Relapse prevention An overview of Marlatt’s cognitive-behavioral model

Despite precautions and preparations, many clients committed to abstinence will experience a lapse after initiating abstinence. Lapse-management strategies focus on halting the lapse and combating the abstinence violation effect to prevent an uncontrolled relapse episode. Lapse management includes contracting with the client to limit the extent of use, to contact the therapist as soon as possible after the lapse, and to evaluate the situation for clues to the factors that triggered the lapse. Often, the therapist provides the client with simple written instructions to refer to in the event of a lapse.

Alternatively, longer pre-lapse abstinence time may actually increase perceptions of control over cessation, and may therefore protect against the AVE, mitigating the detrimental impact of lapses. Cognitive restructuring, or reframing, is used throughout the RP treatment process to assist clients in modifying their attributions for and perceptions of the relapse process. In particular, cognitive restructuring is a critical component of interventions to lessen the abstinence violation effect. Thus, clients are taught to reframe their perception of lapses—to view them not as failures or indicators of a lack of willpower but as mistakes or errors in learning that signal the need for increased planning to cope more effectively in similar situations in the future. This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future.

Specific Intervention strategies in Relapse Prevention

Future research with a data set that includes multiple measures of risk factors over multiple days can help in validating the dynamic model of relapse. A common pattern of self-regulation failure occurs for addicts and chronic dieters when they ‘fall off the wagon’ by consuming the addictive substance or violating their diets [5]. Marlatt coined the term abstinence violation effect to refer to situations in which addicts respond to an initial indulgence by consuming even more of the forbidden substance [11]. In one of the first studies to examine this effect, Herman and Mack experimentally violated the diets of dieters by requiring them to drink a milkshake, a high-calorie food, as part of a supposed taste perception study [27]. Although non-dieters ate less after consuming the milkshakes, presumably because they were full, dieters paradoxically ate more after having the milkshake (Figure 1a).

• Outcomes in which relapse prevention may hold particular promise include reducing severity of relapses, enhanced durability of effects, and particularly for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity21.
• Cognitions—specifically, thoughts and expectations about drinking behavior and sobriety—contribute importantly to the process of relapse.
• Other more general strategies include helping the person develop positive addictions and employing stimulus-control and urge-management techniques.
• AVE describes the negative, indulgent, or self-destructive feelings and behavior people often experience after lapsing during a period of abstinence.

Global strategies comprise balancing the client’s lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urge-management techniques, and developing relapse road maps. Global strategies comprise balancing the client’s lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urge-management techniques, and developing relapse road maps. Cognitive behaviour therapy is a structured, time limited, psychological intervention that has is empirically supported across a wide variety of psychological disorders.

Initial AVE and Resumption of Daily Smoking

For example, based on the dynamic model it is hypothesized that changes in one risk factor (e.g. negative affect) influences changes in drinking behavior and that changes in drinking also influences changes in the risk factors. The dynamic model of relapse has generated enthusiasm among researchers and clinicians who have observed these processes in their data and their clients. Parametric survival analyses that allowed for recurrent events within-subjects treated each lapse episode as the beginning of an interval during which the participant was at risk for having another lapse, and examined how AVE responses to each lapse affected the likelihood of progression.

Other behavioral characteristics that have been identified in patients with bulimia nervosa include impulsivity and mood lability, and it is possible that these traits may contribute to the onset or perpetuation of symptoms in this disorder. In one model, for example, an individual attempting to follow a reduced calorie diet may experience an abstinence violation effect following ingestion of modest amounts of snack foods, leading to a transient inclination to abandon dietary restraint altogether. Factors that may lead to dieting, such as parental or childhood obesity, have been identified as potential risk factors for the development of this disorder. Put simply, the AVE occurs when a client perceives no intermediary step between a lapse and a relapse. For example, overeaters may have an AVE when they express to themselves, “one slice of cheesecake is a lapse, so I may as well go all-out, and have the rest of the cheesecake.” That is, since they have violated the rule of abstinence, they “may as well” get the most out of the lapse.

Relapse prevention. An overview of Marlatt’s cognitive-behavioral model

This provided a more sensitive measure of “routine” smoking that made it possible for us to improve our focus on true abstinence violations. Of note, alternative definitions of low-level resumption did not change the observed pattern of results. The role of pre-lapse abstinence appears to be more subtle, interacting with AVE responses in a way that influences progression to additional lapses. Rather than undermining self-efficacy after a lapse, results indicate that longer periods of pre-lapse abstinence violation effect definition abstinence potentiated the effect of self-efficacy in protecting against subsequent progression. In such instances, the individual’s feeling of confidence may be better grounded in real experience; i.e., their ability to maintain abstinence for a longer time before the lapse event. In contrast, high self-efficacy following a very short period of abstinence may be less realistic and more brittle in the face of challenge, and hence have a weaker association with subsequent behavior.

Chronic stressors may also overlap between self-efficacy and other areas of intrapersonal determinants, like emotional states, by presenting more adaptational strain on the treatment-seeking client4. These covert antecedents include lifestyle factors, such as overall stress level, one’s temperament and personality, as well as cognitive factors. These may serve to set up a relapse, for example, using rationalization, denial, or a desire for immediate gratification. Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse. It involves the degree of balance in the person’s life between perceived external demands and internally fulfilling or enjoyable activities. Urges and cravings precipitated by psychological or environmental stimuli are also important6.

Conversely, the hypothesized result of a failure to cope with a high-risk situation is a decrease in a sense of self-efficacy, which in turn increases the probability of relapse. Each experience of successful or unsuccessful coping with a high-risk situation builds up a greater or lesser sense of self-efficacy, which determines the future risk of relapse in similar circumstances. Marlatt and Gordon (1985) contend that individuals’ reactions to the initial slip and their attributions regarding the cause of the slip are the determining factors in the escalation of a lapse or setback into a full-blown relapse. The transition from slip or lapse to relapse involves the “abstinence violation effect,” which results from a state of cognitive dissonance regarding the nonabstinent behavior and the individual’s image of being abstinent. This dissonance can be reduced by either changing the behavior or changing the image, and characteristically in this population is resolved by the latter. This model has received a good deal of empirical support and has the merit of dismantling the process of relapse and exploring subjective and cognitive variables in a manner that has important treatment implications.

• The technique involves exposure to a hierarchy of cues, which signal craving and subsequently substance use.
• 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.
• Shiffman, Scharf, et al (2006) showed that treatment with high-dose patch impeded overall progression from the first lapse to relapse.
• Additional hours of prospective abstinence time, plotted across each 1-unit change in post-lapse self-efficacy.
• When abstinence violation occurs, individuals typically enter a state of cognitive dissonance, defined as an aversive experience resulting from the discrepancy created by having two or more simultaneous and inconsistent cognitions.
• Abstinence violators realize that their actions (e.g. “I drank”) do not line up with their personal goal (e.g. “I want to abstain”) and feel compelled to resolve the discrepancy.

Smokers who were eligible, who passed a medical screening, and who signed an informed consent form were enrolled. Ark Behavioral Health offers 100% confidential substance abuse assessment and treatment placement tailored to your individual needs. Our addiction treatment network offers comprehensive care for alcohol addiction, opioid addiction, and all other forms of drug addiction. Our treatment options include detox, inpatient treatment, outpatient treatment, medication-assisted treatment options, and more.