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The term “relapse prevention” drew great criticism and was not generally accepted when it was initially introduced in the early 1980s. The idea of talking with clients about the possibility of relapse was an incredibly radical idea until the pioneering work on relapse prevention by Alan Marlatt and his colleagues challenged the prevailing disease conceptualization of addictions and provided a revolutionary perspective that focused on understanding the factors contributing to and maintaining addiction. Today, relapse prevention is both a manualized treatment and a general treatment strategy that has been implemented in addiction treatment centers around the world. The theory and practice of relapse prevention has emerged as one of the most prominent and pervasive approaches in the treatment of addictive behaviors and stands as one of Alan Marlatt's most notable and longest-lasting contributions to the field. This article provides a review of the development, adaptation, and dissemination of relapse prevention over the past 30 years and also provides some ideas for the future of relapse prevention in research and treatment.
Addiction Research and Theory, Early Online: 1–14
Copyright ß2012 Informa UK Ltd.
ISSN: 1606-6359 print/1476-7392 online
DOI: 10.3109/16066359.2011.647133
Relapse prevention: From radical idea to common practice
Dennis Donovan
& Katie Witkiewitz
Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th Street, Seattle, WA 98105-4631,
Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle,
WA 98195, USA, and
Department of Psychology, Washington State University, 14204 Northeast Salmon
Creek Avenue, Vancouver, WA 98686-9600, USA
(Received 7 October 2011; revised 30 November 2011; accepted 2 December 2011)
The term ‘‘relapse prevention’’ drew great criticism
and was not generally accepted when it was initially
introduced in the early 1980s. The idea of talking
with clients about the possibility of relapse was an
incredibly radical idea until the pioneering work on
relapse prevention by Alan Marlatt and his col-
leagues challenged the prevailing disease conceptu-
alization of addictions and provided a revolutionary
perspective that focused on understanding the fac-
tors contributing to and maintaining addiction.
Today, relapse prevention is both a manualized
treatment and a general treatment strategy that has
been implemented in addiction treatment centers
around the world. The theory and practice of relapse
prevention has emerged as one of the most promi-
nent and pervasive approaches in the treatment of
addictive behaviors and stands as one of Alan
Marlatt’s most notable and longest-lasting contri-
butions to the field. This article provides a review of
the development, adaptation, and dissemination of
relapse prevention over the past 30 years and also
provides some ideas for the future of relapse
prevention in research and treatment.
Keywords: Relapse, relapse prevention, substance use disor-
ders, behavior change
Relapse Prevention (RP) is a self-management program
designed to enhance the maintenance stage of the habit-
change process. The goal of RP is to teach individuals who
are trying to change their behavior how to anticipate and
cope with the problem of relapse. In a very general sense,
relapse refers to a breakdown or setback in a person’s
attempt to change or modify any target behavior. Based on
the principles of social-learning theory, RP is a self-control
program that combines behavioral skill training, cognitive
interventions, and lifestyle change procedures (Marlatt,
Alcoholism and drug dependence have a long history
of being described as chronic disorders characterized
by individuals’ loss of control over their alcohol or
drug use, high rates of relapse, and resultant poor
treatment outcomes (White, Boyle, & Loveland, 2002).
Many treatment professionals, as well as alcohol- and
drug-dependent individuals, viewed relapse as inevita-
ble, resulting in a sense of pessimism about the
‘‘treatability’’ and long-term prognosis of addictive
behaviors. The pioneering work of Alan Marlatt and his
colleagues, initiated in the early 1970s, challenged the
then prevailing disease conceptualization of addictions,
provided a vastly different perspective, shifted the
paradigm in our understanding of factors contributing
to and maintaining substance abuse, and presented a
more hopeful possibility that loss of control and relapse
need not be inevitable. Through a series of early
experimental analog studies, clinical observations, and
intervention trials both the theory and practice of
relapse prevention (RP) have emerged as one of the
most prominent and pervasive approaches in the
treatment of addictive behaviors and stands as one of
Alan’s most notable and longest-lasting contributions
to the field.
Correspondence: D. Donovan, Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th Street, Seattle, WA 98105-
4631, USA. Tel: 10206-543-0937. Fax: 1-206-543-5473. E-mail:
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One of the first areas challenged by Alan was the
notion of loss of control as a key component of alcohol
dependence and that this phenomenon was attributable
to the pharmacological effects of alcohol on the altered
physiological state of the alcoholic. The prevailing
belief at the time was that an alcoholic, if given alcohol
even in relatively small amounts, would lose control
over drinking and be unable to stop. The slogan ‘‘First
drink, then drunk’’ was a mantra among many
alcoholics and treatment providers (Sobell, Sobell, &
Christelman, 1972). However, a few small scale studies
had begun to question this tenet of the disease model of
alcoholism. Preliminary results suggested that loss of
control might not occur, but rather may be a ‘‘myth’’;
further, it was suggested that psychological, environ-
mental, and motivational factors might be more
important influences in initiating ‘‘loss-of-control’’
drinking than the direct effects of alcohol (e.g., Merry,
1966; Paredes, Hood, Seymour, & Gollob, 1973;
Sobell, et al., 1972).
In what is considered to be a classic experiment
conducted by Marlatt, Demming, and Reid (1973), the
validity of the loss of control assumption was tested
more fully. Non-abstinent alcoholics and social drin-
kers were recruited to take part in a ‘‘taste-rating’’ task
in which they were led to believe they would be rating
the taste qualities of alcoholic and non-alcoholic
beverages along a number of dimensions. The partic-
ipants were assigned to one of four conditions in a
22 experimental design that has become known as
the ‘‘balanced placebo design’’. One condition manip-
ulated the content of the beverage that the individual
would taste. In half the cases, the beverages contained a
mix of vodka and tonic in a ratio that could not be
reliably identified as containing alcohol; the other half
of the beverages contained no alcohol. The second
condition manipulated what the individuals were told
about the beverage content. In half the cases, they were
told that the beverage contained alcohol; in the other,
they were told that it was tonic and contained no
If the loss of control phenomenon is operative as
incorporated into the disease model, then individuals,
especially the alcoholics, should drink more when the
beverage contains alcohol, independent of their beliefs
about the contents. This is predicated on the assump-
tion that the consumption of alcohol would trigger the
underlying physiological addictive process, which in
turn would increase craving, resulting in continued
drinking. However, the results failed to support this
assumption. Regardless of whether alcoholic or social
drinker, individuals who were told that the beverage
contained alcohol (regardless of its actual content)
consumed nearly twice as much beverage as did those
who were told the beverage contained no alcohol.
While alcoholics consumed more beverage than social
drinkers, participant classification did not interact with
either beverage content or instructional set. A similar
pattern was found on a number of other measures.
Being told that the beverage contained alcohol,
regardless of its actual content and regardless of
whether an alcoholic or social drinker, was associated
with more beverage being consumed per sip and with
participants’ post-drinking estimates of the percent of
alcohol contained in the beverages. Further, for those
conditions in which the beverage actually contained
alcohol, participants who were told that they were
consuming alcohol had significantly higher estimated
blood alcohol levels than those led to believe that the
beverage did not contain alcohol; this difference in
estimated BACs was particularly large for the alcoholic
This experiment was significant for a number of
reasons. First, on a methodological level, it introduced
the balanced placebo design (see George, et al., this
volume, for more details about the balanced placebo
design). This design (Marlatt & Rohsenow, 1980;
Rohsenow & Marlatt, 1981), which is still considered
to be a novel approach (Enck, Klosterhalfen, & Zipfel,
2011), has been generalized beyond its original use
with alcohol to include other substances such as
caffeine (Lotshaw, Bradley, & Brooks, 1996), nicotine
(Juliano & Brandon, 2002), and marijuana (Metrik
et al., 2009).
Second, the results derived from the balanced
placebo highlight the prominent role that cognitive
expectancies play in determining alcohol consumption
of both alcoholics and social drinkers. These expec-
tancies, rather than the physiological effects of alcohol,
appeared to govern their drinking behavior. These
findings, important in their own right, also contributed
to the then emergent focus on the role that expectancies
and other cognitive and social learning factors play in
the etiology and maintenance of alcohol problems
(Brown, Goldman, Inn, & Anderson, 1980; Donovan &
Marlatt, 1980; Goldman, Brown, & Chritiansen, 1987;
Marlatt & Donovan, 1981, 1982). They also provided
the initial seeds for the concept of the Abstinence
Violation Effect (AVE). Since many alcoholics who
have achieved a period of abstinence do drink heavily
following an initial drink, and if such continued
drinking is not driven by physiological mechanisms
but rather expectancies, then there must be some
cognitive-expectational mechanism involved. The
AVE suggests that to the extent that an individual is
committed to a goal of abstinence and then drinks, this
strongly held commitment is broken, leading to a sense
of guilt and a personal attribution of failure and
blaming oneself for the slip. It is hypothesized that it is
this emotional reaction of guilt and self-blame in
response to violating one’s commitment that leads to
the continued drinking. Continued drinking by an
alcoholic might also be the result of the individual
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believing that one drink leads to a drunk, despite
research evidence to the contrary.
A third major contribution of this study is that the
results failed to support and directly challenged the
disease concept of alcoholism and the absolute goal of
abstinence (Pomerleau, Pertschuk, & Stinnett, 1976).
One drink was found to not necessarily lead invariably
to a drunk. Rather than being a physiologically
regulated process, individual difference variables that
are potentially malleable, such as expectancies and
environmental factors, had a greater impact on drinking
behavior. The implications of this were profound on
many levels. The findings suggested that if one takes a
drink, even after a period of abstinence, it did not
necessarily lead to uncontrolled, unstoppable drinking.
Taken together, the findings suggested that since loss
of control is not an inevitable outcome of taking a
drink, it might be possible to prevent future drinking by
modifying these malleable factors. This notion also
represented a nascent step toward the subsequent
distinction Alan would make between a ‘‘lapse’’ and
a ‘‘relapse’’. The results also challenged the need for
absolute abstinence, a finding that entered into the
emergent controlled drinking debate (Sobell & Sobell,
1995), opened the door for the possibility of non-
abstinent treatment goals (Miller & Caddy, 1977),
presaged the development of harm reduction
approaches (Marlatt, 1998; Marlatt & Witkiewitz,
2002) (also see the article by Blume, this volume)
and subsequent relapse preventive strategies that could
accommodate moderation goals (Larimer & Marlatt,
In addition to its impact on the treatment field, the
impact of this seminal research also was highlighted by
a number of honors. The article by Marlatt et al. (1973)
was featured as a ‘‘Citation Classic’’ in 1985 by
Current Contents: Social and Behavioral Sciences;it
was also featured as a ‘‘Seminal Article in Alcohol
Research’’ in a special 1995 edition of Alcohol Health
and Research World for the 25th Anniversary of the
National Institute on Alcohol Abuse and Alcoholism.
Despite the findings challenging a number of tenets of
the disease model of alcoholism, one tenet of this
model still held true, namely the high rates of relapse
across a variety of addictive behaviors. Hunt, Barnett,
and Branch (1971), pooling the results from 84 studies,
demonstrated that individuals addicted to alcohol,
heroin, or tobacco/nicotine were highly likely to
relapse within the first 90 days after stopping their
use of these substances. Only about 40% of the
individuals were still abstinent at the end of
3 months. The relapse curves were remarkably similar
across alcohol, tobacco, and heroin, suggesting that
there might be commonalities in the factors
contributing to relapse across different drugs of
abuse. It appeared, however, that if one were able to
remain abstinent across this 90-day period, the prob-
ability of relapsing subsequently dropped off consid-
erably. Hunt et al. (1971), deriving a clinical
implication from this finding, indicated that the high
rates of relapse suggested that the then current
treatment approaches were either too brief or ineffi-
cient to produce lasting effects and that the majority of
individuals would benefit from further supportive or
booster therapy following completion of formal
At about the same time that Hunt et al. (1971) were
aggregating research studies on relapse, Alan was in
the process of trying to better understand the factors
associated with relapse by interviewing patients who
had been successful in an abstinence-oriented treatment
program but who subsequently relapsed within 90 days
of their treatment completion. As he and colleagues
reviewed this qualitative data, a pattern of interpersonal
and intrapersonal factors began to emerge as individ-
uals described the circumstances surrounding their
return to drinking. Over time, these initial clinical
observations were formalized through content analysis
into a classification scheme of situational factors and
emotional states that immediately preceded a relapse
(Cummings, Gordon, & Marlatt, 1980; Marlatt, 1978;
Marlatt & Gordon, 1980). The resultant taxonomy of
high-risk relapse situations consisted of eight sub-
categories within two broader domains. The first
domain, Intrapersonal/Environmental Determinants,
included: (a) coping with negative emotional states
such as frustration, anger, and depression; (b) coping
with negative physiological or physical states;
(c) enhancing positive emotional states; (d) testing
personal control or one’s will power using a substance;
and (e) giving in to temptations, urges, or desire to use.
The second domain, Interpersonal Determinants, con-
sisted of (a) coping with interpersonal conflict;
(b) social pressure to use; and (c) enhancing positive
emotional states in the context of interpersonal or
social interactions.
Given the finding by Hunt et al. (1971) about the
similarity of relapse rates across substances of abuse,
Cummings et al. (1980) used this classification scheme
to evaluate the determinants of relapse among alco-
holics, smokers, heroin addicts, gamblers, and uncon-
trolled eaters. The classification system was successful
in capturing the high-risk relapse situations of these
diverse groups of substance abusers and individuals
with behavioral addictions, as well as pointing to
variations in the pattern of the determinants related to
each disorder. In addition to serving as one of the main
components of the RP model, the taxonomy of relapse
determinants also has led to the development of a
number of clinically useful assessment instruments that
evaluate the perceived risk, level of temptation, and the
individual’s confidence of dealing effectively without
drinking or using drugs in such high-risk situations
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(Annis & Graham, 1988, 1991; Annis, Graham, &
Davis, 1987; Annis & Martin, 1985; Annis, Sklar,
& Turner, 1997; Zywiak, Connors, Maisto, &
Westerberg, 1996; Zywiak et al., 2001).
Alan and colleagues reasoned that if these high-risk
situations could be identified and if individuals could
be trained to anticipate them in advance and either
avoid or cope more effectively with them if encoun-
tered, the likelihood of relapse could be reduced. This
was the genesis of RP therapy and one of the
cornerstones of the RP theoretical model.
The theoretical assumptions underlying the emergent
RP model were first tested in a study conducted by
Chaney, O’Leary, and Marlatt (1978). The study was
predicated on one of the major tenets of the RP model,
namely that alcoholics were deficient in the social
skills necessary to cope effectively with stressful or
other high-risk situations (O’Leary, O’Leary, &
Donovan, 1976). The clinical corollary of this was
the belief that training alcoholics in appropriate coping
skills would reduce the likelihood of relapse and
improve overall treatment outcome. The focus on
attempting to help patients learn new adaptive behav-
iors through skills training approaches was relatively
novel in general and had minimal application or
evaluation with problem drinkers or alcoholics at that
point in time. The study addressed two basic questions.
First, can alcoholics’ become more effective in
responding to high-risk situations, if provided specific
training in adaptive coping skills? Second, if alcoholics
do acquire more effective coping and problem-solving
skills through such training, does it have the assumed
positive effect on reducing subsequent drinking
The situations targeted for assessment and training
were based on the high-risk relapse situations identified
by Alan (Marlatt, 1978) and were augmented with
others suggested by treatment staff and patients. A pool
of 80 situations was generated and each situation was
rated by a group of patients with respect to the
difficulty each would present if encountered. From this
process, the eight most difficult situations in four
domains were selected. The domains were consistent
with Alan’s relapse situations taxonomy: (a) frustration
and anger; (b) interpersonal temptation; (c) negative
emotional state; and (d) intrapersonal temptation. Half
of the situations were used as stimuli in the training
process. The others constituted one of the primary
assessment procedures, the Situational Competency
Test (SCT), which was administered both at baseline
and following the treatment phase. Individuals were
presented with hypothetical high-risk relapse situations
and asked to respond verbally as they actually would if
encountering each situation. Their responses were
audiotaped and behaviorally rated by trained judges
for both general and drink refusal-specific skill.
Objective measures (e.g., latency to respond, length
of response) and observer-rated skillfulness or ade-
quacy of the response to resolve the situation without
drinking were assessed.
Rather than training participants in skills to a set of
specific high-risk situations, the focus was on the
development of problem-solving skills that could be
applied across a variety of situations. Using instruction,
modeling, role playing, and coaching, individuals in
the intervention group were trained to use the general
problem-solving steps of problem definition and
formulation, generation of alternatives, and decision
making. Both the actual optimal solutions to the high-
risk situation and the cognitive process for generating
the response were rehearsed. This intervention, which
was delivered in 8 biweekly 90-min sessions in a small
group format, was compared to two comparison
conditions. The first was a discussion control group
in which the same high-risk situations were discussed,
but no behavioral training techniques were employed.
The second comparison condition was comprised of
patients in the same intensive combined inpatient and
day treatment program, who received treatment as
usual without the addition of either the discussion or
skills training incorporated.
The results of the study supported the primary
hypotheses. The acquisition of adaptive coping skills
was evaluated using objective measures derived from
the SCT from baseline to the end of the active
treatment phase and a 3-month follow-up. Patients in
the skills training group had significantly longer
durations of responses (e.g., number of words in the
response) than either comparison group at the end of
the active intervention phase. Members of the skills
training group also had significantly greater specifica-
tion of new/alternative behaviors (e.g., the degree to
which the detail in the person’s description of the
problem-solving behavior to be performed in a high-
risk situation was sufficient so that someone else could
use the description as a guide to perform the behavior)
than either comparison group both at the end of
treatment and still better than the discussion control
group at the 3-month follow-up. The evidence supports
the tenet of the RP approach that individuals can
become more effective in responding to high-risk
situations if provided specific training in adaptive
coping skills.
The results also indicated that patients in the skills
training group, compared to the two control groups
whose data were pooled, had significantly fewer days
drunk (11.0 versus 64.0 days), fewer drinks (399.8
versus 1592.8 drinks), and shorter durations/length of
drinking periods (5.1 versus 44.0 days) over the 12-
month post-treatment follow-up. Thus, the skills train-
ing group had 1/6th the average number of days drunk,
1/4th the number of drinks, and an average drinking
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period length less than 1/8th as long as the combined
comparison groups.
As important, and consistent with the second
question the study was designed to address, it was
found that improvement in social skills assessed by the
SCT at the post-treatment assessment was predictive of
a number of drinking outcomes. In particular, the
response latency measure, which reflects the ability to
quickly generate an alternate response to drinking in a
high-risk situation, was most predictive. Patients with
shorter latencies were employed more, had more days
in continuing care and fewer days hospitalized, more
days of abstinence, fewer days drunk, a smaller number
of drinks consumed, and shorter periods of drinking.
The Chaney et al. (1978) study is important
historically for a number of reasons. First, it served
as the first and one of the primary early empirical
cornerstones for testing and supporting Alan’s RP
theory and RP therapy. It provided evidence that it is
possible to train alcoholics in more adaptive methods
of coping and problem solving when confronted with
high-risk situations, that individuals who received this
training had significantly better treatment outcomes,
and that these improved outcomes are mediated by
increased social competence and coping abilities.
Second, the Situational Confidence Test has served as
a prototype for a number of similar behavioral analog
assessments with alcohol and drug-dependent individ-
uals (e.g., Chaney et al., 1978; Hawkins, Catalano, &
Wells, 1986; Monti, Gulliver, & Myers, 1994; Monti
et al., 1993; Schmitz, Oswald, Damin, & Mattis, 1995;
Wells, Catalano, Plotnick, & Hawkins, 1989), evalu-
ating the type of coping strategies employed (e.g.,
active cognitive, active behavioral, avoidance, help-
seeking) and objective response parameters (latency,
duration, specification, compliance) in response to
potential high-risk relapse situations. Third, the study
stimulated subsequent research to evaluate further the
efficacy of skills training approaches with alcohol and
substance abuse patients (Kadden et al., 1992; Kadden
& Penta, 1995; Longabaugh & Morgenstern, 1999;
Monti et al., 1994; Monti & O’Leary, 1999; Monti,
Rohsenow, Colby, & Abrams, 1995; Monti, Rohsenow,
Michalec, Martin, & Abrams, 1997).
Building on the findings that loss of control is not
inevitable if an alcoholic takes an initial drink (Marlatt
et al., 1973), that it was possible to identify and reliably
categorize relapse determinants and high-risk situations
(Cummings et al., 1980; Marlatt, 1978; Marlatt &
Gordon, 1980), and that improving coping skills
reduces subsequent drinking (Chaney et al., 1978),
the foundation for the RP model was set. A series of
papers presented the initial formulation of the RP
model, both on a theoretical level and with respect to
its clinical implications (Cummings et al., 1980;
Marlatt, 1978; Marlatt & George, 1984; Marlatt &
Gordon, 1980). The model, in its simplest form,
suggests that if an individual encounters high-risk
situations for which he or she does not have available
adequate or appropriate coping skills to deal with the
situational demands, then he or she will experience a
decrease in self-efficacy, the salience of the anticipated
positive outcomes of substance use will increase, and
relapse is more likely to occur. The goal of RP is to
provide individuals with the necessary coping skills to
successfully navigate through such situations without
These early empirical studies and preliminary for-
mulations led up to and contributed to the classic 1985
Marlatt and Gordon edited book, Relapse prevention:
Maintenance strategies in the treatment of addictive
behaviors (Marlatt & Gordon, 1985), which articulated
this theoretical model more fully and provided guid-
ance about its clinical application across a number of
different addictive behaviors.
The impact of the RP model in the substance abuse
field following the publication of the 1985 RP book
was rapid. The publication came at a time when
cognitive-behavioral alternatives to the disease model
of alcoholism and addiction were beginning to emerge.
There was a changing climate, a zeitgeist, in which a
number of assumptions of the traditional conceptual
models and resultant treatment approaches were being
challenged, not without controversy, conflict, and
considerable territorial defensiveness. However, such
challenges and debates, in which dissonance is raised
and leads to an evaluation of the pros and cons of
divergent perspectives and assumptions, often serve as
a source of motivation to change (Miller & Rollnick,
1991), resulting in quantum change (Miller, 2004) and
paradigm shifts (Kuhn, 1970). The basic assumptions
of the RP model that alcoholics and other substance
abusers could potentially prevent relapse, improve
treatment outcomes, and reduce the duration and
negative consequences of a drinking or drug use
episode, if it did occur provided a sense of hope that
had been absent from the treatment field. Clinicians
were eager to adopt and incorporate the underlying
model and the treatment strategies that flowed from it.
There were other models of relapse and RP that
were developing in this same time period (Connors,
Maisto, & Donovan, 1996; Donovan & Chaney, 1985),
most notably that presented by Gorski (1986) and
Gorski and Miller (1979, 1986). This model appealed
to counselors because it maintained and integrated a
number of disease model constructs such as a neuro-
logically based consequence of chronic drinking called
the ‘‘post acute withdrawal (PAW) syndrome’’, which
manifests itself after 1–2 weeks following cessation of
drinking, peaks after 1–1/2 months and subsides over
the next 3 months. This persistent sub-threshold
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withdrawal process increases the risk of relapse and
helps trigger a chain of attitudinal and behavioral
changes that serve as warning signs of the individual
‘‘building up to drink’’. While appealing and popular
with many counselors, Gorski’s model has had limited
scientific evaluation (Bennett et al., 2005; Miller &
Harris, 2000).
The model presented by Marlatt and Gordon gained
prominence both because of its empirical support (e.g.,
what is now called an evidence-based practice) and its
clinical applicability. An important step in the dissem-
ination process was the work of Dennis Daley, which
has always been client-focused and treatment-directed
(Daley, 1986, 1988, 1989, 1998; Daley & Lis, 1995;
Daley & Marlatt, 1992, 1997). Having initially read
Alan’s formulations of the RP model in the early
1980s, and as a result of Alan’s influence and their
subsequent collaboration, Daley became highly
involved in RP both in terms of developing clinical
programs and interventions and disseminating infor-
mation from Alan’s work (as well as that of others in
the area of RP) via writings, videos, and teaching.
A drawback of the RP model as presented in the 1985
text was that while it suggested a number of therapeutic
strategies that could be used in clinical practice, there
was no systematic manualized set of procedures,
although the social skills manual developed and
evaluated by Chaney was available. Daley (1986)
wrote the first workbook for patients, entitled Relapse
Prevention Workbook: For Recovering Alcohol &
Drug Dependence Persons, which operationalized
many of Alan’s concepts and framework on high-risk
factors and was written to help patients become more
educated and skillful in dealing with relapse issues.
This workbook has since been updated several times
(most recently in 2011) and is a widely used patient
recovery guide for programs in the US, Canada, and
Europe. This was followed shortly thereafter by the
first patient educational video on RP, entitled Staying
Sober, Keeping Straight (produced by Gerald
T. Rogers Production, Skokie, III.). This video, which
showed ‘‘vignettes’’ of relapse issues and RP in action,
was used in many treatment programs in the US and
other countries. Several years later, a video showing
examples of individuals using RP strategies in their
recovery was developed for therapists as part of a
‘‘Mentor’’ series for clinicians on select clinical topics.
Daley also developed a manual for therapists that
provided background information about the RP model
and a detailed curriculum for a 12-session group-based
RP intervention that was used with the accompanying
interactive workbook for clients (Daley, 1986). This
intervention was implemented initially in an inpatient
rehabilitation program; it has subsequently been
adapted and used in detoxification, therapeutic com-
munity, halfway house, intensive outpatient, outpatient,
and aftercare settings with individuals dependent on a
variety of different substances (Daley & Douaihy,
2011). Many of Daley’s publications targeted and were
published in journals for social workers, counselors,
and other treatment providers (Daley, 1987, 1988;
Daley & Lis, 1995). Alan and Dennis worked together
on a number of book chapters and books over the years
(Daley & Marlatt, 1992, 1997), a tremendous combi-
nation and blending of a brilliant theoretician and a
skilled practitioner and program implementer. The
most recent edition of the counselor manual (Daley &
Douaihy, 2011), which was published in the summer of
2011, is dedicated to Alan.
Subsequently, a number of other manuals that
incorporated social skills training and other cognitive-
behavioral components of the RP model have been
published, including those by Monti and colleagues
(Monti, Abrams, Kadden, & Cooney, 1989; Monti,
Kadden, Rohsenow, Cooney, & Abrams, 2002) and the
Project MATCH research group (Kadden et al., 1992)
focusing on alcohol dependence and by Carroll (1998)
for use with cocaine-dependent individuals. The
National Institute on Drug Abuse (NIDA), in addition
to publishing Carroll’s manual, also has one of its
Research Dissemination and Application Packages
devoted to RP. Among the materials included in this
package, published in 1993, is an introduction to RP, a
handbook for program administrators that discusses
issues involved in implementing a RP program, and an
in-service training curriculum for counselors.
The Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Center of Substance
Abuse Treatment (CSAT) has published manuals on
RP approaches for use with chemically dependent
individuals in the criminal justice system and group-
based RP interventions for older adult substance
abusers. The work of CSAT’s network of regional
Addiction Technology Transfer Centers has also been
instrumental in the training of front-line counseling
staff and the dissemination and implementation of RP
approaches in a variety of treatment settings throughout
the US.
In coming nearly full circle, Hunt and colleagues
over 40 years ago indicated that the relapse curves they
found across substances suggested that the then current
treatment approaches were either too brief or ineffi-
cient to produce lasting effects and that the further
supportive or booster sessions following completion of
formal treatment would be potentially beneficial (Hunt
et al., 1971). Over the more recent past, there has once
again been a focus on alcohol and drug dependence as
chronic conditions (McLellan, 2002; McLellan, Lewis,
O’Brien, & Kleber, 2000), with the implication that a
chronic-disease management approach that provides
some form of continuing care is needed to monitor and
adequately address the fluctuations in symptom man-
ifestations across time. Continuing care for substance
use disorders is very consistent with and incorporates
elements of a RP approach, given its emphasis on the
maintenance of behavior change and the development
of a balanced and healthy lifestyle (Donovan, 1998; Ito
& Donovan, 1986; Ito, Donovan, & Hall, 1988;
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McKay, 2006; McKay et al., 2009). While often
individuals are trained in and initially acquire
relapse-reducing coping skills during the course of a
treatment episode, it is after leaving treatment that
these skills will be more fully practiced, consolidated,
and also put to the test as the individual encounters
potential high-risk situations in his or her daily life. It is
often after treatment that the effects of RP efforts begin
to emerge. The addition of periodic monitoring of how
one is doing and focusing on relapse ‘‘warning signs’’
(Stout, Rubin, Zwick, Zywiak, & Bellino, 1999),
quarterly recovery management checkups to assess
current status and provide rapid linkage to care if
needed (Scott & Dennis, 2009; Scott, Dennis, & Foss,
2005), and ongoing continuing care services, the
intensity/frequency of which is adjusted based on
clients’ changing clinical needs (McKay, 2005, 2006),
are all ways to facilitate long-term client engagement,
extend the benefits of treatment, reduce the likelihood
of relapse, and intervene more rapidly if relapse does
RP 2005–2011
In preparing the first chapter of the second edition of
the Marlatt and Gordon classic text on RP, it became
clear that there was a drastic shift in the attitude toward
relapse in the 20 years since the first edition. One of the
most important advances since 1985 was the acknowl-
edgement that a ‘‘lapse’’ was not necessarily equiva-
lent to a ‘‘relapse’’, where lapses are defined as a
single transgression of a problematic behavior and
relapse has been defined as a process of change
(Witkiewitz & Marlatt, 2007a, b). Several authors have
discussed the clinical course of substance use disorders
as being highly heterogeneous between and within
individuals over time (Genberg et al., 2011; Maisto,
Clifford, Stout, & Davis, 2007; McKay, 2009;
Witkiewitz, Maisto, & Donovan, 2010). For example,
Genberg et al. (2011) studied the course of injection
drug use across 20 years in a community sample of
injection drug users in the Baltimore area and found
that 32% of individuals were persistent drug users over
the 20 years, 16% had frequent lapses intertwined with
periods of abstinence, and 53% ceased drug use and
maintained abstinence. Witkiewitz and Masyn (2008)
examined alcohol trajectories for a year following
treatment and found that 30% of individuals abstained
from drinking for the entire year. Among those who did
have a lapse, only 6% continued to engage in heavy
drinking for the year following treatment, whereas 82%
drank infrequently and 12% engaged in heavy drinking
for a few months before returning to abstinence or light
drinking near the end of the 1-year follow-up.
These examples and the two decades of research
preceding the publication of the RP text in 2005
provide strong support for the notion of relapse as a
process, rather than a discrete event. Following up on
this notion, Marlatt and Witkiewitz began to work on a
revised model of relapse as a dynamic process. The
hypothetical dynamic model of relapse advanced the
notion that the relapse process could be predicted from
the interaction between background risk factors (e.g.,
family history) and contextually bound factors that
change dynamically in the moment (e.g., negative
affect). Initially proposed in 2004 (Witkiewitz &
Marlatt, 2004), the dynamic model of relapse was
derived from the principles of non-linear dynamical
systems theory. Specifically, it was proposed that the
course of substance use following a period of absten-
tion or reduced use could be modeled as a non-linear
dynamical system. Subsequently, several empirical
studies provided evidence in support of a non-linear
dynamical systems approach to analyzing the alcohol
relapse process (Hufford, Witkiewitz, Shields, Kodya,
& Caruso, 2003; Witkiewitz & Marlatt, 2007a, b;
Witkiewitz, van der Maas, Hufford, & Marlatt, 2007;
Witkiewitz & Villarroel, 2009).
Enthusiasm for the dynamic model of relapse
(Hunter-Reel, McCrady, & Hildebrandt, 2009;
Stanton, 2005) has led to several new research studies
that are currently in progress or in the planning stages.
For example, William Shadel and colleagues (NIH
grant no. R01-CA127491) are examining whether the
dynamic model can be used to explain the transition
from an experimentally manipulated smoking lapse to
regular smoking following a period of abstinence.
Stephen Maisto and colleagues (NIH grant no. R01-
AA017701) are examining the interaction among
interpersonal stress, affect regulation, and alcohol use
in a dynamic model of relapse. Likewise, proposed
studies to expand the statistical methodology for
examining relapse as a dynamical system and to
evaluate relapse as a dynamical system within the
context of momentary assessment data are currently
under review at NIH.
The second edition of RP also discussed the
application of RP principles and techniques to diverse
populations (Blume & de la Cruz, 2005) and non-
substance using high-risk behaviors (Collins, 2005;
Zawacki, Stoner, & George, 2005). The original
cognitive-behavioral model of relapse was largely
based on the experiences of 70 white males who
received treatment for alcohol dependence (Marlatt,
1978); thus, it was important to examine whether the
model and treatment could be expanded to individuals
who were from a different ethnic/racial background,
females, and to other high-risk behaviors.
Blume and de la Cruz (2005) noted that more
research needs to be done evaluating the efficacy of RP
among ethnic minority communities and also advo-
cated for examining the biopsychosocial model of
relapse within different cultures. The authors also
noted that many aspects of the RP model might be
appealing to ethnically and racially diverse cultures
and small adaptations may be sufficient to provide
culturally tailored care. For example, Simmons, Cruz,
Brandon, and Quinn (2011) recently adapted a smoking
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RP program for pregnant and postpartum women,
which was originally tailored for non-Hispanic women,
to a sample of pregnant and postpartum Hispanic
women. The multi-stage project identified three major
areas that required program modification in order to be
tailored to the concerns of Hispanic women, namely
the lack of concern for weight gain, the importance of
family approval, and attention to the stress associated
with immigration experiences. Similarly McNair
(2005) noted that RP for African American clients
would benefit from an increased focus on triggers
related to racism and racial discrimination, which often
pose a high-risk situation for African Americans.
Another recent study found that some RP skills,
namely drink refusal skills training, may be more
beneficial to African American clients than non-
Hispanic white clients (Witkiewitz, Villarroel,
Hartzler, & Donovan, 2011). It is noteworthy that
cultural influences were not incorporated into the
original model of relapse proposed by Marlatt and
Gordon (1985), nor were they included in the revised
dynamic model of relapse (Witkiewitz & Marlatt,
2004). Future research should be conducted to examine
the influence of cultural factors (for both majority and
minority cultures) on the relapse process (Blume &
de la Cruz, 2005).
Another population that has been the focus of
adaptations to RP is among adolescents (Liddle &
Rowe, 2006). It has been estimated that approximately
80% of adolescents return to some level of substance
use within the first 6 months after community-based
substance abuse treatment (Brown, D’Amico,
McCarthy, & Tapert, 2001). Ramo, Myers, and
Brown (2007) adapted both the model of relapse and
the RP intervention for the treatment of adolescents
with substance use disorders. The ‘‘youth addiction
relapse model’’ (p. 297) (Ramo et al., 2007) expands
on the original cognitive-behavioral model of relapse
by incorporating motivational issues, neurocognitive
development, psychiatric comorbidity, information
processing patterns, and environmental constraints
that are all specific to adolescent populations. Ramo
et al. (2007) also noted an increased need for family
involvement, initially to help the therapist identify
family-level high-risk situations and in the latter part of
treatment, to incorporate the family into reinforcement/
punishment contingency planning and into discussions
of lifestyle balance.
RP was initially targeted explicitly for the treatment
of alcohol and other drug problems. However, as Alan
(Marlatt & Gordon, 1985) noted early on, the RP model
may have applications that extend beyond the tradi-
tional categories of substance use disorders: ‘‘Habit
patterns such as excessive drinking, smoking, overeat-
ing, or substance abuse may be considered as a subclass
of a larger set of what we refer to as addictive
behaviors. The category of addictive behaviors may be
expanded to include any compulsive habit pattern in
which the individual seeks a state of immediate
gratification’’ (pp. 3–4). The concept has been
expanded further to focus on strategies facilitating the
maintenance of change in a broad range of behaviors.
Consistent with this expanded scope, the RP model has
since been extended to the treatment of sexual offend-
ing (Laws, 1989; Laws, Hudson, & Ward, 2002), eating
disorders (Collins, 2005), and a number of other health
behaviors. A particularly novel early adaptation was
done by Marx (1982, 1986), an organizational psy-
chologist, who applied the RP model to the acquisition
and maintenance of adaptive managerial behaviors in
the business world.
Today, the term ‘‘RP’’ is ubiquitous in the addic-
tion, mental health, and behavioral health fields (e.g.,
entering the term ‘‘RP’’ into PubMed resulted in
39,678 entries), and aspects of the original model of
relapse are incorporated into psychological treatments
for numerous behaviors and disorders (Witkiewitz &
Marlatt, 2007a, b). The 2005 RP book (Marlatt &
Donovan, 2005) also described RP techniques for
obesity and eating disorders (Collins, 2005), gambling
(Shaffer & LaPlante, 2005) and sexual risk taking
(Zawacki et al., 2005). Witkiewitz and Marlatt
(2007a, b) expanded the scope of RP even further in
the edited book, titled ‘‘Therapist’s Guide to Evidence-
Based RP’’, which incorporated chapters on the
treatment of depression (Lau & Segal, 2007), general-
ized anxiety disorder (Whiteside et al., 2007),
schizophrenia (Ziedonis, Yanos, & Silverstein, 2007),
post-traumatic stress disorder (Najavits, 2007), eating
disorders (Schlam & Wilson, 2007), and self-injurious
behavior (Brown & Chapman, 2007).
To date, there have been numerous meta-analyses and
narrative reviews that have either explicitly examined
the efficacy and effectiveness of ‘‘RP’’ (Agboola,
McNeill, Coleman, & Leonardi Bee, 2010; Carroll,
1996; Hajek, Stead, West, Jarvis, & Lancaster, 2009;
Irvin, Bowers, Dunn, & Wang, 1999) or have examined
treatments that incorporate components of RP (Magill
& Ray, 2009; McCrady, 2000; Miller & Wilbourne,
2002). Based on this research and other studies RP is
currently identified as an evidence-based program by
the United State SAMHSA National Registry of
Evidence-Based Programs and Practices (http://nrepp.-, last accessed 9/7/2011).
In one of the earliest studies, Carroll (1996)
conducted a narrative review of controlled clinical
trials evaluating RP in the treatment of smoking,
alcohol, and other drug use. Across substances, RP was
found to be generally effective compared with no
treatment and as good as other active treatments. One
interesting finding was that some RP treatment out-
come studies identified sustained main effects for RP,
suggesting that RP may provide continued improve-
ment over a longer period of time (indicating a
‘‘delayed emergence effect’’), whereas other
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treatments may be effective over only a shorter
duration. This delayed emergence effect is consistent
with the skills acquisition basis of the RP approach. As
with learning any new skill, clients become more
experienced in acquiring and performing the skill,
leading to overall improvements in performance over
Irvin et al. (1999) conducted a meta-analysis on the
efficacy of RP techniques in the improvement of
substance abuse and psychosocial outcomes. Twenty-
six studies representing a sample of 9504 participants
were included in the review, which focused on alcohol
use, smoking, polysubstance use, and cocaine use. The
overall treatment effects demonstrated that RP was a
successful intervention for reducing substance use and
improving psychosocial adjustment. Although these
results are promising, as noted in a recent review by
Hendershot, Witkiewitz, George, and Marlatt (2011),
since RP has evolved into a general term for interven-
tions that aim to prevent relapse, it is fairly difficult to
systematically evaluate the efficacy and effectiveness
of RP, as originally described by Marlatt and Gordon
Notably, cognitive-behavioral treatment manuals for
a variety of psychological disorders incorporate com-
ponents of the original model of relapse put forward by
Marlatt and Gordon (1985). In a recent meta-analysis
by Magill and Ray (2009), who evaluated 53 controlled
trials of CBT for substance use disorders, the authors
noted that the CBT studies evaluated in their review
were based on the RP model. Overall, the results from
their meta-analysis were consistent with the review
conducted by Irvin and colleagues, with 58% of
individuals who received CBT having better outcomes
than those in comparison conditions. Furthermore,
treatments that were ranked among the top 10 of
treatments for alcohol use disorders based on treatment
effect sizes and methodological quality (Miller &
Wilbourne, 2002), including brief interventions, social
skills training, community reinforcement, behavioral
contracting, behavioral marital therapy, and self-
monitoring, incorporate aspects of RP and are largely
based on a cognitive-behavioral model of relapse. It is
noteworthy that since the passing of Alan Marlatt, the
developers of some of the most effective treatments for
substance use disorders have spoken candidly about
Alan’s influence on their work and the field of
addictive behaviors. Some informally via email and
discussion at conferences, others have spoken out
formally in the writing of obituaries in prominent
journals. McCrady (2011) noted that ‘‘Marlatt’s RP
model dramatically changed the way the treatment
community conceptualized relapse’’ (p. 1015).
As noted in an obituary for Alan Marlatt by Miller and
McLellan (2011) ‘‘He departed suddenly and too
soon’’, which is evident in the fact that he was still
actively conducting research, accepting graduate stu-
dents, and applying for new research funding. Just prior
to his passing, he was in the process of completing a
randomized controlled trial evaluating the efficacy of
RP and mindfulness-based RP in comparison to
standard aftercare for the treatment of substance use
disorders (This is discussed further in the article by
Bowen, this volume). In many ways, this final study
represented the culmination of Alan’s work over the
past 30 years in that he was initially interested in the
effects of meditation on substance abuse in the late
1970s, devoted much of his career through the 1980s
and 1990s to disseminating RP, and then developed
mindfulness-based RP in the 2000s. Preliminary results
from that trial look promising and suggest that RP and
mindfulness-based RP are both more efficacious than
standard aftercare. Interestingly this trial, which would
be Alan’s last research project, was the first random-
ized controlled trial evaluating the efficacy of RP
conducted within Alan’s laboratory. Thus, Alan pro-
posed the RP intervention, but never evaluated the
intervention within the context of a randomized trial
until his final days. His lack of direct control over prior
studies of RP eliminated the potential experimenter
bias that can come when several trials of a particular
treatment are conducted within the same laboratory.
Fortunately, many other researchers are continuing
Alan’s work. A quick search of the National Institutes
of Health grant database (,
last accessed 9/7/2011) identified the keyword ‘‘RP’’
in 106 currently funded research studies. With research
topics that vary from RP delivered using virtual reality
technology (R42AA014312, Bordnick, PI) to RP
booklets for tobacco cessation (R01CA137357,
Brandon, PI) to the development of RP interventions
for pregnant drug abusers (R01DA014979, Chisolm,
PI) and postpartum tobacco users (R01CA140310,
Danaher, PI). Interestingly, a good deal of recently
funded RP research focuses on animal studies of
addictive behavior processes and pharmacotherapy.
Alan was publicly skeptical of animal models of
relapse (Marlatt, 2002) most notably for the lack of
external validity in animal models of drug use ‘‘rein-
statement’’, which often does not involve voluntary
goal-directed behavior toward obtaining an addictive
substance. He was also concerned about over-reliance
on pharmacotherapy, noting that behavioral relapse
processes require behavioral intervention to produce
enduring change. It is of note in this regard that the
COMBINE study, (Anton et al., 2006), while demon-
strating the efficacy of naltrexone on reducing drinking
during the active treatment phase, found an emergent
effect for the Combined Behavioral Intervention (CBI),
which incorporated a number of components from RP,
during the follow-up period (Donovan et al., 2008);
participants who had received CBI, regardless of their
medication condition, were approximately 20% more
likely to have had a good clinical outcome over the
1-year post-treatment period than individuals who did
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not receive CBI. Near the end of his career, Alan
observed these changes at the same time that he
observed fewer behavioral studies of human relapse
being funded by the National Institutes of Health.
Nonetheless, a number of individuals including numer-
ous former students and friends of Alan are still
committed to human research. In the words of Alan, we
hope that the currently funded studies will ‘‘Bridge the
gap between animal and human models of drug use and
highlight the significance of both behavioral and
environmental determinants of relapse’’ (Marlatt,
2002, p. 359).
The influence of RP on the treatment of addictive
behaviors and on our thinking about relapse is beyond
measure. Yet, it takes a retrospective to appreciate the
sea change in beliefs that were brought about by Alan
Marlatt’s tireless devotion to the prevention of relapse.
Alan worked throughout his entire career promoting
the scientific study of addiction, trying to provide hope
to those with addictive behaviors, disseminating RP,
and spending countless hours training fellow clinicians
and his students. The clinicians that he trained will
continue to implement RP with their clients and will
provide training to future clinicians. Alan’s students
will continue to push the field forward and will also
train the next generation of addictive behaviors
researchers. We have seen and been part of a quantum
change in the addictions, led by a true visionary and
luminary in the field. We will continue to move
forward, since we have learned how to successfully
prevent falling back.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the article.
Agboola, S., McNeill, A., Coleman, T., & Leonardi Bee, J.
(2010). A systematic review of the effectiveness of smoking
relapse prevention interventions for abstinent smokers.
Addiction, 105, 1362–1380.
Annis, H.M., & Graham, J.M. (1988). Situational confidence
questionnaire user’s guide. Toronto: Addiction Research
Foundation of Ontario.
Annis, H.M., & Graham, J.M. (1991). Inventory of Drug-Taking
Situations (IDTS): User’s guide. Toronto: Addiction Research
Annis, H.M., Graham, J.M., & Davis, C.S. (1987). Inventory of
Drinking Situations (IDS): User’s guide. Toronto: Addiction
Research Foundation.
Annis, H.M., & Martin, G. (1985). The drug-taking confidence
questionnaire. Toronto: Addiction Research Foundation of
Annis, H.M., Sklar, S.M., & Turner, N.E. (1997). The drug-
taking confidence questionnaire user’s guide. Toronto:
Addiction Research Foundation of Ontario.
Anton, R.F., O’Malley, S.S., Ciraulo, D.A., Cisler, R.A.,
Couper, D., Donovan, D.M., Zweben, A., ..., COMBINE
Study Research Group (2006). Combined pharmacotherapies
and behavioral interventions for alcohol dependence: The
COMBINE study. A randomized controlled trial. Journal of
the American Medical Association, 295, 2003–2017.
Bennett, G.A., Withers, J., Thomas, P.W., Higgins, D.S.,
Bailey, J., Parry, L., & Davies, E. (2005). A randomised
trial of early warning signs relapse prevention training in the
treatment of alcohol dependence. Addictive Behaviors, 30,
Blume, A.W., & de la Cruz, B.G. (2005). Relapse
prevention among diverse populations. In G.A. Marlatt &
D.M. Donovan (Eds.), Relapse prevention: Maintenance
strategies in the treatment of addictive behaviors (2nd ed.,
pp. 45–64). New York, NY: Guilford Press.
Brown, M.Z., & Chapman, A.L. (2007). Stopping self-harm
once and for all: Relapse prevention in dialectical behavior
therapy. In K.A. Witkiewitz & G.A. Marlatt
(Eds.), Therapist’s guide to evidence-based relapse preven-
tion (pp. 191–213). San Diego, CA: Elsevier Academic Press.
Brown, S.A., D’Amico, E.J., McCarthy, D.M., & Tapert, S.F.
(2001). Four-year outcomes from adolescent alcohol and drug
treatment. Journal of Studies on Alcohol, 62, 381–388.
Brown, S.A., Goldman, M.S., Inn, A., & Anderson, L.R. (1980).
Expectations of reinforcement from alcohol: Their domain
and relation to drinking patterns. Journal of Consulting and
Clinical Psychology, 48, 419–426.
Carroll, K.M. (1996). Relapse prevention as a psychosocial
treatment: A review of controlled clinical trials. Experimental
and Clinical Psychopharmacology, 4, 46–54.
Carroll, K.M. (1998). Therapy manuals for drug addiction.
Manual 1: A cognitive-behavioral approach: Treating
cocaine addiction. Washingrton, DC: National Institute on
Drug Abuse.
Chaney, E.F., O’Leary, M.R., & Marlatt, G.A. (1978). Skill
training with alcoholics. Journal of Consulting and Clinical
Psychology, 46, 1092–1104.
Collins, R.L. (2005). Relapse prevention for eating disorders and
obesity. In G.A. Marlatt & D.M. Donovan (Eds.), Relapse
prevention: Maintenance strategies in the treatment of
addictive behaviors (2nd ed., pp. 248–275). New York, NY:
Guilford Press.
Connors, G.J., Maisto, S.A., & Donovan, D.M. (1996).
Conceptualizations of relapse: A summary of psychological
and psychobiological models. Addiction, 91, 5–13.
Cummings, C., Gordon, J.R., & Marlatt, G.A. (1980). Relapse:
Strategies of prevention and prediction. In W.R. Miller
(Ed.), The addictive behaviors (pp. 291–321). Elmsford,
NY: Pergamon Press.
Daley, D.C. (1986). Relapse prevention workbook for recover-
ing alcoholics and drug dependent persons. Holmes Beach,
FL: Learning.
Daley, D.C. (1987). Relapse prevention with
substance abusers: Clinical issues and myths. Social Work,
32, 138–142.
Daley, D.C. (1988). Relapse prevention: Treatment alternatives
& counseling aids. Bradenton, FL: Human Services Press.
Daley, D.C. (1989). Relapse: Conceptual, research and clinical
perspectives. New York, NY: Haworth Press.
Addict Res Theory Downloaded from by yaffa tzubery on 01/21/12
For personal use only.
Daley, D.C. (1998). Kicking addictive habits once and for all: A
relapse-prevention guide. San Francisco, CA: Jossey-Bass.
Daley, D.C., & Douaihy, A. (2011). Relapse prevention
counseling: Strategies to aid recovery from addiction and
reduce relapse risk. Murrysville, PA: Daley.
Daley, D.C., & Lis, J.A. (1995). Relapse prevention:
Intervention strategies for mental health clients with comorbid
addictive disorders. In A.M. Washton (Ed.), Psychotherapy
and substance abuse: A practitioner’s handbook (pp. 243–
263). New York, NY: Guilford Press.
Daley, D.C., & Marlatt, G.A. (1992). Relapse prevention:
Cognitive and behavioral interventions. In J.H. Lowinson,
P. Ruiz, R.B. Millman, & J.G. Langrod (Eds.), Substance
abuse: A comprehensive textbook (2nd ed., pp. 533–542).
Baltimore, MD: Williams & Wilkins.
Daley, D.C., & Marlatt, G.A. (1997). Relapse prevention.
In J.H. Lowinson, P. Ruiz, R.B. Millman, &
J.G. Langrod (Eds.), Substance abuse: A comprehensive
textbook (pp. 458–467). Baltimore, MD: Williams &
Donovan, D.M. (1998). Continuing care: Promoting the main-
tenance of change. In W.R. Miller & N. Heather
(Eds.), Treating addictive behaviors (2nd ed., pp. 317–336).
New York, NY: Plenum Press.
Donovan, D.M., Anton, R.F., Miller, W.R., Longabaugh, R.,
Hosking, J.D., & Youngblood, M. (2008). Combined
pharmacotherapies and behavioral interventions for alcohol
dependence (The COMBINE Study): Examination of post-
treatment drinking outcomes. Journal of Studies on Alcohol
and Drugs, 69, 5–13.
Donovan, D.M., & Chaney, E.F. (1985). Alcoholic relapse
prevention and intervention: Models and methods.
In G.A.M.J.R. Gordon (Ed.), Relapse prevention:
Maintenance strategies in the treatment of addictive beha-
viors (pp. 351–416). New York, NY: Guilford Press.
Donovan, D.M., & Marlatt, G.A. (1980). Assessment of
expectancies and behaviors associated with alcohol consump-
tion. A cognitive–behavioral approach. Journal of Studies on
Alcohol, 41, 1153–1185.
Enck, P., Klosterhalfen, S., & Zipfel, S. (2011). Novel study
designs to investigate the placebo response. BMC Medical
Research Methodology, 11, 90.
Genberg, B.L., Gange, S.J., Go, V.F., Celentano, D.D.,
Kirk, G.D., & Mehta, S.H. (2011). Trajectories of injection
drug use over 20 years (1988–2008) in Baltimore, Maryland.
American Journal of Epidemiology, 173, 829–836.
Goldman, M.S., Brown, S.A., & Chritiansen, B.A. (1987).
Expectancy theory: Thinking about drinking.
In H.T.B.K.E. Leonard (Ed.), Psychological theories of
drinking and alcoholism (pp. 181–226). New York, NY:
Guilford Press.
Gorski, T.T. (1986). Relapse prevention planning: A new recovery
tool. Alcohol Health and Research World, 11, 6–11, 63.
Gorski, T.T., & Miller, M. (1979). Counseling for relapse
prevention. Hazel Crest, IL: Alcoholism Systems Associates.
Gorski, T.T., & Miller, M. (1986). Staying sober: A guide for
relapse prevention. Independence, MO: Independence Press.
Hajek, P., Stead, L.F., West, R., Jarvis, M., & Lancaster, T.
(2009). Relapse prevention interventions for smoking
cessation. Cochrane Database of Systematic Reviews, 1,
Hawkins, J.D., Catalano, R.F., & Wells, E.A. (1986). Measuring
the effects of a skills training intervention for drug abusers.
Journal of Consulting and Clinical Psychology, 54, 661–664.
Hendershot, C.S., Witkiewitz, K., George, W.H., &
Marlatt, G.A. (2011). Relapse prevention for addictive
behaviors. Substance Abuse Treatment, Prevention, and
Policy, 6. DOI: 10.1186/1747-597X-6-1.
Hufford, M.R., Witkiewitz, K., Shields, A.L., Kodya, S., &
Caruso, J.C. (2003). Relapse as a nonlinear dynamic system:
Application to patients with alcohol use disorders. Journal of
Abnormal Psychology, 112, 219–227.
Hunt, W., Barnett, L., & Branch, L. (1971). Relapse rates in
addiction programs. Journal of Clinical Psychology, 27,
Hunter-Reel, D., McCrady, B., & Hildebrandt, T. (2009).
Emphasizing interpersonal factors: An extension of the
Witkiewitz and Marlatt relapse model. Addiction, 104,
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,
Ito, J.R., & Donovan, D.M. (1986). Aftercare in alcoholism
treatment: A review. In W.R. Miller & N. Heather (Eds.), The
addictive behaviors: Processes of change (pp. 435–456).
New York, NY: Plenum Press.
Ito, J.R., Donovan, D.M., & Hall, J.J. (1988). Relapse prevention
in alcohol aftercare: Effects on drinking outcome, change
process, and aftercare attendance. British Journal of
Addictions, 83, 171–181.
Juliano, L.M., & Brandon, T.H. (2002). Effects of nicotine dose,
instructional set, and outcome expectancies on the subjective
effects of smoking in the presence of a stressor. Journal of
Abnormal Psychology, 111, 88–97.
Kadden, R.M., Carroll, K., Donovan, D., Cooney, N.,
Monti, P.M., Abrams, D., ..., Hester, R. (1992). Cognitive
behavioral coping skills therapy manual: A clinical research
guide for therapists treating individuals with alcohol abuse
and dependence (Vol. 3). Rockville, MD: National Institute
on Alcohol Abuse and Alcoholism.
Kadden, R.M., & Penta, C.R. (1995). Structured inpatient
treatment: A coping-skills training approach.
In A.M. Washton (Ed.), Psychotherapy and substance
abuse: A practitioner’s handbook (pp. 295–313). New York,
NY: Guilford Press.
Kuhn, T.S. (1970). The structure of scientific revolutions
(2nd ed.). Chicago, IL: The University of Chicago Press.
Larimer, M.E., & Marlatt, G.A. (1990). Applications of relapse
prevention with moderation goals. Journal of Psychoactive
Drugs, 22, 189–195.
Lau, M.A., & Segal, Z.V. (2007). Mindfulness-based cognitive
therapy as a relapse prevention approach to depression.
In K.A. Witkiewitz & G.A. Marlatt (Eds.), Therapist’s guide
to evidence-based relapse prevention (pp. 73–90). San Diego,
CA: Elsevier Academic Press.
Laws, D.R. (1989). Relapse prevention with sex
offenders. New York, NY: Guilford Press.
Laws, D.R., Hudson, S.M., & Ward, T. (2002). Remaking
relapse prevention with sex offenders: A sourcebook and
Practice standards and guidelines for members of the
Association for the Treatment of Sexual Abusers (ATSA).
Journal of Psychiatry and Law, 30, 285–292.
Liddle, H.A., & Rowe, C.L. (2006). Adolescent substance
abuse: Research and clinical advances. New York, NY:
Cambridge University Press.
Longabaugh, R., & Morgenstern, J. (1999). Cognitive-behavioral
coping-skills therapy for alcohol dependence. Current
Addict Res Theory Downloaded from by yaffa tzubery on 01/21/12
For personal use only.
status and future directions. Alcohol Research and Health, 23,
Lotshaw, S.C., Bradley, J.R., & Brooks, L.R. (1996). llustrating
caffeine’s pharmacological and expectancy effects utilizing a
balanced placebo design. Journal of Drug Education, 26,
Magill, M., & Ray, L.A. (2009). Cognitive-behavioral treatment
with adult alcohol and illicit drug users: A meta-analysis of
randomized controlled trials. Journal of Studies on Alcohol
and Drugs, 70, 516–527.
Maisto, S.A., Clifford, P.R., Stout, R.L., & Davis, C.M. (2007).
Moderate drinking in the first year after treatment as a
predictor of three-year outcomes. Journal of Studies on
Alcohol and Drugs, 68, 419–427.
Marlatt, G.A. (1978). Craving for alcohol, loss of control, and
relapse: A cognitive-behavioral analysis. In P.E. Nathan,
G.A. Marlatt, & T. Loberg (Eds.), Alcoholism: New directions
in resaerch anad treatment (pp. 271–314). New York, NY:
Plenum Press.
Marlatt, G.A. (1985). Relapse prevention: Theoretical rationale
and overview of the model. In G.A. Marlatt & J.R. Gordon
(Eds.), Relapse prevention: Maintenance strategies in the
treatment of addictive behaviors (pp. 3–70). New York, NY:
Guilford Press.
Marlatt, G.A. (Ed.). (1998). Harm reduction: Pragmatic
strategies for managing high-risk behaviors. New York,
NY: Guilford Press.
Marlatt, G.A. (2002). Do animal models provide a valid
analogue for human drug lapse and relapse? Comment on
Leri and Stewart (2002). Experimental and Clinical
Psychopharmacology, 10, 359–360, discussion 364–356.
Marlatt, G.A., Demming, B., & Reid, J.B. (1973). Loss of
control drinking in alcoholics: An experimental analogue.
Journal of Abnormal Psychology, 81, 233–241.
Marlatt, G.A., & Donovan, D.M. (1981). Alcoholism and drug
dependence: Cognitive social learning factors in addictive
behaviors. In E.W. Craighead, A.E. Kazdin, & M.J. Mahoney
(Eds.), Behavior modification: Principles, issues, and appli-
cations (2nd ed., pp. 264–285). Boston, MA: Houghton
Marlatt, G.A., & Donovan, D.M. (1982). Behavioral psychology
approaches to alcoholism. In E.M. Pattison & E. Kaufman
(Eds.), Encyclopedic handbook of alcoholism (pp. 560–577).
New York, NY: Gardner Press.
Marlatt, G.A., & Donovan, D.M. (2005). Relapse
prevention: Maintenance strategies in the treatment of
addictive behaviors (2nd ed.). New York, NY:
Guilford Press.
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. (1980). Determinants of relapse:
Implications for the maintenance of behavior change.
In P.O. Davidson & S.M. Davidson (Eds.), Behavioral
medicine: Changing health lifestyles (pp. 1410–1452).
New York, NY: Brunner/Mazel.
Marlatt, G.A., & Gordon, J.R. (Eds.). (1985). Relapse preven-
tion: Maintenance strategies in the treatment of addictive
behaviors. New York, NY: Guilford Press.
Marlatt, G.A., & Rohsenow, D.J. (1980). Cognitive processes in
alcohol use: Expectancy and the balanced placebo design.
In N.K. Mello (Ed.), Advances in substances abuse:
Behavioral and biological research (Vol. 1, pp. 159–199).
Greenwich, CT: JAI Press.
Marlatt, G.A., & Witkiewitz, K. (2002). Harm reduction
approaches to alcohol use: Health promotion, prevention,
and treatment. Addictive Behaviors, 27, 867–886.
Marx, R.D. (1982). Relapse prevention for managerial training:
A model for maintenance of behavior change. The Academy of
Management Review, 7, 433–441.
Marx, R.D. (1986). Improving management development
through relapse prevention strategies. Journal of
Management Development, 5, 27–40.
McCrady, B.S. (2000). Alcohol use disorders and the Division
12 Task Force of the American Psychological Association.
Psychology of Addictive Behaviors, 14, 267–276.
McCrady, B. (2011). In remembrance: G. Alan Marlatt.
Alcoholism: Clinical and Experimental Research, 35,
McKay, J.R. (2005). Is there a case for extended interventions
for alcohol and drug use disorders? Addiction, 100,
McKay, J.R. (2006). Continuing care in the treatment of
addictive disorders. Current Psychiatry Reports, 8, 355–362.
McKay, J.R. (2009). Continuing care research: What we have
learned and where we are going. Journal of Substance Abuse
Treatment, 36, 131–145.
McKay, J.R., Carise, D., Dennis, M.L., Dupont, R.,
Humphreys, K., Kemp, J., ..., Schwartzlose, J. (2009).
Extending the benefits of addiction treatment: Practical
strategies for continuing care and recovery. Journal of
Substance Abuse Treatment, 36, 127–130.
McLellan, A.T. (2002). Have we evaluated addiction treatment
correctly? Implications from a chronic care perspective.
Addiction, 97, 249–252.
McLellan, A.T., Lewis, D.C., O’Brien, C.P., & Kleber, H.D.
(2000). Drug dependence, a chronic medical illness:
Implications for treatment, insurance, and outcomes evalua-
tion. The Journal of the American Medical Association, 284,
McNair, L.D. (2005). Top 10 recommendations for treating
comorbid addictive behaviors in African Americans. the
Behavior Therapist, 28, 116–118.
Merry, J. (1966). The ‘‘loss of control’’ myth. Lancet, 287,
Metrik, J., Rohsenow, D.J., Monti, P.M., McGeary, J.,
Cook, T.A., de Wit, H., ..., Kahler, C.W. (2009).
Effectiveness of a marijuana expectancy manipulation:
Piloting the balanced-placebo design for marijuana.
Experimental and Clinical Psychopharmacology, 17,
Miller, W.M., & Rollnick, S. (Eds.). (1991). Motivational
interviewing: Preparing people to change addictive behavior.
New York, NY: Guilford Press.
Miller, W.R. (2004). The phenomenon of quantum change.
Journal of Clinical Psychology, 60, 453–460.
Miller, W.R., & Caddy, G.R. (1977). Abstinence and controlled
drinking in the treatment of problem drinkers. Journal of
Studies on Alcohol, 38, 986–1003.
Miller, W.R., & Harris, R.J. (2000). A simple scale of Gorski’s
warning signs for relapse. Journal of Studies on Alcohol, 61,
Miller, W.R., & McLellan, A.T. (2011). G. Alan Marlatt:
1941–2011. Journal of Substance Abuse Treatment, 41,
Miller, W.R., & Wilbourne, P.L. (2002). Mesa Grande: A
methodological analysis of clinical trials of treatment for
alcohol use disorders. Addiction, 97, 265–277.
Addict Res Theory Downloaded from by yaffa tzubery on 01/21/12
For personal use only.
Monti, P.M., Abrams, D.B., Kadden, R.M., & Cooney, N.L.
(1989). Treating alcohol dependence: A coping skills training
guide. New York, NY: Guilford Press.
Monti, P.M., Gulliver, S.B., & Myers, M.G. (1994). Social skills
training for alcoholics: Assessment and treatment. Alcohol
and Alcoholism, 29, 627–637.
Monti, P.M., Kadden, R.M., Rohsenow, D.J., Cooney, N.L., &
Abrams, D.B. (2002). Treating alcohol dependence: A coping
skills training guide. New York, NY: Guilford.
Monti, P.M., & O’Leary, T.A. (1999). Coping and social skills
training for alcohol and cocaine dependence. Psychiatric
Clinics of North America, 22, 447–470.
Monti, P.M., Rohsenow, D.J., Abrams, D.B., Zwick, W.R.,
Binkoff, J.A., Munroe, S.M., ..., Pedraza, M. (1993).
Development of a behavior analytically derived alcohol-
specific role-play assessment instrument. Journal of Studies
on Alcohol, 54, 710–721.
Monti, P.M., Rohsenow, D.J., Colby, S.M., & Abrams, D.B.
(1995). Coping and social skills training. In R.K. Hester &
W.R. Miller (Eds.), Handbook of alcoholism treatment
approaches: Effective alternatives (2nd ed., pp. 221–241).
Boston, MA: Allyn & Bacon.
Monti, P.M., Rohsenow, D.J., Michalec, E., Martin, R.A., &
Abrams, D.B. (1997). Brief coping skills treatment for
cocaine abuse: Substance us outcomes at three months.
Addiction, 92, 1717–1728.
Najavits, L.M. (2007). Seeking safety: An evidence-based model
for substance abuse and trauma/PTSD. In K.A. Witkiewitz &
G.A. Marlatt (Eds.), Therapist’s guide to evidence-based
relapse prevention (pp. 141–167). San Diego, CA: Elsevier
Academic Press.
O’Leary, D.E., O’Leary, M.R., & Donovan, D.M. (1976). Social
skill acquisition and psychosocial development of alcoholics:
A review. Addictive Behaviors, 1, 111–120.
Paredes, A., Hood, W.R., Seymour, H., & Gollob, M. (1973).
Loss of control in alcoholism: An investigation of the
hypothesis, with experimental findings. Quarterly Journal of
Studies on Alcohol, 34, 1146–1161.
Pomerleau, O., Pertschuk, M., & Stinnett, J. (1976). A critical
examination of some current assumptions in the treatment of
alcoholism. Journal of Studies on Alcohol, 37, 849–867.
Ramo, D.E., Myers, M.G., & Brown, S.A. (2007). Relapse
prevention for adolescent substance abuse: Overview and case
examples. In K.A. Witkiewitz & G.A. Marlatt
(Eds.), Therapist’s guide to evidence-based relapse preven-
tion (pp. 293–311). San Diego, CA: Elsevier Academic Press.
Rohsenow, D.J., & Marlatt, G.A. (1981). The balanced placebo
design: Methodological considerations. Addictive Behaviors,
6, 107–122.
Schlam, T.R., & Wilson, G.T. (2007). Relapse prevention for
eating disorders. In K.A. Witkiewitz & G.A. Marlatt
(Eds.), Therapist’s guide to evidence-based relapse preven-
tion (pp. 169–190). San Diego, CA: Elsevier Academic Press.
Schmitz, J.M., Oswald, L.M., Damin, P., & Mattis, P. (1995).
Situational analysis of coping in substance-abusing patients.
Journal of Substance Abuse, 7, 189–204.
Scott, C.K., & Dennis, M.L. (2009). Results from two
randomized clinical trials evaluating the impact of quarterly
recovery management checkups with adult chronic substance
users. Addiction, 104, 959–971.
Scott, C.K., Dennis, M.L., & Foss, M.A. (2005). Utilizing
recovery management checkups to shorten the cycle of
relapse, treatment reentry, and recovery. Drug and Alcohol
Dependence, 78, 325–338.
Shaffer, H.J., & LaPlante, D.A. (2005). Treatment of gambling
disorders. In G.A. Marlatt & D.M. Donovan (Eds.), Relapse
prevention: Maintenance strategies in the treatment of
addictive behaviors (2nd ed., pp. 276–332). New York,
NY: Guilford Press.
Simmons, V.N., Cruz, L.M., Brandon, T.H., & Quinn, G.P.
(2011). Translation and adaptation of smoking
relapse-prevention materials for pregnant and postpartum
Hispanic women. Journal of Health Communication, 16,
Sobell, L.C., Sobell, M.B., & Christelman, W.C. (1972). The
myth of ‘‘One Drink’’. Behaviour Research and Therapy, 10,
Sobell, M.B., & Sobell, L.C. (1995). Controlled drinking after
25 years: How important was the great debate? Addiction, 90,
Stanton, M. (2005). Relapse prevention needs more emphasis on
interpersonal factors. The American Psychologist, 60,
Stout, R.L., Rubin, A., Zwick, W., Zywiak, W., & Bellino, L.
(1999). Optimizing the cost-effectiveness of alcohol treat-
ment: A rationale for extended case monitoring. Addictive
Behaviors, 24, 17–35.
Wells, E.A., Catalano, R.F., Plotnick, R., & Hawkins, J.D.
(1989). General versus drug specific coping skills and
posttreatment drug use among adults. Psychology of
Addictive Behaviors, 3, 8–21.
White, W.L., Boyle, M., & Loveland, D. (2002). Alcoholism/
addiction as a chronic disease: From rhetoric to clinical
reality. Alcoholism Treatment Quarterly, 20, 107–129.
Whiteside, U., Nguyen, T., Logan, D.E., Fagan, C.,
Marlatt, G.A., & Witkiewitz, K. (2007). Relapse prevention
for return of pathological worry of CBT-treated GAD.
In K.A. Witkiewitz & G.A. Marlatt (Eds.), Therapist’s
guide to evidence-based relapse prevention (pp. 91–116).
San Diego, CA: Elsevier Academic Press.
Witkiewitz, K., Maisto, S.A., & Donovan, D.M. (2010). A
comparison of methods for estimating change in drinking
following alcohol treatment. Alcoholism: Clinical and
Experimental Research, 34, 2116–2125.
Witkiewitz, K., & Marlatt, G.A. (2004). Relapse prevention for
alcohol and drug problems: That was Zen, this is Tao. The
American Psychologist, 59, 224–235.
Witkiewitz, K., & Marlatt, G.A. (2007a). Modeling the
complexity of post-treatment drinking: It’s a rocky road to
relapse. Clinical Psychology Review, 27, 724–738.
Witkiewitz, K.A., & Marlatt, G.A. (2007b). Therapist’s guide to
evidence-based relapse prevention. San Diego, CA: Elsevier
Academic Press.
Witkiewitz, K., & Masyn, K.E. (2008). Drinking trajectories
following an initial lapse. Psychology of Addictive Behaviors,
22, 157–167.
Witkiewitz, K., van der Maas, H.L., Hufford, M.R., &
Marlatt, G.A. (2007). Nonnormality and divergence in
posttreatment alcohol use: Reexamining the Project
MATCH data ‘‘another way’’. Journal of Abnormal
Psychology, 116, 378–394.
Witkiewitz, K., & Villarroel, N.A. (2009). Dynamic association
between negative affect and alcohol lapses following alcohol
treatment. Journal of Consulting and Clinical Psychology, 77,
Witkiewitz, K., Villarroel, N.A., Hartzler, B., & Donovan, D.M.
(2011). Drinking outcomes following drink refusal skills
training: Differential effects for African American and
Addict Res Theory Downloaded from by yaffa tzubery on 01/21/12
For personal use only.
non-Hispanic White clients. Psychology of Addictive
Behaviors, 25, 162–167.
Zawacki, T.M., Stoner, S.A., & George, W.H. (2005). Relapse
Prevention for Sexually Risky Behaviors. In G.A. Marlatt &
D.M. Donovan (Eds.), Relapse prevention: Maintenance
strategies in the treatment of addictive behaviors (2nd ed.,
pp. 363–386). New York, NY: Guilford Press.
Ziedonis, D., Yanos, P.T., & Silverstein, S.M. (2007). Relapse
prevention for schizophrenia. In K.A. Witkiewitz &
G.A. Marlatt (Eds.), Therapist’s guide to evidence-based
relapse prevention (pp. 117–140). San Diego, CA: Elsevier
Academic Press.
Zywiak, W.H., Connors, G.J., Maisto, S.A., &
Westerberg, V.S. (1996). Relapse research and the
Reasons for Drinking Questionnaire: A factor analysis
of Marlatt’s relapse taxonomy. Addiction, 91,
Zywiak, W.H., Stout, R.L., Connors, G.J., Maisto, S.A.,
Longabaugh, R., & Dyck, I.S.P.A.T. (2001). Factor analysis
and predictive validity of the Relapse Questionnaire in
Project MATCH. Paper presented in a Symposium,
New Perspectives on Relapse and Treatment Outcome,
Annual Meeting of the Research Society on Alcoholism,
Montreal, QB.
Addict Res Theory Downloaded from by yaffa tzubery on 01/21/12
For personal use only.
... Determinants frequently associated with relapse, as well as factors that are protective in preventing relapse, have already been well studied for several decades (Miller 1996;Witkiewitz and Marlatt, 2004;Sliedrecht et al. 2019). Several psychological and psychobiological models have been postulated and tested for their validity in predicting relapse (Connors et al. 1996;Witkiewitz andMarlatt, 2004, 2007;Hendershot et al. 2011;Witkiewitz 2011;Sliedrecht et al. 2019), and have generated therapeutic targets to prevent relapse (Donovan and Witkiewitz, 2012;Huebner and Kantor, 2010;Larimer et al. 1999). Craving is one of the most prominent targets for interventions (Donovan and Witkiewitz, 2012;Larimer et al. 1999) and a limited number of medications (Donoghue et al. 2015;Mann et al. 2018;Witkiewitz et al. 2019;Donoghue 2021) within many treatment settings. ...
... Several psychological and psychobiological models have been postulated and tested for their validity in predicting relapse (Connors et al. 1996;Witkiewitz andMarlatt, 2004, 2007;Hendershot et al. 2011;Witkiewitz 2011;Sliedrecht et al. 2019), and have generated therapeutic targets to prevent relapse (Donovan and Witkiewitz, 2012;Huebner and Kantor, 2010;Larimer et al. 1999). Craving is one of the most prominent targets for interventions (Donovan and Witkiewitz, 2012;Larimer et al. 1999) and a limited number of medications (Donoghue et al. 2015;Mann et al. 2018;Witkiewitz et al. 2019;Donoghue 2021) within many treatment settings. 'Craving', as well as other determinants like 'severity of AUD', 'psychiatric comorbidity', 'emotions' and several social and spiritual factors, have been identified as important factors in the achievement of remission or the occurrence of a relapse (Witkiewitz and Marlatt, 2004;Hendershot et al. 2011;Sliedrecht et al. 2019). ...
For decades predictors of alcohol use disorder (AUD) relapse have been studied, and around 40 different clinical and demographic relapse determinants have been identified. This paper aims to investigate the relationship of two of these AUD relapse factors, namely craving and meaning in life (MiL). We hypothesized that greater meaning in life would be associated with lower cravings and lower relapse rates. An AUD subsample of 81 patients within a clinical population that participated in ongoing exploratory research on religious/spiritual factors related to substance use disorders was followed up to 1 year. Craving (as measured with the Penn Alcohol Craving Scale) and meaning in life (as measured with the Meaning in Life Questionnaire- presence subscale) measures were assessed at baseline and relapse was assessed at 6- and 12-month follow up. Main effects and the interaction between craving and meaning in life in predicting alcohol relapse (with relapse defined as ‘any alcohol use’ and ≥ 3 consecutive days of drinking) were calculated/subject of analyses. We also investigated the relationship between relapse and alcohol dependence severity as measured with the Leeds Dependence Questionnaire. Baseline craving and dependence severity were related to relapse, but there were no associations between meaning in life and levels of craving or alcohol relapse. Our findings suggest a need for additional research on characterizing the Meaning in Life concept.
... Emanating from a study by psychologist G. Alan Marlatt on men with alcohol problems during the 1970s, RP has gained a strong foothold in addiction treatment, and it now also includes behaviours such as smoking and gambling (Marlatt & Witkiewitz, 2005). Originally controversial, as it challenged the disease model of addiction (Dimeff & Marlatt, 1998, p. 514), RP is now a mainstream 'talk therapy' (Donovan & Witkiewitz, 2012;Roy & Miller, 2012). ...
... RP is today considered evidence-based. It is popular globally (Donovan & Witkiewitz, 2012) and is delivered by most addiction treatment agencies in Sweden (Ekendahl & Karlsson, 2021;Socialstyrelsen, 2019). However, distinguishing RP from other psychosocial interventions is challenging. ...
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This article explores how professionals within Swedish addiction treatment (n = 18) describe and make sense of relapse prevention (RP). RP is known as a self-control programme for maintaining behavioural change, helping people deal with high-risk situations. However, since self-control techniques have been incorporated widely in the addiction treatment field, the specificities of RP have become vague. To grasp what RP ‘is’, we draw on John Law’s and Annemarie Mol’s thoughts on how logics enact objects and realities. We thus follow critical scholarship in Science and Technology Studies and view treatment as a local knowledge-making practice that may depart from how it was originally designed. A key question is how RP is potentially transformed and made-to-matter when moved from the controlled settings of theorising and experimental studies to practice. The professionals used a logic of fixity to make RP stable, structured and evidence-based, easily distinguishable from other interventions. They also used a logic of fluidity to explain how and why they tinkered with it and adapted it to the preferences of both staff and attendees. The two logics enacted two different realities of addiction treatment: one in which RP is standardised, temporally demarcated and can solve most addiction problems, and another where interventions must be individualised, continuous and adapted to local settings and needs. It did not appear contradictory to ‘make up’ RP as both fixed and fluid; the two realities exist side by side, but with different material effects.
... Building yet departing from dominant approaches of relapse prevention applied in clinical and public health research (e.g. Donovan & Witkiewitz, 2012), we performed a critical narrative inquiry to understand drug use and relapse as primarily constituted in the broader political (e.g. drug war), socio-cultural (e.g. ...
... As such, the goal of treatment is to strengthen individual resources (e.g. self efficacy) through cognitive and behavioral interventions alongside lifestyle changes (Donovan & Witkiewitz, 2012). For example, interventions may include teaching individuals thought stopping techniques, self-initiated strategies (e.g. ...
In the Philippines where an ongoing national drug campaign is implemented, continuous recovery of drug users is compromised especially those coming from low-income communities. However, studies that explore drug relapse and recovery issues in such communities are still scant. As an exemplar case, a critical narrative inquiry was performed to analyze accounts of 17 Filipino male low-income methamphetamine polydrug users and their experiences of repeated drug relapse. Findings show three overarching narratives namely: drug relapse as being taken by the body, drug use as mode of living and thriving in communities, and as a cyclic narrative of rehabilitation and community reintegration. Implications on understanding the interplay between personal agency and broader risk environments are discussed in light of existing rehabilitation and treatment modalities in drug recovery targeting low-income communities.
... Relapse prevention (RP), which to a large extent pivots around craving, is an important part of addiction treatment globally (Donovan & Witkiewitz, 2012). It was originally developed from cognitive-behavioral therapy (CBT) and is described as a 'self-control program' (Marlatt & George, 1984). ...
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Aims Craving is commonly described as an ‘intense desire’ to use drugs. Due to its relevance for addiction theories and treatment, much effort has been put into understanding how and when craving occurs. An undisputed definition of craving is however still lacking. The aim of this article is to explore how craving is experienced and resisted after cessation of substance use. Methods This article analyses interviews with former addiction treatment clients. By analyzing the described event of craving, the study shows the complexities in such narratives. Findings We found that the interaction between temporal, relational and material forces move people toward or away from craving. Craving thus seemed to be both relational and located in-between forces. Conclusions We conclude that craving appeared in the studied narratives to emanate from different atmospheres, with a concurrent focus on settings rather than on substances. A relational understanding of craving can add to the typical, but limited, account of craving as an individual issue. It also avoids stigmatizing ideas that people who do not resist cravings simply fail to say no. We end by asking if craving is a relevant concept within the addiction field at all.
... The occurrence and recurrence of relapse is also considered to be clinically important, and "relapse prevention" interventions have been widely used in clinical practice (Donovan & Witkiewitz, 2012). Although given the chronic relapsing nature of the disorder (Volkow et al., 2016), stable abstinence might be very difficult to achieve. ...
Objective: The definition of relapse has been the subject of debate for decades, and a semantic ambiguity highlighted in a 2016 article in the Journal of Studies on Alcohol and Drugs remains. The current article replicates and extends the 2016 findings on alcohol use disorder (AUD) relapse definitions. Method: We conducted a systematic review of 321 articles that examined relapse in patients with AUD, published from 2000 to 2019. Relapse definitions were extracted and a narrative review of definitions was conducted. Results: One hundred and one different definitions of relapse were used in 251 (78%) of the reviewed articles. In 70 (22%) of articles, no definition of AUD relapse was provided. Fifty-three articles used diagnostic criteria (i.e., alcohol use after remission of AUD), whereas 99 articles defined relapse as "any alcohol use" or "any use of alcohol/drugs." Additional articles defined relapse by alcohol outcomes (e.g., percent drinking days), alcohol-related problems, or hospitalizations (n = 97). Only 12 articles described the time window of abstinence preceding a relapse. We observed relatively no meaningful intercontinental or time-related differences in relapse definitions, although the outcome "percent heavy drinking days" was used more frequently in recent studies. Conclusions: A wide variety of relapse definitions were identified. Despite decades of research and discussion, there is still no widely accepted consensus definition of AUD relapse. We propose to shift the focus toward clinical continuous outcomes, course specifiers based on the number of AUD symptoms present, and quality-of-life-related criteria instead of using current dichotomous AUD relapse terminology.
Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.
There is emerging evidence on the relationship between career outcomes and success in substance use recovery, in that individuals who are gainfully employed are more likely to have positive recovery outcomes, including reduced risk of relapse. Although career interventions for those in recovery exist, no intervention has focused on the intersection of career development and relapse prevention. This article explores a theoretical integration of relapse prevention and social cognitive career theory to increase the self-efficacy, outcome expectancies, and coping of individuals in recovery, as well as implications and practical applications of this orientation for both career and substance use counselors.
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Objective Strong evidence links exposure to traumatic life events with subsequent substance use disorders (SUD). Compared to men, women in SUD treatment are more likely to have a history of trauma, characterized in part by emotion dysregulation known to negatively influence treatment outcomes. Existing research has been conducted with predominantly male and non-Hispanic White samples, with an emphasis on adverse childhood experiences. Little is known about how exposure to cumulative traumatic events across the lifespan affects emotion dysregulation and how this may influence craving, particularly among racial and ethnic minoritized women with SUD. Mindfulness disposition may serve as a protective factor that could buffer the impact of trauma exposure and emotion dysregulation on substance use craving among underrepresented minoritized women with SUD. This study examined the association between cumulative exposure to traumatic events, emotion dysregulation, and mindfulness disposition on substance use craving in a sample of predominantly Hispanic and non-Hispanic Black women in residential treatment for SUD. Method Cross-sectional data were analyzed for a baseline sample of 241 women (56.96% Hispanic, 20.7% non-Hispanic White, 20.7% non-Hispanic Black; age: M = 32.11) entering a SUD residential treatment facility who agreed to participate in a parent randomized controlled trial. Results Findings indicated that greater cumulative exposure to traumatic events and emotion dysregulation were associated with higher levels of craving. Cumulative traumatic event exposure was indirectly associated with higher craving via lower levels in the mindfulness dimension of acting with awareness. Interaction effects also revealed greater exposure to traumatic events was associated with higher levels of craving among women with low and average (but not high) levels of mindfulness disposition. Conclusion These findings provide insight into the potential benefits of targeting emotion regulation and mindfulness-building strategies such as acting with awareness in interventions among racial-ethnically diverse women with SUD. These strategies may be particularly beneficial among those that have experienced extensive histories of trauma exposure. Overall, knowledge gained from the present study can be particularly valuable towards informing treatment models in minoritized groups that currently experience disparities in treatment utilization and outcomes.
Information technology addicts often exhibit a high rate of relapse, which reflects the failure of previous recovery approaches. However, research on relapse to information technology addiction has been largely neglected, and few means have been developed to address this issue. To fill this research gap, this study identifies essential factors for preventing relapse to information technology addiction with a self-regulation perspective. A longitudinal online survey is conducted. The results show that mindfulness and self-control contribute to reduced urges, which, in turn, prevent relapse. This study provides useful insights by expanding our understandings of relapse to information technology addiction.
This chapter discusses relapse prevention (RP) as it pertains to health behavior change, particularly in the addictions. RP is a cognitive-behavioral approach to treatment of habitual problem behaviors and maintenance of alternative coping behaviors. It is particularly applicable during the maintenance stage of behavior change when patients are most likely to lose their motivation for change and are at risk for reverting back to old, undesirable habits (e.g., smoking, overeating, excessive drinking, or other substance abuse).