Running head: SHORTENED VERSION OF TITLE

Relapse Prevention in the treatment of Alcohol and Drug Use Disorders

Brian Mann
Wake Forest University

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Relapse Prevention in the treatment of Alcohol and Drug Use Disorders

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 populations sampled,
and specific outcome measure utilized (Thakker & Ward, p.155). Table 1 illustrates reported
relapse rates from representative studies across a variety of addictive behaviors.

(Donovan & Witkiewitz, p260)

Given these high rate of relapse, preventing relapse is arguably at least as important as
producing initial behavior change. Yet there is still a relatively slow rate of progress in the
development of theories, research paradigms, or interventions dedicated to relapse and RP
(Donovan & Witkiewitz, p275). This paper explores the contribution of Albert Marlatts model
for Relapse Prevention (RP) in the context of alcohol and drug use disorders, and how it serves
as the seminal work in this area, as well as new developments such as mindfulness that are being
integrated into the RP model for improved efficacy.
Compared with other approaches to alcohol and drug use disorders, cognitive-behavioral
approaches have received considerable empirical support over the past 20 years. One cognitive-

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behavioral treatment, relapse prevention (RP), was initially designed as an adjunct to existing
treatments. It has also been extensively used as a stand-alone treatment and serves as the basis
for several other cognitive and behavioral treatments. (Witkiewitz, Marlatt & Walker, p211). No
model of relapse, or prescription for RP, has been more influential than that of G. Alan Marlatt
and his colleagues. The primary theoretical innovations of their conceptualization of relapse were
(a) the distinction between a lapse and relapse, leading to the notion of relapse is a process rather
than a discrete event and (b) the delineation of a specific cognitive-behavioral model of the
relapse process, as shown in Figure 1 (Donovan & Witkiewitz, p267).

Today, the term RP is ubiquitous in the addiction, mental health, and behavioral health
fields. In a recent meta-analyses of RP, Irvin et al. (1999) evaluated the efficacy of Marlatt-based
RP across substance use disorders in a meta-analytic review based on 26 controlled trials
representing a sample of 9,504 participants. These authors found a significant overall effect size
of r =0.14 for reduction in substance use, and a much larger effect of r =0.48 for improving
overall psychosocial functioning (Donovan & Witkiewitz, p271).
Marlatts RP model centers on the high-risk situation and the individuals response in that
situation. If the individual lacks an effective coping response and/or confidence to deal with the

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situation (low self-efficacy), the tendency is to give in to temptation. The decision to use or not
use is then mediated by the individuals outcome expectancies for the initial effects of using the
substance. Individuals who decide to use the substance may be vulnerable to the abstinence
violation effect (AVE), which is the self-blame and loss of perceived control that individuals
often experience after the violation of self-imposed rules (Witkiewitz & Marlatt, 2004, p229).
Treatment approaches based on RP begin with the assessment of potentially high-risk
situations for relapse. A high-risk situation is defined as a circumstance in which an individuals
attempt to refrain from a particular behavior (ranging from any use of a substance to heavy or
harmful use) is threatened. The circumstances that are high-risk, people (e.g., drug dealers),
places (e.g., favorite bars), and events (e.g., parties) often vary from person to person and within
each individual. Challenging an individuals expectations for the perceived positive effects of a
substance and discussing the psychological components of substance use (e.g., placebo effects)
help the client make more informed choices in threatening situations. Likewise, discussing the
AVE and preparing clients for lapses may help prevent a major relapse. In the assessment of
high-risk situations, a role-play measure, such as the Alcohol-Specific Role Play Test can be used
to assess observable responses in high-risk and seemingly non-high-risk situations. Education
about the relapse process, the likelihood of a lapse occurring, and lifestyle imbalance may better
equip clients to navigate the rough terrain of cessation attempts (Witkiewitz & Marlatt, 2004,
p229).
In a study conducted by Dr. Michael Levy, a survey was created to assess the most
common reasons for relapse, as described by current clients in various levels of care in a large
substance abuse treatment program. The purpose was to better understand what factors were
most relevant for relapse among these clients. Several reasons for relapse were chosen

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significantly more often than others. Common reasons for relapse for both men and women were
the following: feeling bored, feeling anxious or stressed, wanting to use and get high, believing
that use could occur without getting re-addicted, and relationship problems and break up. In
addition, men also commonly reported anger, having too much money, and no longer attending
meetings as significant reasons for relapse. Among female clients, depression, loneliness and the
pain of withdrawal were among their top reasons for relapse (Levy, p167). The outcome from
this research could be applied to the RB model by viewing some or all of these situations as
high-risk situations.
The dynamic relationship between interpersonal factors and relapse is an important area
of future research. In fact, Witkiewitz & Marlatt, two leaders in this field, encourage more
critical thinking about, and revision of the model. They suggest additional research that
incorporates dynamic data collection, such as ecological momentary assessment (EMA) and
analyses in studying the relationship between risk factors and relapse. Through the use of EMA,
it has been shown that clients are good at predicting their high-risk situations for relapse and
interpersonal factors may play a major role in these situations (Witkiewitz & Marlatt 2005,
p341).
In the past 10 years, mindfulness-based approaches have received considerable attention
in the empirical literature and popular press, although the core of these approaches dates back to
the ancient practice of Buddhist meditation. The synthesis of relapse prevention and mindfulness
meditation techniques as a treatment for addictive behaviors could provide a more robust and
durable treatment. Preliminary data provides initial support for the effectiveness of one type of
mindfulness practice in reducing alcohol and drug use, and substance use-related problems,
however future studies will need to evaluate the efficacy and effectiveness of mindfulness-based

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relapse prevention as a treatment for addictive disorders. Likewise, investigations on the

mindfulness-based relapse prevention may be carried out by comparing relapse prevention,
relapse prevention + mindfulness, and mindfulness-only in a randomized controlled trial. The
addition of mindfulness based techniques may ease the arduous process of behavior change and
serve as an effectual adjunct to existing treatments (Witkiewitz, Marlatt & Walker, p.222).
To the extent that mindfulness-based interventions appear to be equally effective as other
empirically validated approaches, mindfulness meditation may provide an alternative to these
more cost-prohibitive treatments. Meditation is inexpensive, widely available, and possibly more
acceptable than other forms of treatment. The process of incorporating a mindfulness practice
and learning to accept and tolerate urges is comparable to the process of building a repertoire of
coping skills within relapse prevention therapy. Both techniques require practice and continued
learning, whereby people develop their skills through a succession of lapses followed by a
prolapse. The use of mindfulness skills may ease the learning curve and enhance long-term
success (Witkiewitz, Marlatt & Walker, p223).
Despite successful use of mindfulness and other adjuncts to RP such as pharmacotherapy,
researchers may be getting ahead of the data. Of particular importance, there is a clear need for
these methods to be studied in more diverse samples of individuals, including ethnic minority
groups and adolescents who receive formal treatment (Witkiewitz & Marlatt, 2004, p232).

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