Author: James Anderson
Treatment and Recovery National Institute on Drug Abuse NIDA
Subsequently, the therapist can address each expectancy, using cognitive restructuring (which is discussed later in this section) and education about research findings. The therapist also can use examples from the client’s own experience to dispel myths and encourage the client to consider both the immediate and the delayed consequences of drinking. Marlatt and Gordon (1980, 1985) have described a type of reaction by the drinker to a lapse called the abstinence violation effect, which may influence whether a lapse leads to relapse.
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- Additionally, attitudes or beliefs about the causes and meaning of a lapse may influence whether a full relapse ensues.
- Positive expectancies regarding alcohol’s effects often are based on myths or placebo effects of alcohol (i.e., effects that occur because the drinker expects them to, not because alcohol causes the appropriate physiological changes).
- Participants unable to attend onsite posttreatment assessments could complete all assessments online, with the exception of the Timeline Follow-back,49 which was administered via telephone with study staff.
- In contrast, several models of relapse that are based on social-cognitive or behavioral theories emphasize relapse as a transitional process, a series of events that unfold over time (Annis 1986; Litman et al. 1979; Marlatt and Gordon 1985).
- These factors can increase a person’s vulnerability to relapse both by increasing his or her exposure to high-risk situations and by decreasing motivation to resist drinking in high-risk situations.
A person’s support system may also play an important role in recovery and the avoidance of relapse. Family counseling and therapy sessions may help loved ones to better understand the disease of addiction and learn to recognize potential relapse triggers and ways they can support in those instances. Communication skills and the overall family dynamic may improve through family therapy as well. Professional treatment can help manage both the psychological and physical factors of addiction to promote recovery. To these ends, comprehensive substance abuse treatment programs often include both therapeutic and pharmacological methods to promote and sustain recovery while working to minimize relapse and manage use triggers.
Covert Antecedents of High-Risk Situations
Interpersonal relationships and support systems are highly influenced by intrapersonal processes such as emotion, coping, and expectancies18. Inaction has typically been interpreted as the acceptance of substance cues which can be described as “letting go” and not acting on an urge. The following section reviews selected empirical findings that support or coincide with tenets of the RP model. Because the scope of this literature precludes an exhaustive review, we highlight select findings that are relevant to the main tenets of the RP model, in particular those that coincide with predictions of the reformulated model of relapse.
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In a subsequent meta-analysis by Irwin, twenty-six published and unpublished studies representing a sample of 9,504 participants were included. Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment. Moderation analyses suggested that RP was consistently efficacious across treatment modalities (individual vs. group) and settings (inpatient vs. outpatient)22. Findings concerning possible genetic moderators of response to acamprosate have been reported 99, but are preliminary.
Marlatt, based on clinical data, describes categories of relapse determinants which help in developing a detailed taxonomy of high-risk situations. These components include both interpersonal influences by other individuals or social networks, and intrapersonal factors in which the person’s response is physical or psychological. Expectancy research has recently started examining the influences of implicit cognitive processes, generally defined as those operating automatically or outside conscious awareness 54, 55. Recent reviews provide a convincing rationale for the putative role of implicit processes in addictive behaviors and relapse 54, 56, 57.
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Instead, a relapse signifies that additional and/or a different form of treatment is necessary. Understanding relapse, triggers, and treatment are important steps toward relapse prevention. Even when alcohol’s perceived positive effects are based on actual drug effects, often only the immediate effects are positive (e.g., euphoria), whereas the delayed effects are negative (e.g., sleepiness), particularly at higher alcohol doses.
One study, in which substance-abusing individuals were randomly assigned to RP or twelve-step (TS) treatments, found that RP participants showed increased self-efficacy, which accounted for unique variance in outcomes 69. Further, there was strong support that increases in self-efficacy following drink-refusal skills training was the primary mechanism of change. Findings from numerous non-treatment studies are also relevant to the possibility of genetic influences on relapse processes.
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While maintaining its footing in cognitive-behavioral theory, the revised model also draws from nonlinear dynamical systems theory (NDST) and catastrophe theory, both approaches for understanding the operation of complex systems 10, 33. Detailed discussions of relapse in relation to NDST and catastrophe theory are available elsewhere 10, 31, 34. There were several differences between TAU and the active treatment groups, including therapist training and assignment of homework. However, RP and MBRP interventions were matched on time, structure, and therapist training, differing only in the intervention delivered, thus offering a rigorous test of MBRP.
Cognitive-behavioral theories also diverged from disease models in rejecting the notion of relapse as a dichotomous outcome. Rather than being viewed as a state or endpoint signaling treatment failure, relapse is considered a fluctuating process that begins prior to and extends beyond the return to the target behavior 8, 24. From this standpoint, an initial return to the target behavior after a period of volitional abstinence (a lapse) is seen not as a dead end, but as a fork in the road.
Preventing relapse or minimizing its extent is therefore a prerequisite for any attempt to facilitate successful, long-term changes in addictive behaviors. The present randomized trial offers evidence that RP and MBRP are beneficial aftercare interventions compared with typical 12-step aftercare treatment. In addition, MBRP resulted in significantly less drug use and a lower probability of any heavy drinking than RP at a 12-month follow-up. These findings suggest that MBRP may support longer term sustainability of treatment gains for individuals with substance-use disorders. Relapse prevention is an umbrella term that refers to strategies that help reduce the likelihood of relapsing.