Substance Abuse and Relapse Prevention Therapy
Ashley, W

Substance Abuse and Relapse Prevention Therapy

Relapse prevention as a theoretical construct for understanding substance abuse and as a cognitive-behavioral treatment model was first developed in 1985 by Marlatt and Gordon (McCance-Katz and Clark, 2004). They based the theory first upon the premise that substance abusers, whether they be abusers of alcohol, nicotine, or heroin, relapse at very high rates. This was first demonstrated by work by Hunt, Barnett, and Branch in 1971. They found that substance abusers of various types had a common rate of incidence for relapse in the first 3 months of remission (Beck et al., 1993). The pattern was that several months after the cessation of substance abuse, the percentage of individuals who had not relapsed ranged between 25% and 40%. Marlatt and Gordon took this insight and incorporated it into a cognitive-behavioral theoretical framework that examined both thought processes and behaviors. They developed the theory that relapses were associated with a combination of internal, emotional characteristics and mental processes and environmental determinants. Relapses were most likely to occur to recovering substance abusers in high-risk situations (McCance-Katz and Clark, 2004). In this framework, high-risk situations involved the potential undermining of the individual’s self-efficacy or self-control (Beck et al., 1993). With the loss of self-efficacy, the substance abuser is more likely to fall back into old patterns and relapse.

The range of high-risk situations in relapse prevention theory include internal conditions like periods of negative emotion, social environments conducive to using and to peer pressure, and relationship conflicts (Najavits et al., 2005). So, a period of depression can reduce a person’s feeling of control, just as a social situation like being invited to go to the local pub can inhibit self-efficacy and lead to a relapse. Moreover, Marlatt and Gordon postulated that positive emotional highs could also weaken people’s commitment and self-control and lead to renewed substance abuse, whether of alcohol or other drugs (McCance-Katz and Clark, 2004). But while the high-risk situation is an initial stimulus, the substance abuser’s risk of relapse is ultimately connected to their coping mechanisms. Marlatt, Gordon, and other cognitive-behaviorists who have studied alcoholism and drug addiction view an individual’s coping strategies as a crucial safeguard against relapse. Coping strategies include both behaviors and thought processes. For example, the recovering addict invited to the pub can choose to avoid that situation by declining or suggesting another venue. Alternatively, a recovering addict can develop positive beliefs about their self-efficacy that can help them manage their recovery even during bouts of depression or interpersonal conflict (Najavits et al, 2005).

Another element in relapse prevention theory that can predispose a substance abuser to relapse is their set of outcome expectations (McCance-Katz and Clark, 2004). Positive outcome expectations regarding substance abuse might be that using a drug will produce positive emotions or help them feel better. Such an outcome expectation would lower an individual’s self-efficacy and can lead to relapse. In other words, how an individual foresees the effects of relapsing can have an impact on whether that person relapses (Beck et al., 1993). Other factors include attributions of causality and decision-making processes. Attributions of causality refer to the reasons that a substance abuser points to for drug use. When people attribute external factors outside their control, like society, or biological factors like their bodies needs, as the reasons for drug use, they are more likely to relapse (Beck et al., 1993). The cognitive-behavioral concept of decision-making processes addresses the ways that individuals place themselves in high-risk situations to begin with. If a person tends to surround themselves, unconsciously or consciously, with people or in environments that are high-risk situations, then it can be said that they have poor decision-making processes. Such individuals would then be at higher probability of relapsing than people who have better decision-making processes and avoid these situations (Beck et al., 1993). A final element at work in laying the way either for relapse or continued sobriety is the array of beliefs an individual has regarding their self-efficacy or control. Individuals who have positive beliefs regarding their ability to refuse drugs or alcohol, to control their desires for them, and to not make excuses for using again are more likely to not suffer a relapse (Beck et al., 1993). Whereas the reverse is true for recovering addicts who have the opposite beliefs and poor self-efficacy.

Ultimately, these theoretical concepts come together in the cognitive-behavioral model for relapse. In the model, a recovering addict is placed in a high-risk situation, which can be either a negative internal state, social situation, or interpersonal conflict. Those individuals with strong coping mechanisms will be able to reinforce their sense of self-efficacy and decrease their odds of relapsing (Heather and Stockwell, 2004). By contrast, those substance abusers who have not developed strong coping strategies will experience decreased feelings of control and positive outcome expectations regarding using again. This then makes an initial lapse, such a single drink for an alcoholic, more likely. The critical point here is that the person after the first lapse crosses a threshold known as the abstinence violation effect (AVE) (McCance-Katz and Clark, 2004). The AVE explains why a substance abuser in recovery may cross from simply making one lapse to becoming an addict against. The individual feels a sense of having lost control, which may then manifest itself as negative emotions like self-blame and guilt. These negative thoughts and feelings then predispose the substance abuser to continue using drugs or alcohol as a form of self-medication (McCance-Katz and Clark, 2004). Moreover, the person may have an internal narrative that one lapse amounts to having failed in his recovery and hence that there is no longer a point in not continuing to substance abuse. If the individual attributes the cause of the lapse to something integral to their internal makeup, like a personality constituted to have poor self-efficacy, then they are likely to have an AVE and relapse (Heather and Stockwell, 2004). The literature describes how an individual who has made a prior commitment to sobriety can experience cognitive dissonance when they see themselves nevertheless using drugs or drinking (Heather and Stockwell, 2004). This cognitive dissonance in combination with feelings of guilt and self-efficacy are further contributors to relapse.

Informed from this theoretical framework, cognitive-behaviorists have developed a series of relapse prevention coping strategies. One basic coping strategy is to be able to identify high-risk situations to begin with. Self-report questionnaires, such as Annis, Turner, and Sklar’s Inventory of Drug-taking Situations, have been developed to help inform substance abusers about which situations to avoid (Heather and Stockwell, 2004). These questionnaires are based upon the substance abuser’s past history of using under the categories of positive, negative, and temptation situations. Individuals are also advised to self-monitor their behavior, for example by keeping daily records of their thought processes, emotions, and compulsions to use again (McCance-Katz and Clark, 2004). Related to this technique, cognitive-behavioral therapists guide their clients to write autobiographies describing the steps leading to their substance addiction and their past history of use in high-risk situations (Heather and Stockwell, 2004). Another strategy is for therapists to encourage the client to develop a new conceptual framework for understanding their past substance abuse. As stated previously, when substance abusers view their drug or alcohol addiction as fundamental to their character and lack of self-efficacy, they are more likely to relapse. As a result, therapists tell recovering addicts to cognitively reframe their past use and lapses in terms of a lack of coping strategies or insufficient motivation at the time (McCance-Katz and Clark, 2004). Since past lapses and substance abuse were not necessarily representative of the person’s character, but a result of a lack of effort or skills, they can establish the frame that they can learn how to remain sober in the future. Relapse prevention therapy also includes strategies to increase self-efficacy, by for example, running through rehearsals of relapses. Finally, the cognitive-behavioral framework requires that individuals develop coping strategies after initial lapses known as relapse emergency procedures (Heather and Stockwell, 2004). These involve the individual gaining an awareness of their situation, to stop what they are doing, lower stress levels, and recommit to maintaining sobriety.

Relapse prevention therapy has been a treatment paradigm for recovering substance abusers for almost thirty years. Research has demonstrated that it continues to be an effective therapy paradigm. Irvin et al. (1999) conducted a meta-analysis of 26 relapse prevention studies and found that it was broadly effective. The meta-analysis found that relapse prevention therapy was particularly effective for alcoholics and for users of multiple illicit substances (Irvin et al., 1999). Moreover, it was found that relapse prevention techniques based upon coping strategies and self-efficacy were effective in both outpatient and inpatient settings. The study also provided substantiation that relapse prevention in combination with pharmaceuticals like fluoxetine and desiprimine is productive. While relapse prevention has continued to a successful framework for treating recovering substance abusers, it has nevertheless been refined over time. Witkiewitz and Marlatt (2004) discuss how the latest research supports a more complex system for explaining relapses than originally postulated in relapse prevention theory. As opposed to the old relatively fixed risk factors in Marlatt and Gordon’s 1985 theory, the current state of research views relapse as a dynamic process that can be precipitated by momentary mood changes and impulses (Witkiewitz and Marlatt, 2004). Moreover, current practitioners stress how seemingly minor cues (such as being in proximity to alcohol) can set-off feedback loops of thought processes, urges, and behaviors that can culminate in a relapse. In this newer theoretical framework, factors leading to renewed drug use are categorized as tonic (such as social supports and self-efficacy) for those that predispose an individual to enter into a high-risk situation and phasic responses which occur at the moment when relapse is eminent. Critically, these tonic and phasic factors are interconnected and can create feedback loops, so that a momentary lapse can connect back to cognitive processes and poor coping strategies and hence lead to full-blown relapse (Witkiewitz and Marlatt, 2004).

The social policy implication of relapse prevention therapy is that public funding for substance abuse treatment should be directed to this cognitive-behavioral paradigm. Indeed, the current administration’s National Drug Control Strategy entails funding for combating drug use in schools that includes relapse prevention therapy (Department of Education, 2011). According to the DEA, 144,000 teenagers participate in substance abuse programs annually. At the same time, it is reported that 85% of these children relapse within a year. This appears to be consistent with research going back to Hunt, Barnett, and Branch concerning the incidence of relapses in substance abusers. As a result, the Obama administration’s National Drug Control Strategy has allocated federal funds for substance abuse programs in schools such as relapse prevention (Department of Education, 2011). Moreover, the Department of Education has expanded relapse prevention programs to college campuses as well under the Higher Education Center for Alcohol, Drug Abuse, and Violence Prevention (HEC).

Relapse prevention also has a profound significance for the criminal justice system. The overwhelming majority of individuals arrested in the U.S. (68%) test positive for drugs and about a third of state inmates are incarcerated for drug offenses (Hiller et al., 1999). Since recidivism rates for former inmates are also linked with drug use, it is in the interest of public policy makers to incorporate relapse prevention into the justice system. There is some evidence that such treatment programs can in fact reduce rates of re-arrest and better adherence to probation (Hiller et al., 1999). Relapse prevention theory could also inform how statistics regarding rates of drug addiction are reported in the prison system. In other words, since cognitive-behavioral theory views relapse as more than simply a recurrence of drug use but as a process (involving failed coping strategies and crossing the AVE), the justice system could better record rates of abuse by incorporating this theoretical framework.

The clinical implications of relapse prevention are, of course, obvious. It can be a powerful framework for therapists to use in guiding clients to maintain sobriety and achieve a successful recovery from addiction. Nevertheless, relapse prevention needs to be tailored to suit the needs of individual substance abuse clients (Najavits et al, 2005). Different coping strategies can be emphasized based upon the patient’s past history and needs. Moreover, cognitive-behavioral therapy in general is most effective when the relationship between therapist and client is a collaborative one (Najavits et al., 2005). Cognitive-behavioral therapists using relapse prevention stress listening, relapse rehearsals, and role playing instead of simply instructing patients in the proper way to stay sober. In fact, therapists using this model actively confront their own thought processes about their clients as much as their clients deal with theirs. Therapists are trained to foster positive thoughts about the likelihood of their patient’s success and odds of not relapsing (Najavits et al., 2005).

Relapse prevention techniques used in the clinical setting include cue exposure, coping imagery, craving cards, cognitive distortion coping (Heather and Stockwell, 2004). Cue exposure is a strategy that therapists use that reduces environmental stimuli in clinical inpatient settings that might foster cravings for drugs or alcohol. In the long run, it also involves the patient themselves developing routines of removing cues in their own homes and daily lives (Heather and Stockwell, 2004). Coping imagery is a strategy that therapists teach to substance abusers in which they visualize their urges in a way that places them in context. Practitioners use the phrase urge surfing to describe the coping imagery which contextualizes sudden cravings as the rise and crest of a wave that ultimately will subside (Heather and Stockwell, 2004). By encouraging patients to view their urges for alcohol or drugs using this imagery, they can recognize that like any wave, their momentary desire will subside. Craving cards are another relapse prevention strategy used by therapists and substance abusers in clinical and outpatient settings. They entail the composition of cards to be read and followed whenever a craving for drug or alcohol emerges. The card then includes information on recognizing the urge, reducing stress levels, and coping mechanisms (Heather and Stockwell, 2004). Finally, therapists teach their clients to recognize the cognitive distortions their mind can use to disguise their craving for substance abusing. In the cognitive-behavioral field apparently irrelevant decisions (AIDs) that nevertheless place a recovering addict in a high-risk situation can be seen as a cognitive distortion. Coping with these distortions means identifying them for what they are (an urge to relapse) and to fall back upon the gamut of strategies for maintaining sobriety.

Taken as a broad and flexible framework, relapse prevention is a powerful theory for understanding why substance abusers fail to stay clean and a useful method for therapists and patients to overcome addiction. Relapse prevention explains the pattern whereby up to three-quarters of substance abusers relapse within a few months of quitting. Moreover, it provides a detailed and sophisticated model for understanding both the behaviors and thought processes leading to decisions that culminate in relapse. From a cognitive-behavioral perspective, the individual is most likely to relapse when they find themselves in a high-risk situation and at the same time discover that they have poor coping strategies for dealing with the craving to lapse (McCance-Katz and Clark, 2004). As the literature makes clear, a high-risk situation for a recovering alcoholic or drug addict can be anything from the bad emotional state such as the turmoil following a breakup to a social situation like a party where others are using. It is at these moments that the individual’s degree of self-efficacy comes into play. Does the addict have a strong sensation that they control their own behavior and can resist the craving to abuse drugs or alcohol again? If so, they can be said to have a strong self-efficacy and good coping skills (Beck et al., 1993).
By contrast, if they find that they feel powerless before the overpowering desire to use again, their self-efficacy and self-control is relatively poor. In such a circumstance, when an individual maintains an internal narrative of negative self-statements regarding the possibility of maintaining their commitment to sobriety, there is a very high risk of an initial lapse. Critically, from the perspective of relapse prevention theory, this first lapse, such as the one drink that interrupts the sobriety of an alcoholic, need not become a full relapse (McCance-Katz and Clark, 2004). Rather, it will likely lead to a relapse when the abuser attributes its causes to global personality characteristics such as poor self-control, and feels sensations of guilt and shame. If instead, the individual views the lapse as a temporary setback resulting from a high-risk environment, poor coping strategies, and lack of momentary effort, then they are better placed to recover and not relapse. Relapse prevention takes off from this theoretical framework and develops a suite of coping strategies for patients to use to both prevent and handle high-risk situations and thus preempt the possibility of using again. These strategies include self-monitoring, relapse role rehearsal, autobiographical investigations of initial drug or alcohol use, cognitive reframing, positive self-statements, protocols for avoiding and escaping high-risk situations, strategies to lower stress, craving cards, and cue control (Heather and Stockwell, 2004).

Importantly, relapse prevention as a cognitive-behavioral paradigm for understanding and treating substance abuse is open and evolving. As Witkiewitz and Marlatt (2004) report, the theoretical model for elucidating the relapse process has developed over the last couple of decades. It is now seen in a more subtle way as a dynamic process involving feedback effects when minor environmental cues and sudden cravings can rebound upon external stimuli or thought processes to lead to relapse (Witkiewitz and Marlatt, 2004). Meanwhile, relapse prevention is now being integrated with pharmaceutical interventions in more robust treatments for substance abuse (Irvin et al., 1999). At the same time, it is finding a place in state prisons as part of drug rehabilitation programs devoted to reducing recidivism rates and in school programs to arrest the incidence of drug use among America’s youth. So far, as Irvin et al. (1999) and other scholars have shown, the range of studies on substance abuse confirm that relapse prevention is an effective treatment model. It is likely that whatever changes occur in the substance abuse field in the future, response prevention will be refined and augmented by cognitive and neurological science as well as by pharmaceutical interventions, rather than replaced. For more information regarding resources for mental health, substance abuse and other services in your community, please visit and click on mental health, then resources.

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Heather, N. and Stockwell, T. (2004) The Essential Handbook of Treatment and Prevention of Alcohol Problems. Hoboken, NJ: John Wiley & Sons.

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