Relapse Prevention: An Overview of Marlatts Cognitive-Behavioral Model

The term “reliability” refers to the ability of a test or method to provide stable results (e.g., when different patients are compared or different investigators rate the same patient). The term “predictive validity” refers to the ability of a test or method to predict a certain outcome (e.g., relapse risk) accurately. Certain fee schedules make it difficult or impossible to be reimbursed for needed services. For instance, if an individual sees a primary care provider and an addiction specialist on the same day, both providers may not be able to obtain reimbursement.672 This may discourage, or even disincentivize, the use of integrated and multisystem care, which is fundamental to effective recovery-oriented services.

Coping

In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). In conclusion, the abstinence violation effect is a psychological effect that impacts those in recovery, as well as those who are focused on making more positive behavioral choices in their lives.

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Self-efficacy often increases as a result of developing positive addictions, largely caused by the experience of successfully acquiring new skills by performing the activity. Despite precautions and preparations, many clients committed to abstinence will experience a lapse after initiating abstinence. Lapse-management strategies focus on halting the lapse and combating the abstinence violation the abstinence violation effect refers to effect to prevent an uncontrolled relapse episode. Lapse management includes contracting with the client to limit the extent of use, to contact the therapist as soon as possible after the lapse, and to evaluate the situation for clues to the factors that triggered the lapse.

Covert Antecedents of High-Risk Situations

For Jim and Taylor, this might involve acknowledging the months of sobriety and healthier lifestyle choices and understanding that a single incident does not erase that progress. Collaboration with other providers from multiple disciplines who have a recovery-oriented approach to care. Opportunities to have better coordination with clients’ other providers, thereby promoting continuing, holistic care.

Theoretical and empirical rationale for nonabstinence treatment

Among social variables, the degree of social support available from the most supportive person in the network may be the best predictor of reducing drinking, and the number of supportive relationships also strongly predicts abstinence. Further, the more non-drinking friends a person with an AUD has, the better outcomes tend to be. Negative social support in the form of interpersonal conflict and social pressure to use substances has been related to an increased risk for relapse. Social pressure may be experienced directly, such as peers trying to convince a person to use, or indirectly through modelling (e.g. a friend ordering a drink at dinner) and/or cue exposure. One of the most critical predictors of relapse is the individual’s ability to utilize effective coping strategies in dealing with high-risk situations. Coping is defined as the thoughts and behaviours used to manage the internal and external demands of situations that are appraised as stressful.

Relapse Prevention

• For example, despite being widely cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown.
• Marlatt and Gordon (1985) have proposed that the covert antecedent most strongly related to relapse risk involves the degree of balance in the person’s life between perceived external demands (i.e., “shoulds”) and internally fulfilling or enjoyable activities (i.e., “wants”).
• In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019).
• It is, however, most commonly used to refer to a resumption of substance-use behavior after a period of abstinence from substances (Miller, 1996).

In this technique, the client is first taught to label internal sensations and cognitive preoccupations as an urge, and to foster an attitude of detachment from that urge. The focus is on identifying and accepting the urge, not acting on the urge or attempting to fight it4. Another factor that may occur is the Problem of Immediate Gratification where the client settles for shorter positive outcomes and does not consider larger long term adverse consequences when they lapse. This can be worked on by creating a decisional matrix where the pros and cons of continuing the behaviour versus abstaining are written down within both shorter and longer time frames and the therapist helps the client to identify unrealistic outcome expectancies5. Similar to the reward thought, you may have another common thought after a period of sobriety.

Seek Support

• This article presents one influential model of the antecedents of relapse and the treatment measures that can be taken to prevent or limit relapse after treatment completion.
• Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies.
• While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use.
• Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002).

This article discusses the concepts of relapse prevention, Substance abuse relapse determinants and the specific interventional strategies. Another approach to preventing relapse and promoting behavioral change is the use of efficacy-enhancement procedures—that is, strategies designed to increase a client’s sense of mastery and of being able to handle difficult situations without lapsing. One of the most important efficacy-enhancing strategies employed in RP is the emphasis on collaboration between the client and therapist instead of a more typical “top down” doctor-patient relationship. In the RP model, the client is encouraged to adopt the role of colleague and to become an objective observer of his or her own behavior. In developing a sense of objectivity, the client is better able to view his or her alcohol use as an addictive behavior and may be more able to accept greater responsibility both for the drinking behavior and for the effort to change that behavior. Clients are taught that changing a habit is a process of skill acquisition rather than a test of one’s willpower.

NEARBY TERMS

This success can then motivate the client’s effort to change his or her pattern of alcohol use and increase the client’s confidence that he or she will be able to successfully master the skills needed to change. Ask the client about strategies they could use now to avoid high-risk situations or external triggers as well as ways to manage internal triggers without engaging in problematic substance use. Telephone check-ins and recovery management checkups (RMCs) are effective, proactive strategies for counselors to stay apprised of clients’ recovery status and intervene early in actual recurrence of use. The consensus panel recommends asking clients to look at the skills they used to obtain substances and reframing those as strengths.

The goal of the specific intervention strategies—identifying and coping with high-risk situations, enhancing self-efficacy, eliminating myths and placebo effects, lapse management, and cognitive restructuring—is to teach clients to anticipate the possibility of relapse and to recognize and cope with high-risk situations. These strategies also focus on enhancing the client’s awareness of cognitive, emotional, and behavioral reactions in order to prevent a lapse from escalating into a relapse. The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process.