15 September 2000
Relapse Prevention Therapy: A Cognitive-Behavioral Approach
By George A. Parks, Ph.D. and G. Alan Marlatt, Ph.D.
Relapse Prevention Therapy (RPT) was originally designed as a maintenance program for use following the treatment of addictive behaviors although it is also used as a stand-alone treatment program (Marlatt & Gordon, 1985; Parks & Marlatt, 1999). In the most general sense, RPT is a behavioral self-control program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse.
Relapse refers to a breakdown or failure in a person's attempt maintain change in any set of behaviors. Like other cognitive-behavioral therapies, RPT combines behavioral and cognitive interventions in an overall approach that emphasizes self-management and rejects labeling clients with traits like "alcoholic" or "drug addict."
The Relapse Process
Relapse rates, usually measured as any use of a substance after a period of abstinence, are notoriously high. Research has demonstrated that the temporal patterning of the relapse process and circumstances under which relapses occur are similar across addictive behaviors.
These commonalties provide clues to a general relapse process. As we conceptualize the relapse process, it involves clients experiencing a sense of perceived control and self-efficacy while maintaining changes gained through quitting or moderating their use. The longer the period of successful abstinence or controlled use, the greater the individual's perception of self-efficacy.
This continues until an individual experiences a high-risk situation that poses a threat to their perceived control, decreases self-efficacy, and eventually increases the probability of relapse. In an analysis of relapse episodes obtained from clients with a variety of addictive behavior problems, we identified three high-risk situations that were associated with almost 75% of the relapses reported (Marlatt & Gordon, 1985). They were negative emotional states, interpersonal conflict, and social pressure.
If an individual has an effective coping response to deal with a high-risk situation, the probability of relapse decreases significantly. When a person copes effectively with a high-risk situation, he or she is likely to experience an increased of self-efficacy. As the duration of abstinence (or controlled use) increases, an individual has the experience of coping effectively with one high-risk situation after another and the probability of relapse decreases accordingly.
However, what happens if a person has not learned or cannot implement an effective coping response when confronted with a high-risk situation? Failure to master a high-risk situation is likely to create decreased self-efficacy and a sense of powerlessness. This is followed by positive expectancies for the effects of alcohol or drugs as alternative coping mechanisms. At this point, a lapse is likely.
If a slip does occur, an abstinence violation effect (AVE) follows which consists of cognitive dissonance and the attribution of responsibility for the lapse to internal and stable characteristics of the person. The AVE combined with the intoxicating effects of substance use increases the likelihood that a full-blown relapse will occur.
In most of the relapse episodes we have studied or worked with clinically, the first lapse is precipitated in a high-risk situation that clients report they were not expecting and/or were poorly prepared for.
Often, our clients found themselves in rapidly escalating circumstances they could not deal with effectively. Usually, after extensive debriefing, the lapse or subsequent relapse appear to be the last link in a chain of events that preceded exposure to the high-risk situation itself. It seems as if, perhaps unknowingly, even paradoxically, clients set themselves up for relapse because they did not or could not see the early warning signs.
Cognitive distortions such as denial and rationalization make it easier to set up one's own relapse episode. The process of relapse set-ups is determined by a number of covert antecedents that eventually lead to exposure to a high-risk situation, but also allow the individual to deny any responsibility for it.
Relapse Prevention Therapy
RPT intervention strategies can be grouped into three categories: coping skills training, cognitive therapy, and lifestyle modification. Coping skills training strategies include both behavioral and cognitive techniques. Cognitive therapy procedures are designed to provide clients with ways to reframe the habit change process as learning experience with errors and setbacks expected as mastery develops. Finally, lifestyle modification strategies such as meditation, exercise, and spiritual practices are designed to strengthen a client's overall coping capacity.
In clinical practice, coping skills training forms the cornerstone of RPT, teaching clients strategies to:
(a) understand relapse as a process,
(b) identify and cope effectively with high-risk situations,
(c) cope with urges and craving,
(d) implement damage control procedures during a lapse to minimize its negative consequences,
(e) stay engaged in treatment even after a relapse, and
(f) learn how to create a more balanced lifestyle.
Encouraging evidence is provided by recent treatment outcome research for the effectiveness of RPT as a psychosocial treatment for alcohol and drug problems (Irvin et al., 1999).
Irvin, J. E., Bowers, C.A., Dunn, M.E., and Wang, M.C. (1999). Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology.
Marlatt, G. A. & Gordon, J.R. (Ed.). (1985). Relapse Prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.
Parks, G. A. and Marlatt, G. A. (1999) Relapse Prevention Therapy for Substance-Abusing Offenders: A Cognitive-Behavioral Approach in What Works: Strategic Solutions: The International Community Corrections Association Examines Substance Abuse edited by E. Latessa. Lanham, MD: American Correctional Association, p. 161- 233.
George A. Parks, Ph.D. is a clinical psychologist practicing in Seattle and a research consultant with the Addictive Behaviors Research Center at the University of Washington. George conducts research and training on integrated cognitive-behavioral therapies for co-occurring disorders including Relapse Prevention Therapy and Harm; Reduction Therapy.
G. Alan Marlatt, Ph.D; is Professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington. Dr. Marlatt's focus is applied clinical research on the effectiveness of relapse prevention and harm reduction in the prevention and treatment of addictive behavior problems.
From the September/October, 2000 (vol. 9, no. 5) of The National Psychologist.