Relapse Prevention An Overview of Marlatt's Cognitive-Behavioral Model

Alcohol Research & Health, Spring, 1999 by Mary E. Larimer, Rebekka S. Palmer, G. Alan Marlatt

Relapse prevention (RP) is an important component of alcoholism treatment. The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse. The RP model also incorporates numerous specific and global intervention strategies that allow therapist and client to address each step of the relapse process. Specific interventions include identifying specific high-risk situations for each client and enhancing the client's skills for coping with those situations, increasing the client's self-efficacy, eliminating myths regarding alcohol's effects, managing lapses, and restructuring the client's perceptions of the relapse process. Global strategies comprise balancing the client's lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urgemanagement tech niques, and developing relapse road maps. Several studies have provided theoretical and practical support for the RP model. KEY WORDS: AODD (alcohol and other drug dependence) relapse; relapse prevention; treatment model; cognitive therapy; behavior therapy; risk factors; coping skills; self efficacy; expectancy; AOD (alcohol and other drug) abstinence; lifestyle; AOD craving; intervention; alcohol cue; reliability (research methods); validity (research methods); literature review

Relapse, or the return to heavy alcohol use following a period of abstinence or moderate use, occurs in many drinkers who have undergone alcoholism treatment. Traditional alcoholism treatment approaches often conceptualize relapse as an end-stare, a negative outcome equivalent to treatment failure. Thus, this perspective considers only a dichotomous treatment outcome--that is, a person is either abstinent or relapsed. In contrast, several models of relapse that are based on social-cognitive or behavioral theories emphasize relapse as a transitional process, a series of events that unfold over time (Annis 1986; Litman er al. 1979; Marlatt and Gordon 1985). According to these models, the relapse process begins prior to the first posttreatment alcohol use and continues after the initial use. This conceptualization provides a broader conceptual framework for intervening in the relapse process to prevent or reduce relapse episodes and thereby improve treatment outcome.

This artide 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. This relapse prevention (RP) model, which was developed by Marlatt and Gordon (1985) and which has been widely used in recent years, has been the focus of considerable research. This article reviews various immediate and covert triggers of relapse proposed by the RP model, as well as numerous specific and general intervention strategies that may help patients avoid and cope with relapse-inducing situations. The article also presents studies that have provided support for the validity of the RP model.

OVERVIEW OF THE RP MODEL

Marlatt and Gordon's (1985) RP model is based on social-cognitive psychology and incorporates both a conceptual model of relapse and a set of cognitive and behavioral strategies to prevent or limit relapse episodes (for a derailed description of the development, theoretical underpinnings, and treatment components of the RP model, see Dimeff and Marlatt 1998; Marlart 1996; Marlatt and Gordon 1985). A central aspect of the model is the detailed classification (i.e., taxonomy) of factors or situations that can precipitate or contribute to relapse episodes. In general, the RP model posits that those factors fill into two categories: immediate determinants (e.g., high-risk situations, a person's coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle imbalances and urges and cravings).

Treatment approaches based on the RP model begin with an assessment of the environmental and emotional characteristics of situations that are potentially associated with relapse (i.e., high-risk situations). After identifying those characteristics, the therapist works forward by analyzing the individual drinker's response to these situations, as well as backward to examine the lifestyle factors that increase the drinker's exposure to high-risk situations. Based on this careful examination of the relapse process, the therapist then devises strategies to target weaknesses in the client's cognitive and behavioral repertoire and thereby reduce the risk of relapse.

Immediate Determinants of Relapse

High-Risk Situations. A central concept of the RP model postulates that high-risk situations frequently serve as the immediate precipitators of initial alcohol use after abstinence (see figure 1). According to the model, a person who has initiated a behavior change, such as alcohol abstinence, should begin experiencing increased self-efficacy or mastery over his or her behavior, which should grow as he or she continues to maintain the change. Certain situations or events, however, can pose a threat to the person's sense of control and, consequently, precipitate a relapse crisis. Based on research on precipitants of relapse in alcoholics who had received inpatient treatment, Marlatt (1996) categorized the emotional, environmental, and interpersonal characteristics of relapse-inducing situations described by study participants. According to this taxonomy, several types of situations can play a role in relapse episodes, as follows: