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Many psychological and psychiatric problems are characterized by a temporal pattern in which symptoms are either chronic or vary in severity over a long period of time, with oscillations between remissions and return of symptoms. Substance-related disorders such as alcohol dependence are often relatively enduring, and mood disorders typically follow the second pattern of alternating symptom presence and remission. The empirical demonstration of the eﬃcacy of psychotherapeutic interventions requires substantiation of the long-term beneﬁts of therapies for such disorders. Accordingly, there has been a growth of interest in the development of therapeutic approaches that are designed to minimize relapse (or, conversely, maximize the maintenance of therapeutic gains) over extended periods of time. Relapse prevention refers to a set of procedures that designed to obtain long-lasting beneﬁts. Marlatt and Gordon (1985) published the seminal work in the area of relapse prevention, in which they described a set of relapse prevention strategies for excessive alcohol consumption and other addictive disorders. This approach applies a cognitive–behavioral perspective to the problem of relapse and involves the employment of a speciﬁc set of treatment techniques. Other researchers have focused on relapse prevention for a diverse range of problems, adapting the original approach accordingly. Empirical support for the approach has been mixed, but there are some encouraging ﬁndings in relation to some speciﬁc problems. Methodological issues in the research place limitations on the conclusions that can be reached at this stage.
1. Conceptual Basis Of Relapse Prevention
The term Relapse Prevention (RP) has been associated with a particular set of techniques as described by Marlatt and Gordon (1985). It can be argued that any approach which has as its clear goal the minimization of relapse (or enhancement of maintenance) might be construed as RP. Few approaches other than Marlatt and Gordon’s RP, however, have been embedded in a coherent theoretical framework that is intended to be generalizable across a variety of psychological or psychiatric problems. Cognitive and behavioral theories provide both the framework for the development of RP techniques and the conceptual basis for understanding why a particular person relapses and how best the problem might be ameliorated. Speciﬁcally, problem behaviors are viewed as arising from the inﬂuence of both learning principles (classical and operant conditioning) and cognitive appraisal processes (attributions, predictions, and other judgments). For example, a person’s alcohol consumption is regarded as being (a) elicited by environmental cues (presence of stimuli associated with drinking such as a glass, bottle, certain companions, time of day) and (b) reinforced by its consequences (stress reduction or mood enhancement). Apart from environmental cues, a considerable amount of attention is given the role of cognitive factors in RP. Cognitive factors may include, amongst others, causal attributions or outcome expectations. Marlatt and Gordon’s RP approach draws heavily upon the concept of self-eﬃcacy (Bandura 1977) in its theoretical foundation. Thus, methods which enhance a person’s conﬁdence that they will be able to perform the necessary behaviors and the belief that their performance will lead to an eﬀective outcome, are thought to be the ones which are most likely to prevent relapse. A good deal of the research literature on predictors of relapse has focused on self-eﬃcacy. For example, low self-eﬃcacy about the performance of particular behaviors has been found to be predictive of relapse across several problem areas such as alcohol use, obesity, depression, and smoking. The underlying philosophy of RP emphasizes the notion that the maintenance period is an opportunity for the practice of newly acquired self-control strategies. Any ‘lapses’ that occur are viewed as being useful to provide information about the ways in which people identify, contribute to the occurrence of, or respond to, high risk situations. A ‘lapse’ may involve a return to the problem behavior on a single, speciﬁc occasion (or a small number of occasions), but a ‘relapse’ involves a repeated accumulation of lapses that approximate the level of severity of the original problem. From this standpoint, ‘lapses’ are seen as providing positive experience from which to draw important information that might assist in preventing future lapses, and, by implication, future relapse.
2. Relapse Prevention Strategies
In principle, RP procedures may be implemented at one of three diﬀerent points in time, either as: (a) an integral part of the initial treatment program; (b) a discrete set of sessions that occur towards the end of treatment; or (c) a set of sessions that are spaced across a period of time after the end of initial treatment. In the case of the latter approach, sessions may sometimes be more properly regarded as ‘booster sessions,’ especially if the predominant approach involves a continuation of the basic components of the original treatment or the use of prompts for the person to employ the techniques used in the original treatment. Most commonly, Marlatt and Gordon’s RP is viewed as an integrated treatment which focuses on the concept of prevention of ‘lapses’ from the outset, and continues this emphasis beyond the normal period of treatment into a ‘maintenance phase.’ In practice, studies of the eﬃcacy of RP diﬀer in the precise details of the timing of the delivery of the speciﬁc components. These components include (but are not limited to) the identiﬁcation of high-risk situations, preparation for any high-risk situations that have been identiﬁed, explicit rehearsal of coping skills, relapse-crisis debrieﬁng, education (e.g., about the eﬀects of drugs), and lifestyle modiﬁcation.
The identiﬁcation of high-risk situations represents an essential component of the RP approach. For example, it might be found that resumption of alcohol consumption occurs when the person has had a clash of opinion with a colleague or manager at work. A list of idiosyncratic high-risk situations can be obtained, based either on knowledge of the person’s previous history or on the responses to self-report inventories of typical situations in which the person is asked to indicate (a) how often these situations occur, and (b) how diﬃcult it is to engage in the desired behavior or not engage in the undesired behavior when such a situation arises. In the case of cigarette smoking, typical high-risk situations could be (a) having a cup of coﬀee; (b) sitting down to study at the desk; or (c) seeing someone else smoke. Learning to recognize that a high-risk situation is occurring or is imminent is a crucial part of the RP approach. People are taught to recognize the importance of ‘apparently irrelevant behaviors,’ exempliﬁed by the gambler who chooses to drive home from work via a more scenic route ( justiﬁed by the better view) when the route just happens to pass the casino. On the other hand, other high-risk situations may be more obvious, even to the individual, such as the person who travels business class by plane and is, therefore, likely to be oﬀered free alcoholic drinks. RP is also connected with the concept of the ‘abstinence violation eﬀect.’ This eﬀect is thought to underlie the occurrence of a relapse in a person who has merely lapsed by breaking a preplanned limit on daily alcohol or cigarette consumption. It is argued that once a person has broken the limit, they may fail to exert any further control over their behavior. RP decreases this emphasis on ‘rule violation’ by focusing on self-control and deriving useful information from the occurrence of any lapses.
RP involves teaching people not only to identify such situations as risky, but also to prepare themselves for reducing the likelihood of a lapse. Simulations of high-risk situations can be used to provide opportunities to practice behavioral responses under supervision of the therapist. Many relapses are thought to occur following the occurrence of negative emotional states such as anger, depressive mood, and anxiety. Thus, RP involves the identiﬁcation of such emotion– behavior linkages and the use of cognitive–behavioral strategies for the management of these negative states. Other lapses may be triggered by interpersonal conﬂict and may necessitate a heavier therapeutic focus on helping people to develop better communication and interpersonal problem-solving skills. In the case of addictive behaviors, there may be social pressure to engage in smoking, drinking or other drug taking. Preparation for dealing with such social pressure through assertiveness training may be incorporated into the treatment. Lifestyle modiﬁcation is also employed in order to increase the frequency of engagement in pleasant, relaxing activities that may also be incompatible with the addictive behaviors.
3. Eﬃcacy Of RP
RP has been the subject of a number of experimental evaluations since it was ﬁrst proposed as a treatment for alcohol and other addictive problems. Wilson (1992) reviewed the existing RP literature in the areas of alcohol problems, smoking, and obesity. Carroll (1996) also published a review of RP to a wide range of problems. Twenty-six studies, on substance use only (covering the years 1978 to 1995), were the subject of a meta-analysis conducted by Irvin et al. (1999). Even before considering the results of the empirical literature, the point needs to be made that there is surprisingly little research published on RP despite its presence as a concept in the treatment-outcome literature for about two decades. The drawing of ﬁrm conclusions is hampered by this relatively small body of literature, especially given the diverse types of psychological problems to which RP has been applied and the variety of procedural modiﬁcations that have been made in the published studies. A second cause for concern is the relatively short length of follow-up periods, especially given the explicit focus on relapse as an empirical issue. While it is likely that maintenance diminishes as time increases, and this appears to be the case (Irvin et al. 1999), it is not clear what type and level of resources need to be put into RP based therapeutic endeavors to bring about meaningful results in the public health sense. With these, and other limitations in mind, the following tentative conclusions can be drawn.
The earliest controlled studies of RP were conducted on alcohol problems and it continues to be the main focus of attention for RP researchers. Varying degrees of success have been reported for RP in these studies. A number of methodological explanations may be offered for some failures to ﬁnd diﬀerences between RP and control groups in some studies, including low statistical power, ceiling eﬀects associated with the success of the initial intervention, the brevity of the follow-up, and the sharing of common elements in the treatments. Irvin et al. (1999) conclude that, amongst the substance use disorders, the strongest positive eﬀects for RP have been found for problem drinking, although even within this group of studies, the outcome variable that is associated with the best response is psychosocial adjustment rather than drinking behavior per se. Like problem drinking, relapse rates following smoking cessation programs are notoriously high. While some success has been achieved using booster sessions, these eﬀects frequently are lost after the eventual termination of the booster sessions. Studies of relapse prevention strategies for smoking cessation have also yielded inconsistent results. In their meta-analysis, Irvin et al. (1999) draw attention to the relatively poor outcomes with RP in the area of smoking cessation. It should be noted that a few studies have been conducted on RP for illegal drug use. Cocaine use has been the subject of a small amount of research. As with smoking, evaluations of RP for these addictions have not been noted for their successful outcomes. Irvin et al. (1999) also conclude that the eﬀects for these problems are weaker than those for alcohol problems.
The maintenance of weight loss following cognitive– behavioral treatment was the subject of a series of studies reported by Perri and co-workers in the 1980s (see Perri et al. 1992). In this research, behavior therapy plus relapse prevention training and contact after treatment produced the largest eﬀects. Despite the sometimes positive outcome of longer-term treatment for obesity using adaptations of RP approaches, it is clear that the overall gains associated with treatments for obesity are often modest and that many people regain the weight loss during an initial treatment period.
Other psychological problems for which an attempt has been made to develop and evaluate RP approaches include depression ( Wilson 1992) and sexual oﬀending (Laws 1989). Although it is well established that relapse following an episode of depression is as high as 50 percent over a two-year period, there has been little systematic exploration of speciﬁc, psychologically informed RP methods for this problem. It is possible that focus on RP for some types of problems such as depression is misdirected because the major impact on maintenance may be derived from the potency of the initial cognitive–behavioral intervention.
4. Methodological Issues
There are several methodological problems in the study of RP and its eﬀectiveness. RP clearly is concerned with long-term maintenance, but the relatively brief length of follow-up periods in many studies places some limitations on the conclusions that can be drawn. The RP approach contains a number of speciﬁc components, but these components are not necessarily employed in all studies and it is not clear which components are necessary for the best outcome. In many studies, RP procedures have been mixed into a broader treatment, making it diﬃcult to separate the eﬀects of RP from those of other components. With some problems, such as depression, it would be preferable for research on RP to be conducted using samples of people who are at high risk for a subsequent episode rather than for all people who complete an initial intervention. In some studies, especially when the RP is being delivered following the completion of an initial broad-based treatment approach (e.g., cognitive–behavior therapy for depression or anxiety), there is a need to separate initial treatment responders from nonresponders. There is little point in examining the impact of a post-treatment RP on nonresponders to an initial treatment program because they have yet to demonstrate responsiveness to treatment. These methodological issues pose particularly diﬃcult problems for which the solutions are generally costly and time consuming to implement.
Despite nearly two decades of research on RP, the research produced has been quite meager and many questions remain to be addressed or resolved. The studies of RP for any given problem are so few in number that it is diﬃcult to draw any ﬁrm conclusions at this stage. Scattered through the literature, there is some encouraging support for RP in relation to alcohol-related problems, but strong conclusions are limited due to methodological shortcomings and the relative scarcity of studies. There is a need for a large-scale evaluation of RP with addictive disorders. There has also been some progress on the development of techniques for other problems such as obesity, depression, sexual oﬀending, and health problems.
The ﬁeld of RP research may beneﬁt from greater attention to improving our understanding of the speciﬁc ways in which RP aﬀects basic psychological processes (i.e., investigations of the mechanism of change). Further research is also needed on both general and problem-speciﬁc predictors of relapse for particular types of symptoms so that the RP approaches can be tailored more speciﬁcally to suit the features of speciﬁc disorders. The timing of the implementation of RP procedures also needs to be considered in relation to knowledge about the temporal patterns of symptom presence and remission that are characteristic of diﬀerent disorders. Continued eﬀorts to reﬁne and develop novel variation on RP approaches to chronic mental health and physical problems should remain a high priority for research.
- Bandura A 1977 Self-eﬃcacy: Toward a unifying theory of behavioral change. Psychological Review 84: 191–215
- Carroll K M 1996 Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology 4: 46–54
- Irvin J E, Bowers C A, Dunn M E, Wang M C 1999 Eﬃcacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology 67: 563–70
- Laws D R (ed.) 1989 Relapse Prevention with Sex Oﬀenders. Guilford Press, New York
- Marlatt G A, Gordon J R 1985 Relapse Prevention: Maintenance Strategies in the Treatment of Addicti e Behaviors. Guilford Press, New York
- Perri M G, Nezu A M, Viegener B J 1992 Improving the Long-term Management of Obesity: Theory, Research, and Clinical Guidelines. Wiley, New York
- Wilson P H (ed.) 1992 Principles and Practice of Relapse Prevention. Guilford Press, New York