothing unless he or she can follow his or her exact fitness routine, the behavioral consistency that supports adherence to a healthy behavior is hampered, and the risk of stopping completely increases. Helping clients incorporate flexibility into their plans from the very start is a good tool for moderating all-or-none thinking and behavior. Certainly, having a plan B (1) is important, but the fitness professional should encourage clients to set up plans that include parameters such as “at least,” “between,” and “or” in designing an exercise or diet program. Planning with flexibility is a foundational context for integrating exercise into someone’s life (2).

Walk 30 minutes 5 days each week →

Walk at least 30 minutes 3 to 5 days each week.

Run 5 miles on Monday, Wednesday, and Friday after work →

Run 5 miles or work out at a high-intensity 40 to 50 min on Monday, Wednesday, and Friday after work with Saturday as a workout backup day

Eat half a banana for a midmorning snack during the week →

Eat a piece of fresh fruit for a midmorning snack at least 4 days during the week.

A flexible plan that has a strong likelihood of success can guide your clients through disruptions without feelings of failure if they don’t enact their plan exactly. The behavioral benefits include having them continue to engage in healthy behaviors and strengthen healthy habits. Instead of skipping a stretching routine because there is not enough time to hold each stretch for 60 seconds, running through the whole routine holding for 30 seconds cuts the time in half but retains some physical benefits. The psychological benefit is a positive effect on self-efficacy from personal success despite a disruption to their planned routine. There is ample evidence for the power in self-efficacy enhancement for behavior change and maintenance (3).

An attitude that can put clients at risk of relapse is described as shoulds outweighing wants. In the column on building motivation (4), the continuum of behavioral regulation from external to internal included a more external regulation of behavior to avoid guilt. This introjected regulation of behavior drives physical activity and diet choices to avoid guilt or anxiety or to enhance ego or pride. Following a healthy lifestyle only because you believe you should can overshadow the enjoyment that is important in sustaining a behavior long term and lead to feeling deprived. Clients can be at particular risk if they repeatedly sacrifice getting what they want to do in favor of doing what they should. Examples include walking at lunch each day while coworkers all go out to eat, turning down a small piece of homemade dessert, or missing each Saturday football game to swim when the pool is open for laps. Feeling deprived also can increase the perceived value of the denied object or behavior. Fitness professionals can examine clients’ motivation and incorporate activities the clients enjoy into the plan and find opportunities to combine shoulds and wants (e.g., walk on the track listening to a favorite audiobook, experiment with healthy cake recipes). Finding what the client wants to do and supporting him or her to find ways to meet those needs while maintaining a flexible fitness plan can go a long way toward keeping a healthy should/want balance.

Finally, there is a tricky belief that can gain power when someone feels deprived — positive expectations about the relapse behavior. Eating that rich dessert after a big meal, sleeping in and not meeting your friends to run, or binge-watching a television series instead of going to a yoga class become more appealing when healthy behaviors have a rigid routine and are motivated by should. The fitness professional can address this head on and be armed with positive aspects and consequences of the fitness behavior to counter the attractions of the relapse behavior. It also is useful to correct some of the positive expectations of relapse behavior, such as helping the client think more about what he or she expects and what he or she really will get from the relapse behavior, such as asking him or her how he or she might feel after eating a rich dessert. A periodic review of the benefits and costs of a healthy lifestyle can go a long way to strengthening commitment and preparing for challenges.

Harley et al (2) developed a model of exercise adherence in African American women and found that for their participants, a temporary hiatus from regular physical activity was a normal part of integrating regular activity into their lives. Reminding clients that following a healthy lifestyle is a dynamic process, and relapsing from a regular routine, can provide important information about modifications to their plan and foster an increase in the conscious commitment.

All-or-none thinking, shoulds outweighing wants, and positive expectations about the relapse behavior put a client at risk of relapse. The fitness professional can identify clients for whom these characteristics can threaten adherence and be proactive with targeted strategies such as setting realistic and flexible plans and goals and exploring the clients’ perceived costs and benefits of their healthy choices and relapse behaviors.

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References

1. Buckworth J. Staying on track: creating a practical plan B. ACSMs Health Fitness J. 2017;21(6):37–8.
2. Harley AE, Buckworth J, Katz ML, Willis SK, Odoms-Young A, Heaney CA. Developing long-term physical activity participation: a grounded theory study with African American women. Health Educ Behav. 2009;36(1):97–112.
3. Buckworth J. Promoting self-efficacy for healthy behaviors. ACSMs Health Fitness J. 2017;21(5):40–2.
4. Buckworth J. Building motivation from basic needs: choose, accomplish, connect. ACSMs Health Fitness J. 2017;21(2):29–30.
Keywords:

Cost-benefits; Planning; Relapse Prevention

© 2018 American College of Sports Medicine.