Understanding and Preventing Relapse
Kelly D. Brownell
G. Alan Marlatt
G. Terence Wilson
University of Pennsylvania School of Medicine
University of Washington
University of Oregon and Oregon Research Institute
ABSTRACT." This article examines relapse by integrating
knowledge from the addictive disorders of alcoholism,
smoking, and obesity. Commonalities across these areas
suggest at least three basic stages of behavior change: mo-
tivation and commitment, initial change, and mainte-
nance. A distinction is made between lapse and relapse,
with lapse referring to the process (slips or mistakes) that
may or may not lead to an outcome (relapse). The natural
history of relapse is discussed, as are the consequences of
relapse for patients and the professionals who treat them.
Information on determinants and predictors of relapse is
evaluated, with the emphasis on the interaction of indi-
vidual environmental, and physiological factors. Methods
of preventing relapse are proposed and are targeted to the
three stages of change. Specific research needs in these
areas are discussed.
The problem of relapse remains an important challenge
in the fields dealing with health-related behaviors, par-
ticularly the addictive disorders. This is true for areas of
obesity (Brownell, 1982; Rodin, 198 l; Stunkard & Pen-
ick, 1979; Wilson, 1980), smoking (Lando & McGovern,
1982; Lichtenstein, 1982; Ockene, Hymowitz, Sexton, &
Broste, 1982; Pechacek, 1979; Shiffman, 1982) and al-
coholism (Marlatt, 1983; Miller & Hester, 1980; Nathan,
1983; Nathan & Goldman, 1979).
The purpose of this article is to focus on relapse by
integrating the perspectives of four researchers and eli-
nicians who have worked with one or more of the addictive
disorders (Brownell, 1982; Lichtenstein, 1982; Marlatt,
1983; Wilson, 1980). We will discuss the natural history
of relapse, its determinants and effects, and methods for
prevention. We hope that our collective experience and
different perspectives will aid in developing a model for
evaluating and preventing relapse.
Commonalities and Differences in the
Compelling arguments can be marshaled for both com-
monalities and differences in the addictive disorders.
Many differences exist, both among the disorders and
among persons afflicted with the same disorder. For ex-
ample, genetic contributions to both alcoholism (Mc-
Clearn, 1981; Schuckitt, 1981) and obesity (Stunkard et
al., 1986) suggest separate pathways for their development.
There may be key differences in the pharmacology of
nicotine and alcohol (Ashton & Stepney, 1982; Best,
Wainwright, Mills, & Kirkland, in press; Gilbert, 1979;
Myers, 1978; Pomerleau & Pomerleau, 1984), and food
abuse fits even less neatly with concepts of physical de-
pendency, withdrawal, and tolerance. Treatment goals
also vary, with abstinence the target in some cases and
moderation in others.
Individual differences within the addictions are also
impressive. Variable treatment responses are an example.
There are also striking differences in patterns of use. Some
smokers, alcoholics, and overeaters engage in steady sub-
stance use, whereas others binge. Combinations of phys-
iological, psychological, social, and environmental factors
may addict different people to the same substance. Finally,
different processes may govern the initiation and mainte-
nance of the disorders.
There is also increasing emphasis on commonalities.
One reason is that rates for relapse appear so similar. In
1971, Hunt, Barnett, and Branch found nearly identical
patterns of relapse in alcoholics, heroin addicts, and
smokers. The picture is the same today (Marlatt & Gor-
don, 1985). There may also be common determinants of
relapse (Cummings, Gordon, & Maflatt, 1980). These
factors suggest important commonalities in the addictive
disorders. Progress may be aided by viewing these dis-
orders from multiple perspectives (Levison, Gerstein, &
Maloff, 1983; Maflatt & Gordon, 1985; Miller, 1980; Na-
The notion of commonalities gained support from
expert panels assembled by two government agencies. The
National Institute on Drug Abuse (NIDA) convened a
panel of researchers in alcoholism, obesity, smoking, and
drug abuse and found both conceptual and practical sim-
ilarities in the areas (NIDA, 1979). Similar conclusions
appeared in a more extensive report by the National
Academy of Sciences (Levison et al., 1983). Both reports
noted the importance of relapse and suggested the utility
of combining perspectives from different areas of the ad-
The question of whether the addictions are more
similar than different is difficult to answer. It may be the
case, for example, that there are common psychological
adaptations to different physiological pressures. Nicotine
dependence may be the central issue for a smoker, ex-
cessive fat cells for a dieter, and disordered alcohol me-
tabolism for an alcoholic, but there may be common social
or psychological provocations for relapse, emotional re-
actions to initial slips, and problems in reestablishing
control. Our hope is to expand the information to be
July 1986 ~ American Psychologist
Copyright 1986 by the American Psychological Association, Inc. 0003-066X/86/$00.75
Vol. 41, No. 7, 765-782
focused on relapse by considering both similarities and
differences. In so doing, both conceptual'and practical
ideas may emerge that would not be suggested by the
knowledge available in any one area.
Rates and Definition
Relapse rates for the addictions are assumed to be in the
range of 50% to 90% (Hunt et al., 1971; Hunt & Mata-
razzo, 1973; Marlatt & Gordon, 1980, 1985). This un-
derscores the importance of the problem. However; de-
fining specific rates is difficult. Hidden within these av-
erages is large variability. The rates depend on
characteristics of the addiction, individual variables, the
success of treatment, and so forth.
The figures generally cited for relapse could over-
estimate or underestimate actual rates. Most data are from
clinical programs, so rates are based on those who have
received formal treatment. These figures could overstate
the problem because only difficult cases are seen and be-
cause only one attempt to change is studied (Schachter,
1982). persons attempting to change on their own may
be more successful and may relapse less frequently
(Schachter, 1982). The vast majority of persons who
change do so on their own (Ockene, 1984). These data
could understate the case because clinical programs are
most likely to provide effective treatments. In addition,
#arious criteria are used to define relapse. For example,
relapse in alcohol studies could be defined as days intox-
icated, days hospitalized or jailed, days drinking out of
control, or the use of any alcohol. This points to the need
for standard definitions and for the study of the natural
history of relapse.
Lapse and Relapse--Process Versus Outcome
There are two common definitions of relapse, each re-
fleeting a bias regarding its nature and severity (Marlatt
& Gordon, 1985). Webster's New Collegiate Dictionary
of 1983 gives both definitions. The first is "a recurrence
of symptoms of a disease after a period of improvement."
This refers to an outcome and implies a dichotomous
view because a person is either ill and has symptoms or
is well and does not. The second definition is "the act or
instance of backsliding, worsening, or subsiding." This
focuses on a process and implies something less serious,
perhaps a slip or mistake.
The choice of the process or outcome definition has
important implications for conceptualizing, preventing,
and treating relapse. We suggest that lapse may best de-
scribe a process, behavior, or event (Marlatt & Gordon,
rhis article had its origins in a symposium on relapse at the World
Congress on Behavior Therapy, Washington, I)(2, 1983. This work was
supported in part by Research SCientist Development Award MH00319
from NIMH and by a grant from the MacArthur Foundation to Kelly
D. BrowneU, grant HL29547 to Edward Lichtenstein from NHLBI,
grant AA00259 to G. Terence Wilson from NIAAA, and grant AA05591
to G. Alan Marlatt from NIAAA.
Correspondence concerning this article should be addressed to Kelly
D. Brownell, Department of Psychiatry, University of Pennsylvania, 133
South 36th St., Philadelphia, Pennsylvania 19104.
1985). Webster's defines lapse as "a slight error or slip
?9 . . a temporary fall esp. from a higher to a lower state."
A lapse is a single event, a reemergence of a previous
habit, which may or may not lead to the state of relapse.
When a slip or mistake is defined as a lapse, it implies
that corrective action can be taken, not that control is
lost completely. There is support for this distinction in
smokers (Coppotelli & Orleans, 1985; Mermelstein &
Lichtenstein, 1983) and in dieters (Dubbert & Wilson,
1984). In these cases, different determinants were found
for lapses (slips) and relapses.
The challenge with this approach is defining when
one or more lapses become a relapse. One former smoker
may lose control with the first transgression, whereas an-
other may smoke one cigarette each month and never
lose control. A lapse, therefore, could be defined con-
cretely as use of the substance in the case of smoking and
alcoholism or violation of program guidelines for a dieter.
The individual's response to these lapses determines
whether relapse has occurred. This varies from person to
person and may be best defined by perceived loss of con-
trol. Reliable measures do not yet exist for this assessment.
Research in this area is important for the field.
The Nature and Process of Relapse
Surprisingly little is known about relapse in its natural
state. Most data are from clinical programs where differ-
ent treatments are used with different populations, so it
is difficult to isolate the factors that influence relapse. In
addition, few researchers have done careful evaluations
of patients when they are most likely to relapse, that is,
after treatment has ended. Periodic follow-ups in groups
are the only contacts with patients in most studies, so
repeated, intensive assessments are needed. There would
be great value in learning more about the nature and
process of relapse.
The Need for a Natural History
A metaphor that describes traditional thought on relapse
is of a person existing perilously close to the edge of a
cliff. The slightest disruption can precipitate a fall from
which there is no return'. A person is always on the brink
of relapse, ready to fall at any disturbance. There may
be physiological, psychological, or social causes of the
disturbance, but the outcome is just as final. The first slip
creates momentum so that a complete relapse is certain.
This metaphor may be inadequate.. It does not ex-
plain why a relapse occurs under the same circumstances
that the person managed before. An eating binge may
precipitate relapse in a dieter, but such an individual has
probably recovered from similar binges in the past. A
smoker may relapse after being offered a cigarette, but
there are cases where this same person refused the ciga-
rette or prevented the lapse from becoming a relapse.
Also, the metaphor is based on observations of people
who have relapsed, not those who have not, therefore,
successful recovery is seldom seen.
Information on natural history could address the
question of whether the probability of relapse increases
766 July 1986 ?9 American Psychologist
or decreases with time. If relapse occurs when treatment
"wears off," the probability should increase with time. If
the metaphor used above is valid, the chance of relapse
should increase with time simply because more distur-
bances could occur. One can speculate, however, that a
person learns to cope effectively as time passes and that
those who "survive" beyond the initial period are those
who will succeed. To the extent withdrawal symptoms
precipitate relapse, particularly in smoking and alcohol-
ism, the likelihood of relapse should decrease as the body
adapts to the absence of the addictive substance.
It is in this context that the concept of a "safe" point
arises. This is a point in time before which relapse is
likely and beyond which relapse is unlikely. In the work
of Hunt et al. (1971) on heroin addiction, smoking, and
alcoholism, relapse curves stabilized after the first three
months. It is appealing to conclude that individuals who
abstain for three months are likely to succeed thereafter,
but more recent evidence does not support a specific safe
point (Lichtenstein & Rodrigues, 1977; Wilson & Brow-
nell, 1980). Defining such a point would have important
conceptual and practical implications, so more study on
this topic could pay high dividends. Interpreting relapse
curves may be the first step.
Relapse curves are one type of survival curve. As
such, the figures must be interpreted with several facts in
mind (Elandt-Johnson & Johnson, 1980; Marlatt & Gor-
don, 1985; Sutton, 1979). Group averages do not repre-
sent individuals. Madatt, Goldstein, and Gordon (1984)
found that abstinence rates for smokers after quitting on
the basis of a New Year's resolution were 21% both 4 and
12 months later, implying that relapse rates stabilize and
show a safe point at 4 months. However, different indi-
viduals formed the 21% these two times; some persons
moved from abstinence to relapse whereas equal numbers
moved in the opposite direction. Second, the cumulative
nature of the curves implies that a person who relapses
will remain so; survival curves are negatively accelerating
by their nature. Schachter (1982) noted that cure for many
persons follows several relapses. Third, the probability of
survival for the entire group increases with time because
the persons at highest risk are most likely to leave the
sample. Life table analyses have been designed to deal
with these issues (Elandt-Johnson & Johnson, 1980).
Therefore, it may be possible in future research to develop
a time line for the relapse process and to determine
whether there are "safe" points.
Some information does exist on the natural history
of the addictions. Vaillant's (1983) report on the long-
term progress of 110 alcohol abusers, 71 of whom were
"alcohol dependent," shows the complexity of the issue.
Vaillant's book, and an article by Vaillant and Milofsky
(1982), showed the importance of cultural and ethnic
factors in alcoholism. Many personal and environmental
factors influenced the propensity to drink excessively. It
was clear from these data that a lapse does not necessarily
become a relapse and that this transition has many de-
Schachter (1982) interviewed 161 persons from the
Psychology Department at Columbia University and from
a resort community. In their retrospective accounts, they
reported much higher rates of success at dieting and
smoking cessation than suggested by the literature. Al-
most all successes were achieved without professional aid.
Although Schachter's methods have been questioned (Jef-
fery & Wing, 1983; Prochaska, 1983), he made several
important points. He noted that cure rates are based on
clinical samples and that self-quitters may differ from
therapy-assisted quitters, a notion supported by Di-
Clemente and Prochaska (1982). Second, he found that
many of the successful quitters had made numerous at-
tempts to change before finally succeeding.
Marlatt and Gordon (1980, 1985) have examined
the natural history of the relapse itself. Beginning with a
high-risk situation, their cognitive-behavioral model ad-
dresses the coping process (Figure 1). The absence of a
coping response leads to decreased self-efficacy (Bandura,
1977a, 1977b), then use of the substance, and then the
cognitive phenomenon they label the "abstinence viola-
tion effect." This phenomenon involves the loss of control
that follows violation of self-imposed rules. The end result
of this process is increased probability of relapse. Recent
data from an analysis of relapse episodes in smokers
showed a significant difference in attributions for slips
between subjects who slipped (smoked at least 1 cigarette)
and regained abstinence and those who relapsed (Gold-
stein, Gordon, & Marlatt, 1984). Persons who relapsed
made more internal, characterological attributions for the
slip. This model is useful in conceptualizing the relapse
process from the point at which the person is in a high-
Marlatt and Gordon's (1985) model allows for mul-
tiple determinants of high-risk situations but emphasizes
cognitive processes thereafter. Other factors of a physio-
logical or environmental nature may also be important.
A Cognitive-Behavioral Model of the Relapse Process
Beginning With the Exposure to a High-Risk Situation
Note. Reprinted from Relapse Prevention: Maintenance Strategies in Addictive
Behavior Change (p. 38) by G. A. Marlatt and J. R. Gordon, 1985, New York:
Guilford Press. Copyright 1985 by Guilford Press. Reprinted by permission.
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