Essay Grade

Experiencing a Traumatic Event
Experiencing a Traumatic Event
Program Transcript
GREG SIMPSON: Growing up, I was a pretty good kid. I did well in school, and I
wasn’t into drugs so my parents didn’t have any problems with me.
I probably had my first drink during my senior year of high school. For me and my
friends, that was normal. We didn’t think anything of it because we were just
celebrating after a school dance or graduation.
In college, I drank much more frequently. And I guess I could say I became a
little reckless. But I was in college, and that’s what we all expected of each other.
Don’t get me wrong, I didn’t hurt anybody. But I could have. I lucked out my junior
year in college when that cop didn’t give me a DUI, just a warning. That wasn’t
the first or the last time I drove when I shouldn’t have, though. So anyway, that
was college.
When I graduated, I met my wife, Tanya. And eventually, we were able to do all
the normal things that most young married couples do because I had a decent
job as a paramedic.
I was good, too. Always had a knack for helping people. Anyway, you can’t
imagine the kinds of things that you see while on the job in the middle of one of
the most dangerous cities. Crime doesn’t stop and neither do the injuries. We
had to help them.
I could be working on a guy in the middle of the road, giving them CPR, and I
would have to look over my shoulder and make sure there wasn’t someone else
who might fire another shot. Even when I was able to help that person, there was
another one, and then another one. Some the same, some different.
Every day was a different day, but it was intense nonetheless. That’s what made
me love the job. But after a while, it wears on you. You’re always in this state of
constant alert.
When I would get home from work, I would have a drink and relax. If the day was
a little harder than the last, then I just had a few more drinks. It made sense. And
at the time, I wasn’t worried.
After my 10th year on the job, I had started drinking a bit even before work, just
to take the edge off. Later on, I even started keeping a flask in my coat pocket
just in case.
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Experiencing a Traumatic Event
Well, one day I guess I had drank a little too much. We were rushed to the scene
of an accident and I was the one in charge of responding to a four-year-old boy.
He looked a lot like my son did at that age.
Well, I was not really all there. Things were kind of in and out of focus because I
had been drinking so much that day. I remember putting him on the stretcher,
making sure he was secure. But I didn’t realize that his leg had been cut really
badly. He was bleeding everywhere, even all over me. But I just didn’t see it.
I had his fingers in my hands and he looked up at me right in the eyes with this
look, like he was so scared. He knew he was about to die. And then, he was
gone.
He died because I was too drunk to realize what was going on around me. That
family no longer has a son because I didn’t do my job. Because I was too weak to
handle the pressure of the job. I turned to alcohol instead of reaching out to
someone who could help me.
That’s the day I knew that I needed to seek out a counselor. I needed to find a
way not to only deal with the pressures of work, but now also needed help in
dealing with the fact that I let this little kid die.
So the next day I did some research online and found a therapist to talk to. I
scheduled an appointment at the next available time that he had, but that was
two weeks from then. I needed someone right then and right there.
I then decided to talk to my wife about it. She tried to make me feel better by
explaining that death is a part of my job, but she didn’t really know how to help,
especially with the drinking aspect of my problem.
She was pretty shocked to hear just how bad it had gotten. Maybe she was just
not paying attention or didn’t want to see it. I mean, everything happened, too,
gradually over the years.
Still, she offered to take all the alcohol that I drink out of the house, which was
nice. But I knew that she still planned on having a drink when she came home
from work every now and then or even just a glass of wine with dinner. Why
would I have her change her lifestyle because of my problem?
I eventually called a friend of mine who was recovering from an alcohol addiction.
He gave me the number to this treatment center, and that’s why I’m here today.
Experiencing a Traumatic Event
Additional Content Attribution
©2013 Laureate Education, Inc.
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Experiencing a Traumatic Event
MUSIC:
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Los Angeles, CA
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Carrollton, TX
Special Thanks:
Fairland Center/Region One Mental Health
©2013 Laureate Education, Inc.
3
Relapse Prevention: A Critique
and Proposed Reconceptualisation
Jo Thakker1 and Tony Ward2
1
2
University of Waikato, New Zealand
Victoria University of Wellington, New Zealand
Relapse prevention (RP) plays a significant role in current treatments and posttreatment approaches to substance abuse problems. It is also widely used in a
number of other problem areas, including other addictive behaviours and sexual
offending. The widespread use of RP in various fields is due to both its clearly articulated theoretical basis, which has significant face validity, and its transferability into
clinical practice. Also, there is a growing (though arguably still modest) body of
empirical evidence that demonstrates its efficacy in a range of therapeutic contexts.
However, arguably, in terms of both the theoretical underpinnings and the practical
application of RP there is room for improvement. This article hypothesises that one
of the key weaknesses of RP is that it takes a generally unconstructive approach to
the therapeutic process through the use of negative concepts and avoidance goals. It
is suggested that a ‘good lives’ framework of psychological wellbeing can provide a
means of remedying these weaknesses of the traditional RP model. It is argued that a
good lives framework can lead to a more optimistic approach to the prevention of
relapse among individuals with substance use problems.
■ Keywords: relapse prevention, good lives model, positive psychology, substance
abuse
154
Since its inception in the 1970s, relapse prevention (RP) has become one the key
treatment models in a range of psychotherapeutic areas. While it was first developed
as a post-treatment maintenance program for drug and alcohol problems, it now
often forms part of treatment proper and is used in the treatment of a variety of problem behaviours, such as over-eating, gambling, and sexual offending (Laws, Hudson,
& Ward, 2000; Prisgrove, 1991; Witkiewitz & Marlatt, 2004). Moreover, the RP
model has contributed enormously to conceptualisations of addictive and compulsive
behaviours; it has enhanced our understanding of the behavioural processes that are
involved and the reasons that many individuals find maintenance of change incredibly difficult. It has led to a fuller understanding of the minutiae of cognitive and
emotional phenomena that are associated with the problematic use of substances and
with compulsive behaviours.
Within the sexual offending field there have been several critiques of RP that
have led to important reconceptualisations. For example, Ward and Hudson
(1998) criticised the unilinear nature of the model, suggesting that there should be
multiple pathways to offending. Empirical research supports this idea and it is now
accepted that offenders relapse for quite different reasons and exhibit distinct etio-
Address for correspondence: Dr Jo Thakker, Psychology Department, University of Waikato, Private Bag 3105,
Hamilton, New Zealand. E-mail: Email: jthakker@waikato.ac.nz
Behaviour Change | Volume 27 | Number 3 | 2010 | pp. 154–175
Relapse Prevention: A Critique and Proposed Reconceptualisation
logical and relapse trajectories (Bickley & Beech, 2002; Webster, 2005). And,
more recently, Ward (2002) offered a more general critique of the model, and
introduced to the field the notion of good lives as a way of developing a more constructive approach to change maintenance. As will be outlined in this article, the
good lives model (GLM) within the area of sexual offending provides opportunities
for the development of a more detailed understanding of why individuals commit
sexual offences and how such individuals may be able to satisfy their needs in more
appropriate ways.
The key purpose of this article is to apply the GLM to RP in the substance
abuse field. In this sense the RP model has come full circle — ideas that were originally taken from the substance abuse field and modified in a different context are
being reapplied back into the drug abuse area. As will be argued below, the GLM
has particular relevance to drug and alcohol problems insofar as these sorts of
problems pose special challenges in terms of an individual’s ability, following longterm drug use, to reestablish positive experiences in their lives. For example,
chronic drug consumption may lead to neurophysiological changes that may make
it difficult for the individual to experience pleasure in the absence of the specific
drug of abuse.
The GLM, with an underlying philosophy that focuses on positive goals and a
framework for understanding fundamental human needs, provides a powerful tool
that can enrich existing models of RP. As we have argued elsewhere (Thakker,
Ward, & Tidmarsh, 2005) the idea is not to abandon RP and move to an alternative
model but rather to integrate the two models and thereby create a more comprehensive treatment framework and more successful method of relapse prevention.
Relapse Prevention
What is Relapse Prevention?
The concept and practice of relapse prevention (RP) arose out of the recognition
that alcohol and other substance dependencies are difficult to treat and that even if
treatment is successful such success is often not enduring. Rates of relapse vary considerably depending on a host of factors, such as the kind of treatment employed,
the drug used, the population sampled, and specific outcome measure that is utilised
(e.g., see Gossop, Marsden, Stewart, & Kidd, 2003; Miller, Walters, & Bennett,
2001; Moyers & Hester, 1999). However, although many approaches to treatment
demonstrate some success, relapse rates for substance use problems remain high. For
example, in a major review of alcoholism treatment in the United States, Miller et
al. (2001) found that after a single treatment event only about one third of the
clients remained abstinent from alcohol during a 1-year follow-up (although the
remainder improved on various other outcome measures by an average of 57–87%).
The treatment phase of behavioural change involves numerous additional elements
such as social interaction, monitoring, and support (regardless of the particular
approach), all of which serve to strengthen the change process. However, once
treatment has been completed, individuals must translate any changes made into
long-term behavioural patterns, typically without the help of therapy. The generalisability of treatment is an important issue across a range of disorders, because the
ultimate goal is always to assist people in making profound and long-lasting changes
in their everyday lives. Facilitation of the application of what is learnt in therapy to
non-therapy settings is a key challenge for every clinician. However, addictive
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Jo Thakker and Tony Ward
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behaviours are especially challenging in this respect because the target behaviour
can involve intense reward. There is, therefore, often ambivalence about the
prospect of giving up the substance or habit.
Although recognition of the importance of preventing relapse in addictive
behaviours has probably been considered throughout the history of the problem, it
was not until the 1970s that investigators began to explore the issue of relapse in
detail (Connors, Maisto, & Donovan, 1996; Gerwe, 2000). One of the key foci of this
exploration addressed the question of what leads individuals to relapse, with the goal
of developing specific interventions aimed at dealing with the underlying causes.
Perhaps the best-known and most widely utilised conceptualisation of relapse is
that developed by Marlatt and colleagues (e.g., Marlatt, 1979, 1985; Marlatt &
George, 1984; Marlatt & Gordon, 1980). This cognitive–behavioural conceptualisation sees relapse as a process that unfolds over time and which has a number of
key components. The process as outlined by Marlatt (1985) revolves around the
presence of high-risk situations (which arise from various personal and environmental factors) that challenge the individual’s ability to cope and therefore increase the
probability of relapse. Specific concepts have been coined by Marlatt to delineate
key aspects of the relapse process. The abstinence violation effect (AVE) refers to
the idea that if individuals have one drink (or one cigarette, and so on) they may
subsequently believe that they have irredeemably broken their own abstinence
pacts. And this, in turn, may lead them to feel somewhat fatalistic about their substance use, thereby leading to an increase in use. In this way their thinking around
the issue may act as a self-fulfilling prophecy. The problem of immediate gratification (PIG) refers to the power and appeal of using a substance that is immediately
available, in contrast to the more distal rewards that abstinence would bring.
As these concepts indicate, the model presented by Marlatt rests on one of the
key tenets of cognitive–behavioural approaches: that thoughts and actions interact
in the development and maintenance of problem behaviours, and that this interaction is central to the understanding of such problems. Accordingly, Marlatt’s
approach to RP involves the unravelling of the various interconnected threads of
thoughts and behaviours that comprise the relapse process and the development of
strategies to interrupt it. To a large extent the focus is on risk avoidance — in other
words, the development of ways and means to avoid being in risky situations (e.g.,
Larimer, Palmer & Marlatt, 1999). However, another important aspect of the model
is the acquisition of coping skills for dealing with high-risk situations if they arise, as
the individual’s response to the challenging situation is fundamental to his or her
ability to manage the situation and circumvent a lapse, and ultimately a relapse
(Larimer et al., 1999; Rawson, Obert, McCann, & Marinelli-Casey, 1993).
According to Rawson and colleagues (1993), along with the aforementioned elements, RP for substance abuse typically also includes psycho-education, development
of new lifestyle behaviours, and the acquisition of skills for enhancing self-efficacy.
Rawson et al. note that self-efficacy is also improved indirectly through the practical
success of the treatment. For example, if treatment has been effective and the individual has had some positive experiences in which he or she coped effectively with
risky situations or lapses, then the individual will have increased self-efficacy.
Thus, the RP model does focus on the promotion of strengths and subsequent
enhanced coping although in our view this constructive element tends to be somewhat overshadowed by the concern with avoiding relapse and managing high-risk
situations. In other words, the primary orientation of RP is on avoiding or reducing
Behaviour Change
Relapse Prevention: A Critique and Proposed Reconceptualisation
the impact of high-risk situations rather than on promoting certain types of goods
(and wellbeing) in an individual’s life.
Since its introduction over two decades ago there have been many changes to
RP and it has been adopted, as Marlatt (1985) proposed, into a range of other treatment areas in which problems with impulse control play a prominent role. For
example, it has been widely applied in the understanding of gambling (e.g.,
Echeburua, Fernandez-Montalvo, & Baez, 2000) and, perhaps most notably, in the
understanding and treatment of sexual offending (e.g., Laws et al., 2000; Ward &
Stewart, 2003). One of the most fundamental changes in the way that RP is applied
is that it is now commonly used as an overarching framework for the instigation of
treatment proper (Laws et al., 2000). This is in part because the factors that are
understood to contribute to relapse are the same factors that contribute to the
development and maintenance of the problem. In a sense, RP has changed the way
in which the problem of addiction is understood. It has provided a guide to the
identification of various components of the problem and accordingly offered a structure around which treatment can be organised.
From this point of view, the influence of RP on the treatment of disorders of
impulse control, and especially substance use disorders, cannot be overemphasised.
It has penetrated and directed many different therapeutic approaches and is one of
the most widely mentioned treatment models (Carroll, 1996). Given the extent of
its influence on treatment it is surprising that there have been relatively few evaluations of its efficacy. Perhaps one of the reasons for this is the difficulty of evaluating
the long-term outcomes of intervention. It is not easy to track people over time, or
to engage them in an evaluation process (however, it should be noted that
researchers in the field have developed quite effective means of doing so). Perhaps
also it is due to the complexity of substance use problems and the associated complexity of measuring treatment outcomes.
A Critique of Relapse Prevention
In recent years there have been a number of evaluations of RP as a theoretical and
treatment approach to the treatment of addictive and compulsive behaviours. In
summary, it has been argued that RP has a number of strengths as a theory and
treatment model. The most prominent of these virtues include: it has tremendous
clinical utility; it unifies a considerable number of ideas and treatment techniques
within a single framework; and it can account for a significant range of clinical
problems. However, RP also suffers from some weaknesses as a theory, including (see
Laws et al., 2000; Rawson et al., 1993; Ward & Stewart, 2003): a lack of logical
consistency due to its incorporation of a range of diverse ideas ranging from social
learning theory to cognitive dissonance; inadequate explanatory coherence due to
multiple, confusing, and inconsistent postulated mechanisms thought to underlie
relapse pathways; a lack of explanatory depth, as in essence, RP is primarily a theory
of the relapse process; and a lack of clarity in the formulation of key constructs such
as the AVE.
From a clinical perspective, a number of problems have proved to be particularly
worrisome (Miller, 1996). First, the dichotomy implied by the term ‘relapse’ fails to
capture the diversity of possible treatment outcomes. Either one relapses or one does
not relapse and there appears to be no middle road. While Marlatt and other theorists in the field have used the term ‘lapse’ to refer to situations in which individuals
takes steps towards relapsing, the fact remains that RP relies heavily on the notion
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of relapse and, as Miller suggests, it is an uncompromising term. Second, although
widely employed, the term ‘relapse’ is not always well defined. Different theorists
and clinicians use different definitions of relapse (as Marlatt himself acknowledges,
e.g. 1985). For example, while some may see a relapse as a return to previous levels
of drinking, others may see it as simply being one drink, or one drinking session
(Miller, 1996). Third, the term is unable to capture the multiplicity of drug use patterns that follow treatment. For instance, post-treatment there is inevitably tremendous variation in the range of drugs used, the frequency of consumption, the
amount consumed and the length of time from treatment till first use. From this perspective, the concept of relapse is not particularly useful as it denotes an overly simplistic approach to the understanding of post-treatment drug use that forces people
into one of only two possible categories.
Miller (1996) argues that one of the implications of this conceptualisation is
that relapse ‘… may become a self-fulfilling prophecy’ (p. s15). That is, if one perceives that one has relapsed then one may be more likely to continue with the problematic behaviour because he or she may feel that a point of no return has been
crossed. This is exactly what Marlatt meant by the abstinence violation effect
(AVE). The inclusion of the concept of AVE in the RP model is obviously intended
to alert people to this cognitive tendency. But Miller argues that alerting them to
this tendency may make it more likely that they will succumb to it. Marlatt (1985)
proposes that including the term ‘lapse’ in the model minimises the impact of this
effect, because it allows for the eventuality of a minor slip-up, which may be effectively managed with adequate coping skills. However, Miller proposes that regardless of the inclusion of this concept, the problem still remains, insofar as the
occurrence of a lapse may still lead individuals to believe that they have violated
their own commitments.
While Miller’s criticism is interesting and perhaps has some degree of face validity, it should be noted that there is no evidence to support his claim. In other words,
there is to date no research that suggests that if an individual learns to describe his
or her behaviour in terms of a lapse or relapse he or she will be more likely to return
to the problem behaviour. Nonetheless, it raises the important issue of how individuals’ conceptualisations of their addictive behaviours interact with the behaviours.
One criticism of the RP model, which is exemplified by the issue of using terms
such as ‘lapse’ and ‘relapse’ is the model’s reliance on negative goals or concepts
(Thakker, Ward, & Tidmarsh, 2005). For example, it focuses on reducing risk,
avoiding particular situations, and eliminating various beliefs and behaviours. These
may be summarised as avoidance goals — goals that centre on avoidance of certain
thoughts, feelings and behaviours. The challenge is that avoidance goals are particularly difficult to achieve, as there are many ways a person can fail to maintain a
problem-free state (Emmons, 1999). Obviously this poses a challenge for the therapeutic environment insofar as clinicians ordinarily endeavour to create a positive
atmosphere, in part by encouraging the client to use positive terminology and to
maintain a positive frame of mind. It is also a problem in that it creates a situation
in which clients are more likely to notice failure (as that is what they are trained to
focus on) and less likely to notice episodes of success.
In a related fashion, although clients may then know what to avoid, they may
not necessarily know what to aim for. They will have an understanding of activities
and situations that are problematic, but not necessarily ideas about what might be
good alternative activities. Obviously, in order to encourage people to maintain
Behaviour Change
Relapse Prevention: A Critique and Proposed Reconceptualisation
abstinence — to continue to avoid making choices that may lead to the return of
their problematic behaviours — it is helpful to offer ideas for alternative courses of
action. While RP programs typically include this in their treatment approach, such
aspects often play a significantly less important role and are only considered in relation to risk avoidance. In other words, positive or approach goals remain overshadowed by avoidance goals.
In terms of empirical support for RP there is a growing body of evidence that
shows that it is generally effective; however, given its pervasiveness as a treatment
model it would appear that there is room for further research. A literature review by
Carroll (1996) identified a total of 24 published randomised controlled trials that
evaluated relapse prevention for substance use problems across a range of substances
(mainly tobacco and alcohol, but also some studies looking at cocaine and
cannabis). Carroll found that when RP was compared with a control intervention
(simply involving discussion and attention) only four out of ten studies found RP to
be significantly superior at post-treatment. However, at follow-up the influence of
RP was more pronounced, with seven out of ten suggesting that RP was superior.
When RP was compared with alternative treatments Carroll found that it was similar and not significantly better at post-treatment or follow-up.
Carroll concludes: ‘Ten years of research on relapse prevention as a psychosocial
treatment for adult substance abusers has produced mixed results regarding its effectiveness’ (p. 53). She goes on to state that there is evidence indicating that RP is
superior to no treatment at all but that there is no clear evidence that RP is superior
to other treatment approaches. She also concludes that RP may hold particular
promise in maintaining enduring treatment effects and decreasing the intensity of
relapse; however, this is qualified with the comment that these possibilities are in
need of further research.
Another review article (Irvin, Bowers, Dunn, & Wang 1999) begins with the
comment: ‘Despite the increasing appeal of relapse prevention (RP) interventions
based on the work of Marlatt and Gordon (1985), studies have failed to yield a consistent picture of the effectiveness of this cognitive–behavioural approach’ (p. 563).
However, this meta-analysis concluded, following an analysis of 26 studies, that
there is empirical support for the general effectiveness of RP (when compared to no
treatment) in decreasing the problematic use of substances and also in improving
psychosocial functioning (though this was qualified with the comment that most
individuals in the various studies had been involved in previous treatment which
may have confounded the results).
The study also concluded that RP was particularly effective when used for alcohol abuse and drug problems involving more than one substance. It should be noted
that 16 of the studies utilised in this review were the same as those used by Carroll
(1996). It should be noted also that effect sizes reduced dramatically from immediate post-treatment to 12-month follow-up (r = .27 to r = .09 respectively), indicating that a significant proportion of RP gains were not maintained over time. This
has important implications for the interpretation of outcomes given that RP is
intended to target relapse.
These results are consistent with the findings of a more recent investigation by
Brown and colleagues (Brown, Seraganian, Tremblay, & Annis, 2002). This study
found that RP aftercare was superior to a 12-step aftercare approach in reducing
feelings of temptation and increasing confidence in relation to high-risk situations,
at the completion of a 10 week aftercare program. However, it found that the
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changes were not maintained beyond the termination of treatment. Other conclusions reported by Brown et al. were that both RP and twelve step aftercare
approaches brought about positive behavioural changes which were related to more
optimistic outcomes and that there was no obvious difference in the overall treatment efficacy of the two approaches.
It would appear that, in line with other research on the efficacy of CBT across
a range of problem areas, RP has been demonstrated to be as effective as other
treatment modalities but has not been shown to be superior. Of particular concern
is that RP has yet to clearly demonstrate that it is an intervention method that
may bring about enduring change, especially as its conceptual foundations are
based on the notion of change maintenance. As highlighted by Corrigan (2001),
there are a host of specific types of cognitive behavioural interventions that are
widely used but not strongly supported by empirical research. Therefore the
studies on RP should be viewed in this context and it may be true to say that RP
has been more intensely researched and has a more robust empirical basis than
some other treatment approaches.
In summary, RP has a number of strengths and weaknesses as a clinical theory.
Collectively, these features indicate its value alongside the need to think critically
about how its weaknesses can be addressed. What is intended here is not a diminution of the contribution and value of RP to the substance abuse field. Its role has
been extremely significant; however, arguably some of the empirical outcomes have
not been as successful as expected. It is not an exaggeration to propose that RP
swept through the addictions field at a pace that was beyond the scope of evidential
research, and today it appears that empirical research still lags behind its theoretical
development and clinical application. Of course this is not a unique situation and
therefore not a criticism that is limited to this particular form of cognitive–
behavioural treatment. It is a frequently seen issue that arises from a host of complex factors including limitations of time and resources and difficulties in accessing
appropriate populations.
Due largely to the work of Ward and colleagues (e.g., Ward, 2002; Ward & Mann,
2004; Ward & Stewart, 2003) RP within the field of sexual offending has recently
been reconceptualised and arguably a similar rethinking should be carried out in the
substance abuse area. As will be explained below, many of the criticisms and suggested
modifications outlined by Ward are also highly pertinent to substance abusers.
Ward and Mann (2004) propose that there are a number of problems associated
with RP in the context of sexual offending. First, as a theory RP is conceptually weak
in terms of its capacity to establish engagement with offenders and to provide guidance to therapists. It pays insufficient attention to the therapeutic alliance and socalled noncriminogenic needs such as personal distress and low self-esteem. It has
been argued that the creation of a sound therapeutic alliance requires a suite of interventions that are not directly concerned with targeting risk, and it has been shown
that the establishment of a good therapeutic alliance is a necessary feature of effective
therapy with offenders. Second, the RP model does not pay enough attention to the
role of personal or narrative identity and agency (i.e., self-directed, intentional actions
designed to achieve valued goals) in the change process. Third, it works with a narrow
notion of human nature and ignores the fact that as evolved, biologically embodied
organisms humans naturally seek and require certain goods in order to live fulfilling
and personally satisfying lives. Fourth, it often results in a relatively rigid approach to
treatment that is not sufficiently flexible in regard to individual needs.
Behaviour Change
Relapse Prevention: A Critique and Proposed Reconceptualisation
Last, but perhaps most importantly, it is argued that the notion of risk is significantly overemphasised within the RP approaches in this field, to the detriment of
other important concepts. It is often translated in practice into a ‘one size fits all’
manner and fails to take critical individual needs and values into account For example, Ward states that offenders are seen as ‘disembodied bearers of risk’. He uses an
analogy of a pin cushion to make this point, proposing that risks are seen as holes in
an individual which need to be plugged, regardless of what else is going on within
the individual. Ward’s central tenet is that an RP approach based on traditional
principles fails to get to the heart of the matter. Specifically, it fails to address the
issue of why individuals engage in problematic behaviours.
This may appear to contradict earlier comments on the nature of RP and its
constituents in therapeutic settings and it therefore requires clarification. What RP
does provide is a framework for the description of offence chains, which are detailed
analyses of the chain of events which lead a particular person to offend. While these
are no doubt explanatory, they are nonetheless essentially proximal and also reasonably superficial. They may include such important variables as thoughts and emotions but these tend to be tied closely to the events and situations that unfold in
r