Evidence-Based Addiction Treatment || Relapse Prevention

Summary PointSl Lapsesarethemostcommonoutcomefollowingaddictiontreatment,

andoftentimesalapsecanleadtoacompletereturntoproblematicsubstanceuse.

l Severalfactorshavebeenidentifiedthatareoftensignificantpredictorsoflapses,includingnegativeeffect,self-efficacy,coping,psychologicalfunctioning,andsocialsupport.

l Akeychallengeforaddictivebehaviorsresearchersandcliniciansistoidentifythosefactorsthataremostpredictiveforaparticularclientandthenusethatinformationtoinformintervention.

l Relapsepreventiontechniqueshavebeendevelopedtoforestalllapsesandpreventlapsesfromturningintoarelapse.

l Relapsepreventionandothercognitivebehavioralaftercareapproachesareeffectiveatreducingtotalrelapserates.

l Mindfulness-basedrelapseprevention,atreatmentshowntobeeffec-tiveinreducingsubstanceusefollowingtreatment,hasgreatpromiseasaninterventionstrategyforreducinglapseandrelapse.

Relapse Prevention: Evidence Base and

Future Directions G. alan marlatt and Sarah W. Bowen

Addictive Behaviors Research Center, University of Washington

Katie Witkiewitz

Alcohol and Drug Abuse Institute, University of Washington

C h a p t e r | e l e v e n

215Evidence-Based Addiction TreatmentCopyright © 2009 by Academic Press. Inc. All rights of reproduction in any form reserved.

216 Relapse Prevention: Evidence Base and Future DirectionsRelapse Prevention: Evidence Base and Future Directions

BaCKGround of relaPSe Prevention

In 1985 Marlatt and Gordon published the seminal text on relapseprevention (RP), which was designed to help explain the contexts inwhichlapsesoccurandhowalapsecanleadtoarelapse.Inthisbookandforthischapteralapseisdefinedastheinitialuseofasubstancefollowing a period of abstention or reduced use, whereas a relapse isdefinedasthereturntoproblematicsubstanceusefollowingtheinitialtransgression. Regardless of how one defines “relapse,” it is the casethatusing substances at somepoint following treatment is themostcommonoutcomeofnearlyallsubstanceusetreatmentprograms.Thefirst 3months following treatment appear to be themost critical forlapsing and thus implementing a program to prevent relapse duringthistimecanbeveryhelpfulinimprovingoveralltreatmentoutcomes(Witkiewitz,2008).Throughoutthischapterwewillbefocusingprimarilyonrelapsetosubstanceuse;however,itisimportanttokeepinmindthatrelapsepreventionhasbeenappliedsuccessfullytoseveralotheraddictiveandnonaddictivebehaviors,includingproblemgambling,eatingdisorders,depression,schizophrenia,andbipolardisorder.

The development of relapse prevention originated from a “failed”drinking treatment study in which Marlatt (1980) took careful notesonthefactorsthatcommonlytriggeredrelapseinhissampleoftreatedalcoholics. Marlatt (1980, see also Marlatt [1996]) organized theserisk factors into a taxonomy of high-risk situations for relapse. Thetaxonomy consists of three hierarchical levels of categories used inthe classification of relapse episodes. The first level of the hierarchydistinguishesbetweenintrapersonalandinterpersonalprecipitants forrelapse.ThesecondlevelconsistsofeightsubdivisionswithinthetwoLevel 1 categories, including five within the intrapersonal category—copingwithnegativeemotional states, copingwithnegativephysical-psychologicalstates,enhancementofpositive-emotionalstates,testingpersonal control, and giving in to temptations and urges—and threewithin the interpersonal category—copingwith interpersonal conflict,social pressure, and enhancement of positive emotional states. ThethirdlevelofthetaxonomyprovidesamoredetailedinspectionoffiveoftheeightLevel2subdivisions(e.g.,copingwithnegativeemotionalstatesissegregatedintocopingwithfrustrationand/orangerandcopingwith other negative emotional states). Drawing from this taxon-omy,Marlatt proposed thefirst cognitivebehavioralmodel of relapse(Marlatt&Gordon,1985),whichisshowninFigure11.1.

As seen in Figure 11.1, the risk of relapse is heightened via asequenceofcognitionsandbehaviorsthateitherprecipitatelapses(e.g.,negative effect) or increase the risk of a lapse turning into a relapse

G. Alan Marlatt et al. 217

(e.g.,theabstinenceviolationeffect).Inaddition,themodelhighlightsprotectivefactors(e.g.,copingresponses)thatwillhelpforestallalapse.Followingfromthismodel,Marlattandcolleaguesdevelopedaninter-ventionthattargetedmanyaspectsofthemodelandwasintendedasanaftercaretreatmentforsubstanceabusedisorders.Sincetheoriginalpublicationin1985,relapsepreventionhasbeenadaptedtobeusedinavarietyoftreatmentsettingsandhasalsobeenusedasastand-alonetreatment.

The core component of relapse prevention interventions is theassessment of high-risk situations for relapse and the client’s abilitytocopewithhigh-risksituations.Ifcopingdeficitsarerecognizedthenthetherapistincorporatescopingskillstrainingandaddressestheissueofclientself-efficacy.Self-efficacyisaclient’sbeliefinhis/herabilitytomaintainabstinenceorsomeothergoal(e.g.,moderatedrinking),andlowself-efficacyhasbeenshowntobeaconsistentpredictorofrelapse.Thecollaborationbetweenclientandtherapistcanplayacriticalrolein increasing self-efficacy. Relapse prevention practitioners attempttoengagetheclientinthetherapeuticprocess,therebyincreasingtheclient’ssenseofownershipofasuccessfultherapyoutcome.Providingpositive feedback to the client regarding successful completion ofhomeworkandrelatedtasksduringtherapycanhelpincreaseasenseofself-efficacyoverall,whichcanfurthermotivateclientstobelieveintheirabilitytomaintaintreatmentgains.

Theassessmentofhigh-risksituationsshouldencompasstheassessmentofinterpersonal,intrapersonal,environmental,andphysiologicalriskfactors.Oncepotentialrelapsetriggersareidentified,cognitiveandbehavioraltech-niques are implemented that incorporate specific strategies for reducingrisksassociatedwithrelapse,aswellasglobalstrategiestoincreaselifestylebalanceandpreventfutureoccasionsofhigh-risksituations.Forexample,

High-risksituation

Ineffectivecoping

response

Decreasedself-efficacy

�Positiveoutcome

expectancies

Initial useof

substance

Increasedprobability of

relapse

Abstinenceviolation

effect�

Perceivedeffects ofsubstance

Effectivecoping

response

Increasedself-

efficacy

Decreasedprobability of

relapse

fiGure 11.1 The first cognitive behavioral model of relapse.


ifanindividualdescribesaparticularstreetcorner(whereheorshepre-viouslypurchasedcrackcocaine)asanenvironmentalriskfactor,thenthetherapistworkswiththeclienttoexaminewaystoavoidthatstreetcorner.Whenahigh-risksituationisunavoidable(e.g.,interactionswithafamilymember),thencopingskillstrainingandcognitiverestructuringtechniquescanbeusedtohelptheclientcopewithorrestructuretheirexperienceduringaninteractionwithafamilymember.

Relapsepreventionalsoincludestopic-focusedpsychoeducationalandcognitivecomponents,problem-solvingskills,andopportunitiestoengagesocial support. Identifying the client’s thoughts surrounding addictivebehaviorisacriticalaspectofrelapseprevention.Onetechniquethatiscommonlyusedisthedecisionalbalancetool,whichprovidestheclientwiththeopportunitytodiscusstheprosandconsofusingasubstance,aswellastheprosandconsofnotusingasubstance.Thisactivitycanhelp the practitioner identify discrepancies among a client’s thoughts,feelings,andactions. Ifnecessary, thepractitionercandiscuss the issueofmaladaptivethoughtsandhowtochallengecognitivedistortions(e.g.,“Iamworthlessandneverwillbeabletoquit”).Thefinalcomponentofrelapsepreventionisaddressinglifestylebalanceandencouragingclientstoidentifyhealthyalternativeactivitiesthatdonotinvolvetheaddictivebehavior. As described in the last section of this chapter, mindfulnessmeditationcan serveas a rewarding,healthy, andhelpful alternative tosubstanceuse.

theoretiCal modelS Behind relaPSe Prevention

The cognitive behavioral model of relapse provides the backbone forrelapse prevention. Shown in Figure 11.1, the relationships amongsituations,thoughts,andfeelingsareallconsideredintandeminordertounderstandlapseevents.Thelackofaneffectivecopingresponseleadstodecreasedself-efficacy(Bandura,1977)inconjunctionwithincreasedpositiveexpectanciesfortheinitialeffectsofusingthesubstance(Jones,Corbin,&Fromme,2001). If thesecognitiveandbehavioralprocesses,incombinationwithotherdeterminantsofrelapse,leadtothefirstuseofthesubstance,thentheindividualmaybevulnerabletoexperiencean“abstinence violation effect.” This effect involves the loss of perceivedcontrolthatanindividualexperiencesafterthedefianceofself-imposedrules(Curry,Marlatt,&Gordon,1987).

The cognitive behavioral model of relapse addresses several keyquestions:

1. Aretherespecificsituationaleventsthatserveastriggersforlapses?


2. Arethedeterminantsofthefirstlapsethesameasthosethatcauseacompleterelapsetooccur;ifnot,howcantheybedistin-guishedfromoneanother?

3. Howdoesanindividualreacttoandconceptualizetheeventsprecedingandfollowingalapseandhowdothesereactionsaffecttheperson’ssubsequentbehaviorregardingtheprobabilityofafull-blownrelapse?

4. Isitpossibleforanindividualtocovertlyplanarelapsebysettingupasituationinwhichitisvirtuallyimpossibletoresisttemptation?

5. Atwhichpointsintherelapseprocessisitpossibletointerveneandalterthecourseofeventssoastopreventareturntotheaddictivehabitpattern?

6. Isitpossibletoprepareindividualsduringtreatmenttoanticipatethelikelihoodofrelapseandtoteachthemcopingbehaviorsthatmightreducethelikelihoodoflapsesandtheprobabilityofsubsequentrelapse?

Thesesixquestions,incombinationwithaseriesofstudiesthatques-tionedthevalidityoftheoriginalrelapsetaxonomy(seeLowman,Allen,Stout, & Relapse Research Group, 1996), led to the development of arevisedcognitivebehavioralconceptualizationoftherelapseprocess,whichincorporatedbothdynamicandstaticriskfactors(Witkiewitz&Marlatt,2004).The“dynamicmodelofrelapse,”showninFigure11.2,providesamorecomplexviewofthefactorsleadinguptoalapseandpotentiallysubsequentrelapseandaddstothemodelanemphasisonthetimingandinterrelatedness of events. An individual’s response in a high-risk situ-ation is influencedby theunderlying tonicandphasicprocesses,wheretonic processes include the stable and enduring risk factors and phasicprocessesincludemoreimmediateprecipitantsofthehigh-risksituation.

Thedynamicmodelof relapsewasdesignedtoemphasizethecom-plexityoftherelapseprocessandthemultiplepathwaystosubstanceuse.Recentempirical studieshaveprovidedsupport for thedynamic roleofphysicalwithdrawalinpredictingsmokingbehavior(Piaseckietal.,2000)and the complex relationship between self-efficacy and post-treatmentalcoholuse(Witkiewitz,vanderMaas,Hufford,&Marlatt,2007).Thesestudiesprovideinitialsupportfortheutilityofthedynamicmodelbeingincorporated into relapse prevention interventions. For example, basedontheworkofPiaseckiandcolleagues(2000)itisimportantforsmok-ingcessationcounselorstoprovideanongoingassessmentofwithdrawalsymptomsandnotassume(or,evenworse,tell theirclients) thatwith-drawalsymptomstendtodecreaseovertime.


emPiriCal evidenCe SuPPortinG relaPSe Prevention

Three reviews, two meta-analyses (Dutra et al., 2008; Irvin, Bowers,Dunn,&Wang,1999),andonequalitativereview(Carroll,1996)haveconcluded that relapse prevention is as effective as any other activetreatment for substanceusedisorders and significantlymore effectivethan no treatment. Carroll reviewed 24 randomized controlled tri-alsofrelapsepreventionforsmoking,alcohol,marijuana,andcocaineaddiction.Basedonherreview,Carrollintroducedtheideathatrelapseprevention,incomparisontoothertreatments,mayprovidecontinuedimprovementoveralongerperiodoftime(indicatinga“delayedemer-genceeffect”).Irvinandcolleagues(1999)conductedameta-analysisof26alcohol,tobacco,cocaine,andpolysubstanceusestudies.Overall,thetreatmenteffectssuggestedthatrelapsepreventionsuccessfullyreducedsubstance use and led to improvements in psychosocial functioning.Importantly, relapse prevention was most effective in the treatment ofalcoholdependenceascomparedtorelapsepreventionforothersubstanceuse.Thisfinding isnot surprising considering that relapse preventionwasdevelopedforalcoholdependenceinitially.

Themostrecentmeta-analysisofrelapsepreventionforsubstanceusedisorders(Dutraetal.,2008)includedfivestudiesthatweredescribedspecificallyasusingrelapsepreventiontreatmentand10additionalstudiesthatweredefinedas“othercognitivebehaviortherapy.”Relapsepreventionevidencedlow/moderateeffectssizes(d0.32),butwasthesecondmost

Substance usebehavior

(quantity or frequency)

Coping behavior(behavioral/cognitive

coping, self-regulation)Cognitive processes(self-efficacy, outcomeexpectancies, craving,

motivation)

Physical withdrawal

Phasic responses

Tonic processes

High-risk situations(contextual factors)

Distal risks(family history,social support,dependence)

Perceived effects(reinforcement,

abstinence violationeffect)

Affective State

fiGure 11.2 The “dynamic model of relapse.”


effective treatment evaluated (combined cognitive behavioral therapywith contingency management and contingency management alonewere the most effective treatments [d1.02 and d0.58, respec-tively]).Importantly,noneofthefiverelapsepreventionstudiestargetedalcoholdependence.Twoofthestudiesexaminedrelapsepreventionasatreatmentforcocaineuse(Carroll,Rounsaville,Nich,&Gordon,1994;Schmitzetal.,2002),onetargetedopiateuse(McAuliffe,1990),andtwoofthestudiesevaluatedrelapsepreventionformarijuanause(Roffman&George, 1988; Stephens, Roffman, & Curtin, 2000). Effect sizes werestrongestforrelapsepreventionformarijuanause(d0.31tod0.73)andweresmallestforcocaineusedisorders(d0.03tod0.05).

In addition to standard “relapse prevention” programs, severalother treatments that have incorporated components of relapse pre-ventionhavebeendeveloped.Forexample, thematrixmodel (Rawsonetal.,2004)isamanualizedoutpatienttreatmentprogramfortreatingstimulant disorders, which combines cognitive behavioral techniqueswith12-stepprogramparticipation,andhasbeenshowntobeeffectiveinthetreatmentofmethamphetamineandcocainedependence.Relapsepreventionhasalsobeencombinedwithotherapproachesforthetreat-mentofsubstanceabuseinconjunctionwithothercomorbiddisorders.“Seekingsafety” (Najavits,2002) isanevidence-based treatment thatcombinesaspectsofrelapsepreventionwithinterpersonaltherapyandcase management for individuals with comorbid substance use disor-dersandpost-traumaticstressdisorder.“Focusonfamilies”(Catalano&Hawkins,1996)providesacombinationof relapseprevention forpar-entsinmethadonemaintenanceprogramswithamultifacetedprogramtohelpincreaseprotectivefactorsagainstdrugabuseamongchildrenofmethadone-treatedparents.Pharmacotherapyinthetreatmentofsub-stanceusedisordersiscommonlyreferredtoas“relapseprevention”(forareview,seeSpanagel&Kiefer,2008);however,acompletedescriptionofthepharmacotherapytreatmentliteratureisbeyondthescopeofthischapter.Theinterestedreaderisreferredtothechapteronadjunctivepharmacotherapyinthisvolume.

theraPeutiC ComPonentS of relaPSe Prevention interventionS

Relapseprevention isdesignedto teachclients toanticipateandcopewith the possibility of relapse. In the beginning of relapse preven-tion training, clients are taught to recognize and cope with high-risksituations that may precipitate a lapse and to modify cognitions andother reactions to prevent a single lapse from developing into a full-blownrelapse.Becausetheseproceduresarefocusedontheimmediate


precipitants of the relapse process, they are referred to collectively as“specific intervention strategies.” As clients master these techniques,clinicalpracticeextendsbeyondamicroanalysisoftherelapseprocessand the initial lapse and involves strategies designed to modify theclient’s lifestyleand to identifyandcopewithcovertdeterminantsofrelapse(earlywarningsignals,cognitivedistortions,andrelapsesetups).Asagroup,theseproceduresarecalled“globalinterventionstrategies.”

SPeCifiC intervention StrateGieS

Assessmentofmotivationandcommitment

Prochaska and DiClemente (1983) have described relapse within atranstheoreticalmodelofsixstagesofchange:precontemplation,con-templation, preparation, action, maintenance, and relapse. Thesestages of changehave been applied successfully tounderstanding themotivationofpatientsreceivingtreatmentforsubstanceusedisorders(DiClemente&Hughes,1990).Motivationforchangehasbeenfoundtobehighlycorrelatedwith treatmentoutcomesandrelapse.Relapseprevention and lapse management strategies are necessary at theaction,maintenance,andrelapsestagesinorderforhabitchangetobesuccessfulovertime.

The decision matrix is one tool that can be used to evaluate theclient’smotivationstochange.Theprimaryassumptioninusingthistechniqueisthatpeoplewillnotdecidetochangetheirbehaviorortocontinueanongoingbehaviorunlesstheyexpecttheirgainstoexceedtheir losses. To complete the decision matrix, the client is presenteda four-way table with the following factors represented: the pros andconsofthedecisiontoremainabstinentandtheprosandconsofthedecision to resume using alcohol or drugs. Further, the practitionercanreviewboththe immediateandthedelayedpositiveandnegativeeffectsofeitheralternative.

Relapsehistoryandrelapsesusceptibility

Oneofthefirsthomeworkassignmentsisforclientstowriteanauto-biography describing the history and development of their addictivebehavior problem. The clients are asked to focus on their subjectiveimage of themselves as they progressed through the stages of habitacquisition from first experimentation to abuse of or dependence onalcoholordrugs.Thepurposeofthistechniqueistoidentifyhigh-risksituations and to get a baseline assessment of the client’s self-imagewhileengagingintheaddictivehabit.

Mostclientsintreatmentwillhavetried,eitherontheirownorinprevioustreatment,toabstainfromalcoholanddrugs.Askingclients


todescribepast relapsesmayprovide important clues to futurehigh-risksituationsforrelapse.Thetherapistandtheclientcanclassifythedescriptionsofpastrelapsesintothesituationalorpersonalfactorsthathadthegreatestimpact.Theideathatthingscanbedifferentthistimeisagoodtopictoexploreandchallengestheclientto“makeitso.”

Whenclientswhoarestilldrinkingalcoholorusingdrugsenterther-apy,theyareaskedtoself-monitortheiruseonadailybasisbykeepingtrackof thebehavior and the situational context inwhich it occurs, aswellastheimmediateconsequencesofthebehavior.Inmostcases,relapsepreventionprogramsareinitiatedafterabstinenceorsomereductionsinusehavebeenachievedbysomemeans.Inthissituation,self-monitoringofexposuretohigh-risksituationsisausefultechnique.Clientsareaskedtokeeptrackofexposuretosituationsorpersonalfactorsthatcausethemtohaveurgesorcravingtoresumedrinkingortakedrugs.

Copingskillstraining

Once high-risk situations have been identified, the client can then betaught to respond to these situational cues as discriminative stimuli(highway signs provide a good analogy) for behavior change. Takencollectively,theassessmentofhigh-risksituationsandcopingskillsdefi-citscanbeusedtotargetareasthatrequirespecialtrainingorattentionduring the coping skills training components of the relapse preventionprogram.Effectivecopingskillstrainingfocusesonthosehigh-risksitua-tionsidentifiedintheclient’sassessmentascreatingthegreatestpotentialforincreasingtheprobabilityofrelapse.Asstatedearlier,insomecases,itmightbebesttosimplyavoidriskysituations,ifpossible.Inmostcases,however,thehigh-risksituationsorpsychologicalstatescannotbeavoidedeasily,andtheclientmustrelyoncopingskillsoralternativestrategiesto“getthrough”thesituationwithoutengaginginsubstanceuse.

Coping skills training methods incorporate components of directinstruction, modeling, behavioral rehearsal, therapist coaching, andfeedbackfromthetherapist.Therapistscanhelpclients identifytheirstyleofapproachingproblemseitherbyelicitingexamples fromthemor by giving them a problem and asking them to outline how theywouldgoaboutsolvingit.Generatingalternativesisperhapsthemostimportantstep toeffectiveproblemsolving.Oncea listofalternativesolutions has been generated a particular solution can be selected byevaluating the “pros”and“cons”of each solutionand selectingwhatpromisestobethebestavailableoption.

In addition to teaching clients to respond effectively when con-frontedwithspecifichigh-risksituations,thereareanumberofadditionalrelaxationtrainingandstressmanagementproceduresthetherapistcan


drawupontoincreasetheclient’soverallcapacitytodealwithstress.Relaxation training may provide the client with a global increasedperception of control, thereby reducing the stress that any given sit-uation may pose for the individual. Such procedures as progressivemuscle relaxation training, meditation, exercise, and various stressmanagement techniques are extremely useful in aiding the client tocopemoreeffectivelywiththehasslesanddemandsofdailylife.

Increasingself-efficacy

Inmanycases,aparticularcopingresponsemayfailtobeexecuteddespitehighlevelsofmotivationiftheindividualhaslowself-efficacyconcerninghisorhercapacitytoengageinthebehavior.Theconverseisequallytrue,ofcourse;anindividualmayfailtoengageinaspecificbehaviordespitehigh levels of self-efficacy if the motivation for performance is low orabsent(“Iknewwhattodo,butIjustdidn’tfeellikedoingit”).

The probability of relapse in a given high-risk situation decreasesconsiderably when the individual harbors a high level of self-efficacyfor performing a coping response. If a coping response is performedsuccessfully, the individual’s judgmentof efficacywill be strengthenedforcopingwithsimilarsituationsastheyariseonsubsequentoccasions.Repeated experiences of successful coping strengthen self-efficacy andreducetheriskthatoccasionalslipswillprecipitaterelapseinthefuture.Guided imagery techniques may also be used to help clients imaginecopingsuccessfullywithahigh-risksituation.Efficacy-enhancingimageryisusedtoaugmentcopingskillstrainingandtoassesstheclient’scurrentlevelofself-efficacyandcopingskillsmastery.

Copingwithlapses

An individual is most vulnerable to return to problematic substanceuseduringthetimeimmediatelyfollowinganinitiallapse.Thefollowlistcontainsavarietyofrecommendedstrategiestoemploywheneveralapseoccurs.Clientscanbetoldtothinkofthislistasasetofemergencypro-cedurestobeusedincasealapseoccurs.Thestrategiesarelistedinorderof temporal priority, with the most important immediate steps listedfirst.Themainpointsofthis informationcanbepresentedtoclientsinsummaryformbyuseofaremindercardthatshouldbekepthandyintheeventthatalapseoccurs.Becausespecificcopingstrategieswillvary from client to client, therapists may wish to help a particularclient prepare an individualized reminder card that fits that person’suniquesetofvulnerabilitiesandresources.

1. Stop, look, and listen.Thefirstthingtodowhenalapseoccursistostoptheongoingflowofeventsandtolookandlistento


whatishappening.Thelapseisawarningsignalindicatingthattheclientisindanger.

2. Keep calm.Justbecausetheclientslippedoncedoesnotindi-catefailure.Oneslipdoesnothavetomakeatotalrelapse.Lookupontheslipasasingle,independentevent,somethingthatcanbeavoidedinthefuture.Aslipisamistake,anopportunityforlearning,notasignoftotalfailure.

3. Renew commitment.Afteralapse,themostdifficultproblemtodealwithismotivation.Theclientmayfeellikegivingupandmayneedremindingofthelong-rangebenefitstobegainedfromthischange.Clientsshouldbeencouragedtoreflectopti-misticallyontheirpastsuccessesinbeingabletoquittheoldhabitinsteadoffocusingoncurrentsetbacks.

4. Review the situation leading up to the lapse.Lookattheslipasaspecificuniqueevent.Thefollowingquestionsmayhelpclarifythelapseepisode:Whateventsleduptotheslip?Werethereanyearlywarningsignalsthatprecededthelapse?Whatwasthenatureofthehigh-risksituationthattriggeredtheslip?Eachofthesequestionsmayyieldvaluableinformationconcerninghigh-risksituationsfortheclient.

5. Make an immediate plan for recovery.Afteraslip,renewedcommitmentsshouldbeturnedintoaplanofactiontobecar-riedoutimmediately.Therapistscanhelpclientsidentifyemer-gency action plans,whichmayincludeacrisishotlinetelephonenumber,analternativeactivity,oratrustworthyfriend.

6. Dealing with the abstinence violation effect.Itisimportanttoteachclientsnottoviewthecauseofthelapseasapersonalfailureorasalackofwillpower,butinsteadaskthemtopayattentiontotheenvironmentalandpsychologicalfactorsinthehigh-risksituation,toreviewwhatcopingskillstheyhadavail-ablebutdidn’timplement,andtonotehowtheyfeltwhentheycouldn’tdealwiththesituationadequately.

7. Dealing with guilt and shame.Clientsoftenneedhelprecov-eringfromtheinevitablefeelingsofguiltandshameandthecognitivedissonancethatusuallyaccompaniesalapse.Guiltandshamereactionsareparticularlydangerousbecausetheemotionstheyproducearelikelytomotivatefurthersubstanceuseorotheraddictivebehaviorsasameansofcopingwiththeseunpleasantreactionstotheslip.


8. Learning from the lapse.Afterthelapsehasoccurred,therelapsepreventiontherapistreactstotheclientwithcompassionandunderstanding.Itisimportanttoapproachthesituationwiththeencouragementtolearneverythingpossibleabouthowtocopewithsimilarsituationsinthefuturebyathoroughdebriefingofthelapse.Cliniciansmusthelpclientsidentifyanyofthecognitivedistortionstheymayhavesuccumbtoinexposingthemselvestothehigh-risksituation,limitingtheirabilitytoengageinaneffec-tivecopingresponse,and,finally,makingthedecisiontoresumesubstanceuse.

GloBal intervention StrateGieS

Providingclientswithbehavioralskillstrainingandcognitivestrategiesto cope effectivelywithhigh-risk situations and lapses is vital to thesuccessofanyrelapsepreventionprogram.Thesetechniquesarelikelytobetheexclusivefocusofeffortstoabstainandtoremainabstinentfromtheaddictivehabitintheearlypartofthemaintenancestageoftherapy. However, simply teaching clients to cope with one high-risksituationafteranotherisnotenoughforlong-termsuccessinaddictiveorcriminalbehaviorhabitchange.Thisistruebecauseitisimpossibleforthetherapistandclienttoidentifyallpossiblehigh-risksituationsthattheclientmayencounter.

Lifestylebalance

Oftentimesthedegreeofbalanceor imbalance inaperson’sdaily lifehas a significant impact on the desire for indulgence and immediategratification.Lifestylebalancerefers to theamountofstress inaper-son’sdailylifecomparedwithstress-reducingactivities,suchassocialsupport, exercise, mediation, or other stress-buffering or -relievingactivities.Lifestylebalance isalsorelatedtodiet,socialrelationships,and spiritual endeavors. Whatever the cause of lifestyle imbalance,thisfactorislikelytobethefirstinachainofcovertantecedentsthatbecomerelapsesetupsbycreatingexposuretohigh-risksituationsthatmayprecipitatealapseorevolveintoafull-blownrelapse.

Lifestylemodificationproceduresaredesignedtoidentifythecovertantecedentsofrelapsethatsetupexposuretohigh-risksituationsandtopromote lifelonghabit change to create greatermental, emotional,physical, and spiritual well-being. The specific lifestyle modificationsrecommended in the relapse prevention approach depend on the cli-ent’suniqueneedsandabilities.Aprogramofexercisesuchasjogging,hiking,orwalking;meditation,yoga,orreading;enhancedsocialactivi-tieswithnewfriends;orweeklymassagetoreducemuscletensionareamongthemanypossibilities.


Becauselifestyleimbalanceislikelytocreateadesireforindulgence,oneeffectivestrategyistosearchforactivitiesthatmightbesubstituteindulgencesthatarenotharmfuloraddictive,butthatovertimewithrepeatedpracticecanbecomeadaptivewants thatprovidesomeof thesame pleasure and enjoyment that addictive behaviors have providedwithoutthedelayedcosts. Inthisregard,Glasser (1976)hasdescribedbehaviorssuchasexcessivedrinkinganddrugabuseasnegativeaddic-tions that initially feelgood,butproduce long-termharm.Conversely,Glasserdescribespositiveaddictions(e.g.,running,meditation,hiking,hobbies)asproducingshort-termdiscomfortorevenpainwhilecreatinglong-termbenefitstophysicalhealthandtopsychologicalwell-being.

Extendingrelapsepreventiontoincludeafocusonmindfulness

Marlattandcolleagueshaveintegratedmindfulnessmeditationpracticesandstandard relapseprevention techniques intoanewprogramcalledMindfulness-BasedRelapsePrevention(MBRP;Marlatt,Bowen,Chawla,&Witkiewitz,2004;Marlattetal.,2008;Witkiewitz,Marlatt,&Walker,2005).MBRPisdesignedtoenhancebothspecificandglobalinterven-tion strategies of relapse prevention, providing further techniques thatenableclientstoincreaseawarenessandpracticeeffectivecopingstrat-egies. MBRP shares the RP goals of decreasing contact with high-risksituations,increasingcopinginhigh-risksituations,keepinglapsesfrombecomingfull-blownrelapses,anddevelopinglifestylebalance.

ThetechniquesusedinMBRPoriginatefromtheBuddhistpracticeofVipassana (or “insight”)meditation.Thesepracticeswere assessedforusewithtreatmentofsubstanceuseinasmallstudydemonstratingtheeffectivenessofVipassana in reducingsubstanceuse ratesamongan incarceratedpopulation (Bowenet al.,2006).Traditionalmindful-ness meditation practice involves sitting, walking, and lying downmeditations,witha focusontheobservationofone’sexperience inanonjudgmental and accepting manner. Meditators focus on physicalsensations, aswell asonany thoughtsor emotions thatmightarise.Theypracticeobservingthemindas itbecomes involved inthoughtsorstories,repeatedlybringingtheirfocusbacktothepresentmoment.

A central component of MBRP is recognizing the tendency tobehaveon“automaticpilot,”whichcanoftenleadtoreactive,habitual,andunhealthybehaviors.Themindfulnesspracticeshelpclientsstepout of this automatic mode by increasing attentional control, allow-ing improved ability to maintain focus on the present moment, anddevelopingametacognitiveawarenessofthebehaviorofthemind.Forexample, meditators practice observation of the mind’s “automatic”


tendency to make attributions and assumptions about neutral orambiguousstimuli.Theprocessesthatarestrengthenedthroughmind-fulnesspracticefosterawarenessofhow“triggers”canleadtosubsequentproliferationsof thoughts,emotions,andbehavior.Clients learn todif-ferentiatebetweenwhatisactuallyhappeninginthemomentandwhatthemind “says” ishappening, cultivating the awareness andflexibilityneededtomakehealthierchoices.

Mindfulness-Based Relapse Prevention combines meditation prac-tices with standard relapse prevention strategies throughout eight2-hourweeklysessions.Clientsareaskedtocontinuemeditationprac-tice throughout theweekwiththeaidofaudio-recorded instructions.Additionally, they are assigned meditation exercises to implementthroughout their day, such as eating a meal mindfully or practicingwalkingmeditation.After3weeksofbasicpractice,clientsbeginengag-inginpracticesdesignedtoincreaseawarenessandcopinginhigh-risksituations.Worksheetsdesignedtohelpclientsidentifytheirownhigh-risksituations,aswellashealthyandunhealthycopingstrategies formanaginghigh-risksituations,areemployedthroughoutthecourse.

A core component of RP is addressing and coping with the absti-nence violation effect, in which individuals experience thoughts andemotions following an initial lapse that can increase the probabilityofescalation into full relapse.Forexample, instandardRP,clientsaretostop,look,andlistenasfirststepsfollowinganinitiallapse.MBRPpracticespromoteskillsthatincreasetheawarenessofproblematicsignsbothpriortoandfollowingalapse(stop)andincreasetheobservationalskills (look and listen) to enable a client to monitor his or her ownexperience and reactions. A client might notice thoughts such as “IblewitsoImightaswelljustkeepdrinking.I’mafailure.”Practicingobservation of thoughts and recognition that they are not always anobjective reflection of the truth helps clients view these as merely“automatic” thoughts, allowing them to simply observe the thoughtswithout engaging in or “buying into” them, thus preventing a chainofreactiveor“automatic”thoughtsandbehaviorsthatmighthaveledpreviouslytocontinueduse.

Inadditiontoteachingobservationalskills,standardRPteachescli-ents to “keep calm” after an initial lapse. MBRP includes meditationsdesignedtoincreaseclients’willingnessandabilitytoendureemotionallyorphysicallyuncomfortablestateswithacalmandnonjudgmentalatti-tude.Thiscanpreventfurtherexacerbationofthedistressbycultivatingcalmnessratherthan“feeding”theanxietyordiscomfort.RPencouragesclientstolearnfromtheirlapseandsuggeststhattherapistsrespondtotheirclients’lapseswithcompassionandunderstanding.MBRPfurtherencouragesclientstoadoptanencouragingandcompassionatestance


In “relapse prevention over time” (American Psychological Association, 2007), Dr. Marlatt demonstrates his approach to helping clients with sub-stance use disorders prevent or cope with relapses during efforts to change addictive behavior. In this series of six monthly sessions, he works with a man, Kevin, in his 30s who is striving to overcome a crack cocaine addic-tion. Although he is a successful African-American businessman, Kevin experiences a number of problems in his personal life, having recently separated from his wife and his young daughter over problems associated with his drug use. When the treat-ment sessions began, Kevin was liv-ing in a recovery center following his prior inpatient treatment for cocaine

addiction. Although he was success-ful in abstaining from drug use for weeks at a time, he also experienced several setbacks or lapses during the 6 months of relapse prevention. During these six sessions, Dr. Marlatt helped the client determine high-risk situations and potential triggers for relapse and taught skills for getting through these situations. One com-mon high-risk situation for Kevin was his tendency to become excessively self-critical and depressed about his life situation. When feeling down, Kevin had thoughts of using cocaine as a means of self-medicating his low moods. His temptation to buy crack was particularly difficult to resist whenever he had cash on hand (e.g., paydays). He would then tell himself

towardtheirownexperienceand,asbestastheycan,torefocustheirattitudefromoneofshameanddiscouragementtooneofcompassionand encouragement. MBRP practices adopt an underlying attitude ofcompassiontowardexperience,withtheunderstandingthatthisisthenatureofmindandofaddiction; it isnot their fault.MBRPpurportsthat initial reactions, urges, cravings, and emotions are often condi-tionedandthusarenotundervolitionalcontrol.Whatcanbefostered,however,istheabilitytomindfullychoosehowtorespond.

The specific practices of coping in high-risk situations are afundamentalpartofbothRPandMBRP.Boththerapiesalsorecognizetheimportanceofthebroaderaspectsoflifestylebalanceinmaintain-ing recovery. MBRP includes exercises and practices assessing dailyactivities and relationships and whether they are beneficial or detri-mentaltooverallhealthandrecovery.Additionally,MBRPclientsprac-tice interact with “depleting” or aversive experiences that might beinevitableindailylifeinawaythatdecreasestheaversivenature,thusreducingthestressornegativeeffectthatmayincreaseavulnerabilitytorelapse.

C a s e S t u d y


that he needed to buy a pack of ciga-rettes and would go to a store near where one of his dealers would be sell-ing drugs (this is an example of what is known as a “seemingly unimportant decision” to buy cigarettes in an area where he would run into his dealer). Under the influence of this drug, he felt powerful and confident about his life, but this was usually followed by

another period of self-criticism and guilt over the fact that he violated his commitment to abstinence (absti-nence violation effect). Together they worked to restructure the guilt and shame that arise after lapses in absti-nence. This compassionate interven-tion effectively reframes relapse as a mistake to learn from—and avoid—as the client moves toward recovery.

Summary and ConCluSionS

Relapse prevention has accumulated a strong evidence base over thepast 23 years, particularly for the treatment of alcohol use disorders(Irvin et al., 1999). RP is a versatile and straightforward cognitivebehavioral therapy-based treatment that is well liked by clients andimplementedeasilyinavarietyofsettings.Althoughitcanbeusedasastand–alonetreatment,RPisoftenincorporatedintootherbehavior-ally oriented treatments for addiction (e.g., coping skills therapy andmindfulness-based therapy). Formore informationon the implemen-tationofRP,theinterestedreaderisreferredtoMarlattandDonovan(2005)andWitkiewitzandMarlatt(2007).

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