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Relapse Prevention
G. Alan Marlatt, Ph.D.
University of Washington
Addictive Behaviors Research Center
[email protected]
http://depts.washington.edu/abrc
Contemporary Approaches to
Substance Abuse Treatment
 12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA
 Traditional Minnesota Model Inpatient Treatment - Detox,
medical supervision, disease model, AA, group, drug education
 Intensive Outpatient Minnesota Model Treatment - Medical
supervision, individual sessions, disease model, AA, groups
 Therapeutic Communities for Substance Abuse - 24-hour
residential setting, norms, responsibility, encounter groups
 Pharmacological Therapy – Antabuse, methadone, LAMM,
buprenorphine, naltrexone, etc
 Psychological Therapies – Group, couple, and individual therapy
 Behavior Therapy – Aversion therapy, cue exposure, skills training,
contingency management, community reinforcerment
 Cognitive-Behavioral Therapy – Relapse Prevention, coping skills
training, cognitive therapy, lifestyle modification
Brickman’s Model of Helping & Coping
Applied to Addictive Behaviors
Is the person responsible for
changing the addictive behavior?
YES
NO
MORAL MODEL
(War on Drugs)
SPIRITUAL MODEL
(AA & 12-Steps)
Relapse = Mistake, Error, or
Temporary Setback
Relapse = Reactivation of
the Progressive Disease
Is the person YES
Relapse = Crime or Lack of
Relapse = Sin or Loss of
responsible
Willpower
Contact with Higher Power
for the
development
of the
COMPENSATORY MODEL
DISEASE MODEL
addictive
(Cognitive-Behavioral) (Heredity & Physiology)
behavior? NO
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 10 Drinking is a risk behavior, not a disease. Both
drinking and smoking can become addictive
behaviors – and a leading cause of potentially
fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 9 Unlike biological disease, alcoholism can be
eliminated or arrested by a voluntary decision
made by the drinker.
# 10
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 8 There is no official medical diagnosis of
“Alcoholism,” only degrees of alcohol abuse and
alcohol dependence (DSM-IV).
#9
# 10
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 7 There is no known single biological or genetic
cause of alcoholism (The “Alcoholism Gene”
Theory has not been replicated).
#8
#9
# 10
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 6 Effective treatments for alcoholism are almost
always based on psychosocial, cognitivebehavioral, or spiritual self-help groups, not
‘Medical Treatment’ (Antabuse or Naltrexone).
#7
#8
#9
# 10
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 5 Unlike with most diseases, many people resolve
alcohol problems on their own without treatment
(e.g. maturing out, spontaneous remission).
#6
#7
#8
#9
# 10
Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help
groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 4 Loss of control drinking in alcoholics is triggered
more by psychological factors (expectancy) than
by the biological effects of alcohol.
#5
#6
#7
#8
#9
# 10
Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out,
spontaneous remission).
Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help
groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 3 Belief in the disease model of alcoholism predicts
greater relapse in a recent prospective treatment
outcome study (Univ. of New Mexico) funded by
NIAAA.
#4
#5
#6
#7
#8
#9
# 10
Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of
alcohol.
Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out,
spontaneous remission).
Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help
groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 2 The ‘Father’ of the disease model of alcoholism,
Benjamin Rush, M.D., supported a continuum
model of drinking, including moderate drinking
(Temperance = Moderation, not Abstinence)
#3
#4
#5
#6
#7
#8
#9
# 10
Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of
New Mexico) funded by NIAAA.
Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of
alcohol.
Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out,
spontaneous remission).
Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help
groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
… and the #1 reason
why alcoholism
is NOT a disease …
Marlatt’s Top Ten Reasons Why
Alcoholism is NOT a Disease
# 1 If alcoholism is not a disease, what is it? It is an
Addictive Behavior (with multiple biopsychosocial causes and consequences) that increases
the risk of physical disease (i.e. cirrhosis)
#2
#3
#4
#5
#6
#7
#8
#9
# 10
The ‘Father’ of the disease model of alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including
moderate drinking (Temperance = Moderation, not Abstinence)
Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of
New Mexico) funded by NIAAA.
Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of
alcohol.
Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out,
spontaneous remission).
Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help
groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of
potentially fatal diseases, such as cirrhosis and cancer.
Biopsychosocial Factors in Development
and Maintenance of Addictive Behaviors





BIOLOGICAL FACTORS
Biological vulnerability and genetic predisposition in
interaction with certain facilitating environments create
problems and eventually disease.
Pharmacological impact of excessive use of alcohol and
other drugs on body chemistry, physiology , and the
organ systems of the body.
Tolerance – Increased frequency of use and higher doses
over time.
Withdrawal – Negative effects of cessation of addictive
behaviors.
Higher risk of developing specific physical disorders
(diseases) associated with the chronic and excessive use
of particular substances.
Biopsychosocial Factors in Development
and Maintenance of Addictive Behaviors







PSYCHOLOGICAL FACTORS
Motivation – Stages of habit initiation and stages of habit
change.
Expectancies – Positive outcomes of drug use and self-efficacy.
Attributions – Effects of substance use and reasons for relapse.
Sensation-Seeking – Excessive need for stimulation
Impulsivity – Inability to effectively control or restrain
behavior.
Negative Affect – Dysphoric moods such as anxiety &
depression.
Poor Coping – Deficits in cognitive and behavioral skills or
inhibitions in the ability to perform behaviors due to the effects
of anxiety.
Biopsychosocial Factors in Development
and Maintenance of Addictive Behaviors




SOCIOCULTURAL FACTORS
Family History – Dysfunctional family settings especially
parental alcohol and drug problems and parental abuse or
neglect of children.
Peer Influences – Social pressure to engage in risk-taking
behaviors including substance use especially when related to
gang membership.
Culture and Ethnic Background – Norms and religious
beliefs that govern the use of alcohol and drugs and ethnic
variations the body’s rate and efficiency of metabolizing
drugs and alcohol.
Media/Advertising – Societal emphasis on immediate
gratification and glorification of the effects of alcohol and
drug use.
Analysis of High-Risk Situations for Relapse
Alcoholics, Smokers, and Heroin Addicts
Alcoholics
(N=70)
Smokers
(N=35)
Heroin
Addicts
(N=32)
TOTAL
Sample
(N=137)
38%
43%
28%
37%
Negative Physical States
3%
-
9%
4%
Positive Emotional States
-
8%
16%
6%
Testing Personal Control
9%
-
-
4%
Urges and Temptations
11%
6%
-
8%
TOTAL
61%
57%
53%
59%
Interpersonal Conflict
18%
12%
13%
15%
Social Pressure
18%
25%
34%
24%
3%
6%
-
3%
39%
43%
47%
42%
RELAPSE SITUATION
(Risk Factor)
INTRAPERSONAL DETERMINANTS
Negative Emotional States
INTERPERSONAL DETERMINANTS
Positive Emotional States
TOTAL
“Let’s just go in and see what
happens.”
Analysis of High-Risk Situations for Relapse
Alcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and Overeaters
Alcoholics
(N=70)
Smokers
(N=64)
Heroin
Addicts
(N=129)
Gamblers
(N=29)
Overeaters
(N=29)
TOTAL
Sample
(N=311)
Negative Emotional States
38%
37%
19%
47%
33%
35%
Negative Physical States
3%
2%
9%
-
-
3%
Positive Emotional States
-
6%
10%
-
5%
4%
Testing Personal Control
9%
-
2%
16%
-
5%
Urges and Temptations
11%
5%
5%
16%
10%
9%
TOTAL
61%
50%
45%
79%
48%
56%
Interpersonal Conflict
18%
15%
14%
16%
14%
16%
Social Pressure
18%
32%
36%
5%
10%
20%
Positive Emotional States
3%
3%
5%
-
28%
8%
TOTAL
39%
50%
55%
21%
52%
44%
RELAPSE SITUATION
(Risk Factor)
INTRAPERSONAL DETERMINANTS
INTERPERSONAL DETERMINANTS
A Cognitive Behavioral Model of
the Relapse Process
Effective coping
response
Increased
self-efficacy
Decreased
probability of
relapse
Lapse
Increased
probability of
relapse
High-Risk
Situation
Ineffective
coping response
Decreased
Self-efficacy
¤
Positive outcome
Expectancies
(for initial effects of
the substance)
(initial use of the
substance)
Abstinence
Violation Effect
¤
Perceived effects
of the substance
Relapse Prevention: Specific Intervention Strategies
Self-Monitoring
¤
Inventory of
Drug-Taking Situations
¤
Drug Taking
Confidence
Questionnaire
High-Risk
Situation
Description of
Past Relapses
¤
Relapse Fantasies
Mediation,
Relaxation Training,
Stress Management
¤
Efficacy-Enhancing
Imagery
Ineffective
Coping
Response
Decreased
Self-Efficacy
¤
Positive
Outcome
Expectancies
Situational
Competency Test
¤
Coping-Skill
Training
¤
Contract to limit
extent of use
¤
Reminder Card
(what to do if
you have slip)
Lapse
Education about
immediate vs.
delayed effects
¤
Decision Matrix
Abstinence
Violation Effect
Cognitive
Restructuring
(a lapse is a mistake:
coping vs.
Skill-Training with Alcoholics:
One- Year Follow-Up Results
Days of Continuous Drinking
60
SD = 62.2
p < .05
40
20
0
SD = 6.9
Skill training
(Mean = 5.1)
Combined Controls
(Mean = 44.0)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
Number of Drinks Consumed
2000
1500
1000
SD = 2218.4
p < .05
SD = 507.8
500
0
Skill training
Combined Controls
(Mean = 399.8)
(Mean = 1592.8)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
Days Drunk
80
SD = 17.8
60
p < .05
40
SD = 17.8
20
0
Skill training
(Mean = 11.1)
Combined Controls
(Mean = 64.0)
Skill-Training with Alcoholics:
One- Year Follow-Up Results
Controlled Drinking
6
SD = 17.8
P = N.S.
4
SD = 2.6
2
0
Skill training
Combined Controls
(Mean = 4.9)
(Mean = 1.2)
RELAPSE PREVENTION
Empirical Support for the RP Model
Narrative Review of 24 Randomized Controlled Trials
Kathleen M. Carroll (1996)
1. While RP usually does not prevent a lapse better than other
active treatments, RP is more effective at “Relapse
Management,” i.e. delaying the first lapse longer and
reducing the duration and intensity of lapses that do occur
before abstinence is regained.
2. RP is particularly effective at maintaining treatment effects
over long-term follow-up measurements of one to two years
or more.
3. RP treatment outcomes often demonstrate “delayed
emergence effects” in which greater improvement in coping
occurs over time.
4. RP may be most effective for “more impaired substance
abusers including those with more severe levels of substance
abuse, greater levels of negative affect, and greater perceived
deficits in coping skills.” (Carroll, 1996, p.52)
RELAPSE PREVENTION
Empirical Support for the RP Model
Meta-Analysis Review of 17 Controlled Studies
Irvin, Bowers, Dunn & Wang (1999)
Irvin, Bowers, Dunn, & Wang (1999) selected 17 controlled
studies to evaluate the overall effectiveness of the RP model as
a substance abuse treatment and to statistically identify
moderator variables that may reliably impact the outcome of
RP treatment. In their discussion, they conclude that their
“Results indicate that RP is highly effective for both alcoholuse and substance-use disorders” (p.3)
RELAPSE PREVENTION
Empirical Support for the RP Model
Meta-Analysis Review of 17 Controlled Studies
Irvin, Bowers, Dunn, & Wang (1999)
Moderator Variables with Significant Impact on RP Effectiveness
1. Group therapy formats were more effective than individual
therapy formats.
2. RP is more effective as a “stand alone” than as aftercare.
3. Inpatient settings yielded better treatment outcomes than
outpatient settings.
4. Stronger treatment effects on self-reported use than on
physiological measures.
5. While RP was effective across all categories of substance use
disorders, stronger treatment effects were found for
substance abuse than alcohol abuse.
The “Black and White” Model of Relapse
Abstinence
Relapse
Thin Line
The Abstinence Violation Effect
 Emotional- guilt, blame, failure, etc.
 Cognitive- Internal, stable,global, uncontrollable
 Self-awareness increase
 Comparison to Internalized Standardsgreater difference, more guilt
 Behavioral Reaction- dominant habitual
response
 Cognitive Reaction- resolve discrepancy
Relapse Prevention
Specific Intervention Strategies






What to do if a lapse occurs
Stop, Look, and Listen
Keep Calm
Renew Your Commitment
Implement your Relapse Prevention
plan
Ask For Help
Review the situation leading-up to the
lapse
RELAPSE PREVENTION
Specific Intervention Strategies
Coping with Lapses
(Initial Use of a Substance)
 Relapse Plan with Emergency Procedures
 Relapse Contract to limit extent of use
 Relapse Reminder Card
“What do I do in case of a lapse?”
Decision Matrix
ALCOHOL ABSTINENCE
POSITIVE
NEGATIVE
Immediate Consequences
Improved
self-efficacy,
confidence
and esteem;
family approval;
better health;
financial gains;
continued success
Frustration;
denial of
pleasure;
anger at
oneself for
not doing
what one wants
Delayed Consequences
Enhanced ability
to control
one’s life;
more money;
more respect;
greater
popularity
Denial of
immediate
and seemingly
easy
gratification
ALCOHOL USE
POSITIVE
NEGATIVE
Immediate Consequences
Immediate
reduction of
anxiety; revenge
against one’s
spouse; better
feeling about work;
immediate
gratification
Feeling that
one has
lost control;
anger at family
and employer;
financial loss;
weakness
Delayed Consequences
Feeling as though
one is
caught in a
fog, so one
doesn’t have
to deal with
reality
Continued
deterioration;
loss of one’s
family; loss of
one’s employment;
poor health;
loss of friends;
greater self-hatred
Stages of Change in Substance Abuse &
Dependence: Intervention Strategies
Maintenance
Stage
Precontemplation
Stage
Contemplation
Stage
Preparation
Stage
Action
Stage
Relapse
Stage
Motivational
Enhancement
Strategies
Assessment
& Treatment
Matching
Relapse
Prevention
& Relapse
Management
Thank You.