Relapse Prevention

Description of the Strategy

Alan Marlatt and Judith Gordon developed relapse prevention (RP) as a response to their concerns over the steadily plummeting survival of treatment gains once clients discontinued alcoholism treatment if no further intervention was implemented. Their observations revealed that treatment, with all of its costs and benefits, was attenuated over time. A significant number of clients who responded to a variety of treatments for addictive behaviors could expect to reach abstinence for a certain period to time, only to lose control of the target behaviors again following cessation of treatment.

Thus, the primary assumption of RP evolved: It is problematic to expect the effects of a treatment that is designed to moderate or eliminate an undesirable behavior to endure beyond the termination of treatment. Hunt, Barnett, and Branch found that within 1 year of ending alcoholism treatment, more than 80% of clients would resume drinking (treatment failure) and two thirds of these relapses would occur in the first 3 months. Standard abstinence treatments involve an intense but limited period of time during which clients are brought into contact with new influences or experiences, information, and contextual components [Page 477]that aid in creating changes in their behaviors. In addition, these therapies include accountability and a regular dose of treatment given reliably over a period of time in a restricted environment. Once accountability and dose elements are significantly reduced or removed (typically after the client has reached his or her treatment goals), the treatment is terminated, and the client must learn to implement the skills and knowledge learned in a new context in an old context with little or no assistance. In fact, clients often enter environments in which their demonstration of treatment gains may be punished. For example, a cocaine addict who is trying to learn new ways to cope with difficult situations may be cajoled for becoming “boring.” Generalizing the skills to varied situations and across time poses a significant challenge, and many treatment failures are the result.

Marlatt and his colleagues believed that treatment failures could be analyzed in order to discover internal and external variables that increased risk for relapse. They further reasoned that knowing events such as situational factors, mood states, and cognitions would identify individualized targets of change for clients, targets focused not on the acquisition of quitting behavior, but the maintenance of that behavior. Based loosely on Albert Bandura's social learning theory, the RP model proposes that at the cessation of a habit control treatment, a client feels self-efficacious with regard to the unwanted behavior and that this perception of self-efficacy stems from learned and practiced skills. Over time, the client contacts internal and external risk factors, such as seemingly irrelevant decisions (SIDS) (also called seeming unimportant decisions, or SUDs) and/or high-risk situations (HRS), which threaten the client's self-control and consequently his or her perception of self-efficacy. According to the model, if clients have adaptive coping skills to adequately address the internal and external challenges to their control, they will not relapse. However, if their skills are not sufficient to meet challenges, a lapse or relapse may occur. In response to a resumption of the undesirable behavior, the client has a reaction that either increases attempts to implement adaptive coping skills—or fails to cope effectively and consequently engages in the undesirable behavior, perhaps because it provides immediate gratification. Marlatt's supposition that the targets of RP are cognitions and behaviors that are collectively referred to as “coping skills” is embedded within this framework. Marlatt and colleagues' treatment therefore employs cognitive-behavioral techniques to improve the retention, accessibility, and implementation of adaptive coping responses following the termination of treatment.

...