Substance Abuse Treatment Modalities: Literature Review

Relapse Techniques

Relapse prevention is a multifaceted treatment modality. It was formulated in the 1970s by Alan Marlatt based on the observation that relapse was the most frequent outcome of any treatment for substance abuse. A key article by Hunt et al. (1971) had summarized results of outcome evaluations for alcohol, smoking, and heroin treatment, showing the treatments to have remarkably similar outcomes: the vast majority of abusers relapsed by six months following treatment, and more than half had relapsed by three months following treatment. Another precursor to the approach was Bandura's (1977) development of self-efficacy theory. The important aspect of that formulation was that Bandura differentiated between the acquisition of behaviour change (i.e., quitting smoking) and the maintenance of behaviour change (i.e., staying quit). These lines of work, plus Marlatt's finding of a high relapse rate in his own study of treated alcoholics, led Marlatt to focus on attempting to understand the relapse process, and based on that model to develop procedures to prevent relapse from occurring.

Marlatt's original work involved asking relapsed individuals at follow-up to describe the situation that precipitated their relapse. These were referred to as high-risk situations. He found that he was able to group situations into categories, and that three categories accounted for nearly three-fourths of the relapses: negative emotional states, social pressure, and interpersonal conflict. This research formed the basis for a major part of the relapse prevention model; namely, the identification of situations likely to place one at risk of relapse, and the development of skills to avoid those situations or to deal with them by other than substance use. Key components of the model are that the individual should be able to anticipate and identify high risk situations, possess skills to deal with those situations, and should have expectations that using those skills will result in a positive outcome.

Some caution should be used in accepting abusers' reports of precipitants of relapse, however. Hall et al. (1990) studied alcoholics prospectively and later asked them to recall relapse precipitants. The alcoholics' retrospective (i.e., after the fact) reports associated stressful states with relapses, but a comparison of their actual reports of stress levels during the week preceding relapse and the week of relapse found no difference in stress levels. This suggests that when questioned about a relapse after it had occurred, subjects may have assumed that they must have been stressed because they had relapsed, whereas the relapse may not actually have been stress–related.

Finally, another important aspect of Marlatt's relapse prevention approach concerns how individuals react to a relapse. In particular it is stressed that they should end a relapse quickly and minimize the damage it causes (this is sometimes called “relapse management”; Curry & McBride, 1994), and that they should consider the slip as an unfortunate but isolated incident rather than an indication that they are incapable of recovering.

The relapse prevention model received its first impetus from a study reported by Chaney et al. (1978) that evaluated the efficacy of social skills training treatment for alcoholics. The treatment had positive results that increased over time (Marlatt, 1983). These findings were taken as evidence that preparing to deal with potential relapse situations led to an improved treatment outcome. Since that time several studies relevant to relapse prevention have been published. Sobell and Sobell (1993) have reviewed 12 studies relating to relapse prevention, covering a range of psychoactive substances. Many of the studies can also be considered tests of skills training treatments, since that is the usual way of preparing to deal with high risk situations. By and large the evidence supports the efficacy of relapse prevention, although improvements attributable to relapse prevention tend to be modest. The studies contributing to this conclusion are included in the reference list below and are not individually discussed herein.

One of the main contributions of relapse prevention to the addictions field may be that it legitimized acknowledging that relapse was a frequent event following treatment. Perhaps for that reason, it has become fashionable for many service providers to proclaim that they provide “relapse prevention” treatment. In this regard, perhaps the most widely available treatment called relapse prevention is an approach based on Gorski's developmental model of recovery. This approach, superficially, relates to two bodies of research literature: relapse prevention, and stages of change. It relates to relapse prevention in that it assumes that recovery will typically be punctuated by set 6-backs, referred to by Gorski as getting “stuck on the road to recovery”(1989, p.5). The stages of change model of recovery was developed by Prochaska and DiClemente (1986) and basically postulates that behaviour change involves becoming aware of the need to change, followed by taking actions to change, followed by efforts aimed at maintaining change. The main contribution of the stages of change model to the field of addictions has been to suggest that treatment for persons who have not yet decided to change should aim at encouraging the persons to decide to change, and that treatments intended to help people enact change are only appropriate for individuals who are seeking to change. The Gorski model also postulates stages of change, but these are quite different than those studied by Prochaska and DiClemente.

In Gorski's developmental model of recovery (DMR), the six stages of recovery are: (1) Transition — the individual recognizes problems but tries to surmount them by controlling his/her substance use; (2) Stabilization — the individual decides to refrain from substance use completely and recuperates over an extended length of time (6 – 18 months); (3) Early Recovery — the individual becomes comfortable with being abstinent; (4) Middle Recovery — the individual repairs past damage caused by his/her substance use and develops a balanced lifestyle; (5) Late Recovery — the individual overcomes barriers to healthy living that stem from childhood experiences; (6) Maintenance — the individual recognizes a need for continued growth and for balanced living. The DMR is explicitly linked to the philosophy and operations of Alcoholics Anonymous. For instance, various “recovery tasks” are recommended, such as making an inventory of persons harmed by one's substance use and how to make amends in each case (basically Step 4 of AA).

Unfortunately, the relationship between Gorski's developmental model of recovery and the research based relapse prevention and stages of change approaches is limited to nomenclature. Because Gorski's approach is extremely popular and is often confused with Marlatt's model of relapse prevention and with Prochaska and DiClemente's stages of change model of recovery, it is important to be aware of the similarities and differences between these approaches. These are summarized below.

Similarities

Marlatt's relapse prevention model was developed in the late 1970s, and the term “relapse prevention” became well known during the 1980s as an empirically-based, cognitive social learning theory explanation of the relapse process, with associated treatment implications. Gorski's model was introduced several years later and is referred to by Gorski as “relapse prevention”. The CENAPS Corporation, of which Gorski is President, offers training workshops and certificates in relapse prevention counselling. In sum, both approaches have come to be referred to as “relapse prevention.”

Prochaska and DiClemente, and also Gorski, have proposed that recovery is a staged process.

Differences

Marlatt's relapse prevention model is scientific. It was originally formulated as a possible explanation for data obtained in treatment outcome studies. It consists of a well formulated and testable set of hypotheses about factors that determine the likelihood of relapse, and research has been underway for several years testing various aspects of the model. Prochaska and DiClemente's model of stages in the recovery process is based on Prochaska's more general model of the process of recovery through psychotherapy. It has been the subject of considerable research for several years, and assessment instruments associated with it have been developed through rigorous research. .

Gorski's relapse prevention approach has no scientific or research basis and is based on his work as a chemical dependency counsellor for several years. It consists of Gorski's personal observations of the recovery process among patients he has known. In essence, it is a restatement of the traditional 12-Step (AA) approach to treatment aided by structured written exercises. It has not been evaluated scientifically. The stages of recovery in Gorski's DMR are based on Gorski's own experience and have no relationship to Prochaska and DiClemente's research based stages of change approach.

High-risk situations for relapse as defined in Marlatt's relapse prevention model derive from extensive scientific research on actual reported and observed precipitants of relapse. As a continuing area of scientific activity, new knowledge about the nature of risk situations frequently appears in the scientific literature. An important feature of a scientific approach is that its details change as a consequence of research findings (i.e., the model keeps improving). Gorski's high-risk situations are formulated based on his own experience and have not been scientifically evaluated. They draw heavily on 12-Step literature and include poorly defined categories such as “awfulizing sobriety” and “chronic low-grade emergency.” The important point is not whether Gorski's postulated situations ultimately have any validity (that should be the topic of research), but rather that they are based on a single individual's personal observations.

Marlatt's model of relapse prevention and Prochaska and DiClemente's model of the recovery process yield explicit, testable and theory grounded hypotheses about which types of interventions will be most effective given individual case characteristics. These hypotheses are subject to experimental test, and some have been tested, e.g. see Miller, Benefield and Tonigan (1993). Many of the terms and relationships in Gorski's model have not been well enough defined to be susceptible to measurement and test, and no scientific evaluations of the model's components have been reported.

Marlatt's relapse prevention model yields highly individualized treatment strategies that take account of an individual's particular circumstances, unique learning history, and environment. Gorski's model prescribes a single treatment approach for all cases, consisting of a series of recovery tasks embodying the 12-Steps of Alcoholics Anonymous and Gorski's personal view of dysfunctional interpersonal relationships.

Marlatt's relapse prevention model places particular emphasis on ways of minimizing the damage associated with relapses, learning from relapses so as to be better able to avoid relapse in the future, and cognitively processing relapses so as to not unduly diminish one's motivation to succeed. Gorski's model deals little with the facts of relapse, beyond acknowledging that “each of us will get stuck in our recovery process periodically”(Gorski, 1989, p. 138).

Because of its overlap with the 12-Step approach, Gorski's model has a strong spiritual component, which is not found in Marlatt's or Prochaska and DiClemente's approach. This aspect of an approach can affect whether or not an individual finds the approach personally acceptable and relevant.

Whereas Marlatt's approach supports treatments aimed at individuals gaining skills to overcome their problem, thereby increasing the individuals' sense of self-confidence (self-efficacy), Gorski's approach, consistent with its 12-Step basis, requires an admission that the individual has become “powerless” over alcohol. For example, he states: “we recognize that there is something seriously wrong with us, and that we cannot understand or correct the problem by ourselves. We need the help of someone or something that is stronger, smarter, and bigger than we are”(1989, p. 27).

Marlatt's and Prochaska and DiClemente's approach are consistent with scientific knowledge about alcohol and alcohol problems. The work appears in peer-reviewed journals, meaning that its foundation, methods and interpretation have been critically and objectively evaluated by well trained and knowledgeable third parties as a precondition for publication. Gorski's writings contain multiple inconsistencies with the scientific literature and virtually no citations of that literature. For example, Gorski states that for individuals who might have a genetic predisposition to alcohol problems: “All that is necessary for those people to become addicted is to begin using alcohol and other drugs, even if moderately at first. The biochemistry of addiction will do the rest!”(1989, p. 15). No current genetic research suggests such a simplistic explanation of genetic effects. Another example is that Gorski postulates the existence of an extended “Post-Acute Withdrawal” period where people have difficulties such as difficulty “avoiding accidents,” and moreover that “approximately one-third of all chemically dependent people have very mild post-acute withdrawal....Another one-third of recovering people have moderate post-acute withdrawal....(and) the final one-third of recovering people have severe post-acute withdrawal” (1989, p. 35, italics in original). A protracted withdrawal period with the characteristics postulated by Gorski simply is not supported by research, and his presentation of prevalence estimates has no basis in fact.

It is therefore extremely important, whenever relapse prevention or stages of recovery models are being considered, to define the specific models to which reference is made. Gorski's relapse prevention model has never been scientifically evaluated, and it is questionable that the model could be scientifically evaluated because many of its features are not well enough defined to be measured.

References for Relapse Techniques:

Annis, H. M., & Davis, C. S. (1988), “Self-efficacy and the prevention of alcoholic relapse: Initial findings from a treatment trial”, In T. Baker & D. Cannon (Eds.), Assessment and treatment of addictive behaviors (pp. 88-112), New York: Praeger.

Annis, H. M., & Davis, C. S. (1989), “Relapse prevention”, In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Alternative approaches (pp. 170-182), New York: Pergamon Press.

Annis, H. M., & Peachey, J. E. (1992), “The use of calcium carbimide in relapse prevention counselling: Results of a randomized controlled trial”, British Journal of Addiction, 87, 63-72.

Annis, H. M. (1986), “A relapse prevention model for the treatment of alcoholics”, In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 407-435), New York: Pergamon Press.

Bandura, A. (1977), “Self-efficacy: Toward a unifying theory of behavioral change”, Psychological Review, 84, 191-215.

Birke, S. A., Edelmann, R. J., & Davis, P. E. (1990), “An analysis of the abstinence violation effect in a sample of illicit drug users”, British Journal of Addiction, 85, 1299-1307.

Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986), “Understanding and preventing relapse”, American Psychologist, 41, 765-782.

Chaney, E. F., O'Leary, M. R., & Marlatt, G. A. (1978), “Skill training with alcoholics”, Journal of Consulting and Clinical Psychology , 46, 1092-1104.

Condiotte, M. M., & Lichtenstein, E. (1981), “Self-efficacy and relapse in smoking cessation programs”, Journal of Consulting and Clinical Psychology, 49, 648-658.

Cummings, C., Gordon, J. R., & Marlatt, G. A. (1980), “Relapse: Prevention and prediction”, In W. R. Miller (Ed.), Addictive Behaviors (pp. 291-321). New York: Pergamon Press.

Curry, S.J., & McBride, C.M. (1994), “Relapse prevention for smoking cessation: Review and evaluation of concepts and interventions”,. Annual Review of Public Health, 15, 345-366.

Eriksen, L., Björnstad, S., & Götestam, K. G. (1986), “Social skills training in groups for alcoholics: One-year treatment outcome for groups and individuals”, Addictive Behaviors, 11, 309-329.

Gorski, T.T. (1989), Passages through recovery: An action plan for preventing relapse. Center City, MN: Hazelden.

Hall, S. M., Havassy, B. E., & Wasserman, D. A. (1990), “Commitment to abstinence and acute stress in relapse to alcohol, opiates, and nicotine”, Journal of Consulting and Clinical Psychology, 58, 175-181.

Hawkins, J. D., Catalano, R. F., Jr., & Wells, E. A. (1986), “Measuring effects of a skills training intervention for drug abusers”, Journal of Consulting and Clinical Psychology, 54, 661-664.

Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971), “Relapse rates in addiction programs”, Journal of Clinical Psychology, 27, 455-456.

Ito, R. J., Donovan, D. M., & Hall, J. J. (1988), “Relapse prevention in alcohol aftercare: Effects on drinking outcome, change process, and aftercare attendance”, British Journal of Addiction, 83, 171-181.

Killen, J. D., Fortmann, S. P., Newman, B., & Varady, A. (1990), “Evaluation of a treatment approach combining nicotine gum with self-guided behavioral treatments for smoking relapse prevention”, Journal of Consulting and Clinical Psychology, 58, 85-92.

Larimer, M. E., & Marlatt, G. A. (1990), “Applications of relapse prevention with moderation goals”, Journal of Psychoactive Drugs, 22, 189-195.

Marlatt, G. A., & George, W. H. (1984), “Relapse prevention: Introduction and overview of the model”,. British Journal of Addiction, 79, 261-273.

Marlatt, G. A., & Gordon, J. R. (Eds.) (1985), Relapse prevention, New York: Guilford Press.

Marlatt, G. A. (1983), “The controlled drinking controversy: A commentary. American Psychologist, 38, 1097-1110.

McCrady, B. S. (1989), “Extending relapse prevention models to couples”, Addictive Behaviors, 14, 69-74.

Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993), “Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles”, Journal of Consulting and Clinical Psychology, 61, 455-461.

Prochaska, J. O., & DiClemente, C. C. (1986)., “Toward a comprehensive model of change”, In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change (pp. 3-27). New York: Plenum.

Rawson, R. A., Obert, J. L., McCann, M. J., & Marinelli–Casey, P. (1993), “Relapse prevention strategies in outpatient substance abuse treatment”, Psychology of Addictive Behaviors, 7, 85-96.

Roffman, R. A., Stephens, R. S., Simpson, E. E., & Whitaker, D. L. (1988), “Treatment of marijuana dependence: Preliminary results. Journal of Psychoactive Drugs, 20, 129-137.

Saunders, B. & Allsop, S. (1992), “Incentives and restraints: Clinical research into problem drug use and self-control”, In N. Heather, W. R. Miller, & J. Greeley (Eds.), Self-control and addictive behaviors (pp. 283-303). New York: Maxwell MacMillian.

Shiffman, S. M. (1982), “Relapse following smoking cessation: A situational analysis”, Journal of Clinical and Consulting Psychology, 50, 71-86.

Sjoberg, L., & Samsonowitz, V. (1985), “Coping strategies in alcohol abuse”, Drug and Alcohol Dependence, 15, 283-301.

Sobell, M. B., & Sobell, L. C. (1993), Problem drinkers: Guided self-change treatment, New York: Guilford Press.

Stephens, R. S., Roffman, R. A., & Simpson, E. E. (1994), “Treating adult marijuana dependence: A test of the relapse prevention model. Journal of Consulting and Clinical Psychology, 62, 92-99.