Correctional
Service of Canada
Review of Substance Abuse Treatment
Modalities
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 behavior
change (i.e., quitting smoking) and the maintenance of behavior 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-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 behavior 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.
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 counseling. 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.
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 counselor 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 Development Moeld of Recovery 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).
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 counseling: 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
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Killen, J. D., Fortmann, S. P., Newman,
B., & Varady, A. (1990), Evaluation of a treatment approach combining
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Larimer, M. E., & Marlatt, G. A.
(1990), Applications of relapse prevention with moderation goals, Journal of
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Marlatt, G. A., & George, W. H.
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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.
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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
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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., &
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92-99.
Domains of Substance Abuse Treatment
Reviewed by the Correctional Service of Canada
| Assertion
Training |
|
Bibliotherapy |
|
Confrontation/Encounter Techniques |
| Controlled
Drinking Strategies |
| Cue
Exposure| Detoxification |
| Drug and
Alcohol Education |
| Employment
Training |
| HIV
Prevention/Support|
| Life Skills
Training |
|
Marital/Family Therapy |
| Methadone |
| Nutritional
Counseling |
| Problem
Solving |
| Provision of
Aftercare |
| Psychiatric
Care |
|
Psychotherapy or Psychodynamic Techniques |
| Recognizing
High Risk Situations |
| Recreational
Therapy |
| Relapse Techniques |
| Social
Skills Training |
| Spirituality
|
| Stress
Management/ Relaxation |
| Surveillance
Techniques |
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