addiction medicine || relapse prevention and recycling in addiction

Relapse Prevention and Recycling in Addiction

Carlo C. DiClemente, Meredith A. Holmgren, and Daniel Rounsaville

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . 765Understanding the Concept of Relapse and Its

Role in Recovery . . . . . . . . . . . . . . . . . . 765Relapse Prevention . . . . . . . . . . . . . . . . . . 767

Models for Relapse Prevention . . . . . . . . . . 767Review of Relapse Prevention and Substance

Abuse Studies . . . . . . . . . . . . . . . . . . 769Effectiveness Studies Across Addictive

Behaviors . . . . . . . . . . . . . . . . . . . . . 769Critical Mechanisms for Relapse Prevention . . 770

Strategies for Relapse Prevention . . . . . . . . . 772Assessment . . . . . . . . . . . . . . . . . . . . . . 773Insight and Awareness . . . . . . . . . . . . . . . 774Behavioral Coping Skills . . . . . . . . . . . . . 774Cognitive Strategies . . . . . . . . . . . . . . . . 775Lifestyle Interventions . . . . . . . . . . . . . . . 776Mindfulness-Based Strategies for Relapse

Prevention . . . . . . . . . . . . . . . . . . . . 776Medications for Relapse Prevention . . . . . . . 777

When Relapse Prevention Fails . . . . . . . . . . 777A Life Course Perspective on Recovery . . . . . 777Successive Approximations, Recycling, and

Learning from the Past . . . . . . . . . . . . . 778

Treatment Recommendations . . . . . . . . . . . 779References . . . . . . . . . . . . . . . . . . . . . . . 779

C.C. DiClemente (�)Department of Psychology, University of MarylandBaltimore County, Baltimore, MD 21250, USAe-mail: [email protected]

Introduction

In the struggle to be free from Addiction,repeated attempts are required for most indi-viduals to stop the addictive behavior. Multipleattempts to change and multiple treatment eventsare the norm rather than the exception in recov-ery from addiction [28]. There seems to be apredictable cycle in the path to recovery. Onceaddicted individuals become convinced that theyneed to change problematic addictive behaviors(illegal or nonprescription drug use, excessivealcohol consumption, tobacco use, or gambling),they will attempt either to quit completely orto significantly modify these behaviors (e.g.,cutting down or using methadone or buprenor-phine instead of heroin). The majority of theseindividuals who make an attempt to change,however, are unsuccessful. In any cohort of indi-viduals that enters treatment and makes a bonafide attempt to change, the majority, between60 and 80%, return to the problematic behaviorafter some period of success [9, 28]. This event,though defined in various ways, has been labeleda “relapse”.

Understanding the Concept ofRelapse and Its Role in Recovery

The definition of what constitutes a relapsevaries depending on the definition of suc-cess and failure in changing an addictivebehavior. The most stringent definitions define

B.A. Johnson (ed.), Addiction Medicine, DOI 10.1007/978-1-4419-0338-9_38, 765© Springer Science+Business Media, LLC 2011

766 C.C. DiClemente et al.

success as complete abstinence from the behav-ior and identify relapse as any engagement in theaddictive behavior (any consumption of alcohol,use of cocaine, etc.) [58]. Other clinicians andresearchers make a distinction between a slip orlapse and a full blown relapse [39]. Slips andlapses have been defined variably as a singleuse, a single period of use, minimal amounts ofuse, or use without any consequences. Relapseis then a more significant engagement in thebehavior than a single event or a brief periodof use. Lapses could extend into what has beendefined in the Diagnostic and Statistical Manualof Mental Disorders, 4th edition, Text Revisionas “partial remission”, indicating that there aresome vestiges of the behavior present, but thatthere is an absence of the negative consequencesand the physiological and psychological depen-dence that marked the problematic period ofuse [19].

Making a distinction between a lapse and arelapse can be clinically useful because the verystrict definition of complete abstinence or fail-ure can have unintended consequences, as willbe described later. It is important first to notesome common misconceptions about the phe-nomenon of relapse. Relapse is often viewed asa unique problem of substance abusers by prac-titioners and the public. However, relapse andlapsing back to unhealthy behaviors occurs in alltypes of health behavior change and is not lim-ited to addictions. Many health behaviors, suchas dietary change, diabetes management, regularphysical activity, and medication adherence havea similar course with large numbers of individu-als lapsing and relapsing [9, 42]. Relapse is notmerely a function of physiological addiction; itis a function of the process of behavior changewhen individuals attempt to change difficult-to-modify patterns of behavior [20, 43].

Another misconception is that relapse is oftenviewed as failure since the desired behaviorchange is not sustained. However, although itdoes not represent complete success, relapse isan integral part of learning during the recoveryprocess. Individuals do not become addicted, nordo they recover from an addiction, with a singlelearning event [20]. Within the stages of change

model, relapse represents an event that not onlyinvolves a return to a problematic behavior butalso signifies a return to an earlier stage ofchange for that behavior [11, 63]. After relaps-ing, individuals can return to any of the pre-vious stages, Precontemplation (not consideringchange in the near term), Contemplation (consid-ering and decision making), Preparation (build-ing commitment and planning), or Action (ini-tial change lasting for 3–6 months). Individualsreturning to the Precontemplation stage afterrelapse likely believe they cannot change orare they are no longer interested in changingthe addictive behavior. Relapsers who recon-sider the pros and the cons of the addiction,try to resolve the associated ambivalence andmake a new decision to quit have returned tothe Contemplation stage. Those who determinewhat went wrong during the last quit attemptand are poised to make another attempt returnto the Preparation stage. Relapsers who quicklymake another attempt move back into the Actionstage of change. The return to earlier stages ofchange after relapsing from the action or main-tenance stage is called “recycling” back throughthe stages and often leads to another attemptthat is successful [21, 54]. The cyclical move-ment though the stages of change represents thelearning process of “successive approximations”whereby an individual learns gradually throughtrial and error how to avoid the problems frompast attempts and to make a successful change inbehavior.

Relapse, considered from this perspective, isnot so much a failure as an opportunity to learnwhat went wrong and what was missing in theunsuccessful process of change. Most individ-uals who enter stable recovery do so only aftermultiple attempts to change. This pattern is trueof individuals who have changed the addictivebehavior without the aid of formal treatment aswell as those who have been successful after aparticular course of treatment [22, 45, 49]. Inany case, understanding relapse and recyclingis critical to understanding successful recov-ery. Helping individuals avoid relapse and/orto learn how to profit from the experience andbecome more successful is the goal of relapse

Relapse Prevention and Recycling in Addiction 767

prevention and of successful recycling. Thischapter will examine relapse prevention models,highlight critical components of relapse preven-tion, identify key clinical strategies that can beused in the service of preventing relapse, anddiscuss how to promote successful recycling forthose who were unable to change their behaviorat any one point in time.

Relapse Prevention

As the field of addiction moved from a moralexplanation of addiction to a focus on habit anddisease, the challenge of maintaining change andavoiding relapse became a focus of research andtheory [9, 35, 39, 61]. Interest and research activ-ity expanded to understand what precipitatesrelapse and the possible interventions that wouldreduce the relapse rate and increase the poten-tial for recovery from a slip or a relapse. Therewere several dominant theories that were devel-oped during the 20th century not all of whichwere compatible with one another.

Models for Relapse Prevention

The two partially compatible models for under-standing relapse came from different explana-tory frameworks. The Medical Model coun-tered the prevailing perspective at the beginningof the twentieth century that alcoholism andother addictions were moral problems that couldbe overcome with willpower and by observingmoral standards. The view of addiction as a dis-ease was intended to change the conversationabout addiction, remove some of the stigma,and make it a medical condition that was treat-able. This model was not only adopted by themedical professionals but also by the influentialfounders of Alcoholics Anonymous and the 12-step model for recovery [58]. At the same time inthe academic community, the social and behav-ioral learning perspectives described addic-tions as over-learned behaviors that were sup-ported by contextual forces. Interestingly, both

models arrived at some similar relapse preven-tion strategies.

Medical and Mutual Help Model

In the Medical Model addiction is viewed interms of the changes that are made in the neu-rochemistry of the addicted individual, whichcauses physiological dependence. The perspec-tive is that the addiction acts as a disease andchanges biological processes which, in turn,pose significant barriers for change for theaddicted individual. The physiological changesthat result from prolonged substance abuse man-ifest themselves in craving, which continuallypushes the addicted individual to return to theaddictive behavior [52]. For the addicted indi-vidual their “normal” biological state inherentlyis resistant to behavior change [14, 33]. MedicalModel oriented interventions to prevent relapseinclude periods of hospitalization that focus onbreaking the physiological and psychologicalconnections to addiction as well as using med-ications that decrease cravings.

In the Medical/Mutual Help or Twelve-StepModel, addiction is also described as an illnessor disease that addicted individuals are power-less to control [53]. One analogy for the diseaseis an “allergy” such that the individual cannothave contact with the substance without a lossof control. This perspective supports the viewof relapse as any contact with addictive sub-stance or behavior. The addicted individual isseen as someone who has a defect such thatwillpower can not be the solution for recovery.Preventing relapse must include an admission ofpowerlessness and a reliance on a higher power,whether that is seen as a spiritual power or thepower of the mutual help network that is createdby associating with Alcoholics Anonymous andworking the 12 steps of recovery. The programincludes a number of strategies (e.g., approachrecovery, one day at a time, you are always analcoholic and must always be vigilant, meetingattendance) and support systems (e.g., sponsors,fellowship of Alcoholics Anonymous) for theprevention of relapse.


Social Learning Models

In 1980, G. Alan Marlatt and Judith Gordondeveloped the Relapse Prevention Model, anextensive, empirically focused conceptual modelthat we will use as the basis of our discus-sion of relapse in this chapter. Their cognitive-behavioral model of the relapse process [39] isbased on social cognitive and learning modelsof behavior and posits that addiction stems frommaladaptive habit patterns. Relapse is conceptu-alized as resulting from a series of predictablecognitive and behavioral events that lead to areturn to substance use. This relapse preven-tion model hypothesizes that common cognitive,behavioral, and affective mechanisms underliethe process of relapse for a variety of prob-lem behaviors. This view of recovery is basedon learning theory and differs from the diseasemodel in many ways, though does share sometheoretical precipitants of relapse.

The model assumes that a complex arrayof determinants is involved in the develop-ment of an addiction and the ability to suc-cessfully change the addictive behaviors. Someinfluential factors include genetics, environmen-tal/situational factors, family history of addic-tion, peer influence, early use of substances,and expectancies of the effects of the substance.During periods of abstinence, individuals movealong a continuum of engagement in cognitiveand behavioral activities that lead to success-ful behavior change. Along the way, they arelikely to face situations that put them at riskfor relapse. These high-risk situations are a corecomponent of Marlatt and Gordon’s RelapsePrevention Model. Eight categories of relapsedeterminants were formulated from detailed,retrospective interviews of substance abuserswho had experienced a return to their sub-stance use [40]. This was done to identity theexperiences that immediately preceded relapseepisodes. From this investigation, a taxonomywas developed which included interpersonaland intrapersonal factors. Cummings et al. [17]found that the most frequently reported precip-itants of relapse included negative emotionalstate (35% of relapses), social pressure (20%),

interpersonal conflict (16%), and urges andtemptations (9%). Factor analysis on the Reasonfor Drinking Questionnaire [68] expandedbeyond Marlatt’s taxonomy of relapse precipi-tants to reveal three major factors that differen-tiated the types of relapses people experienced:(1) negative emotions, (2) social pressure andpositive emotions with others, and (3) temptationand craving.

According to the cognitive-behavioral relapsemodel [39], individuals with effective copingresponses and high self-efficacy are less likely toelicit the problem behavior. When an individualfaces a high-risk situation and has access to theappropriate coping behavior, the successful useof this coping behavior increases self-efficacy[5, 6]. This accomplishment should reduce theprobability of subsequent relapse in similar high-risk situations. If an individual does not use theappropriate coping behavior, the attractivenessof substances will increase while self-efficacyto abstain decreases, escalating the likelihoodthat the individual will use the substance in thatparticular situation. Guilt and low self-esteemcan occur if the substance is used during thisperiod of abstinence. These feelings can pro-pel an individual from the initial use of alcohol,often termed a “lapse”, into a full-blown relapse.

Marlatt and Gordon [39, 40] describe theonset of guilt and lowered self-efficacy as apossible effect of a lapse from an initial goalof abstinence. They label this reaction as theAbstinence Violation Effect. This reaction isrelated to the individual’s causal attribution forthe slip. For example, when drinkers attribute thelapse to their own personal failure they tend toexperience guilt and negative emotions that canlead to increased drinking in an attempt to avoidor escape those feelings. When people attributethe lapse to stable, global factors that are beyondtheir control, they are more likely to avoid afull-blown relapse. A subsequent relapse is morelikely for those who attribute the lapse to a per-sonal inability to cope with high-risk situations[39]. It is the individuals who are able learn fromthe mistake and avoid future relapses that arebetter able to develop effective coping skills todeal with triggers [34].


Review of Relapse Prevention andSubstance Abuse Studies

Since the advent of a focus on relapse and main-tenance and, in particular, the response to thedetailed, conceptual perspective of the RelapsePrevention Model, interventions designed to pre-vent relapse have been developed as a clinicalapplication of Marlatt and Gordon’s model [39].The conceptual foundations of this model anda review of its applications have been recentlyupdated by Marlatt and Donovan [38]. Theseinterventions are designed to enhance the main-tenance stage of intentional behavior change andemphasize self-management and coping skills inorder to withstand the challenges presented byrelapse precipitants [38]. The goals of relapseprevention are twofold: to prevent an initiallapse and to provide lapse management to pre-vent a complete relapse if a lapse does occur.Although treatment goals based on harm reduc-tion and decreasing substance use have also beenattempted, most controlled studies that admin-istered relapse prevention treatment measuredoutcome success based on the goal of abstinence[12, 30].

The effectiveness of relapse prevention as anintervention has been reviewed for a variety ofdifferent substances, as well as compared witha variety of alternative interventions. Relapseprevention programs have been designed specif-ically for smoking, alcohol, marijuana, cocaine,and other drug use. Although early reviews con-cluded that there was little evidence for differ-ential effectiveness of relapse prevention acrossclasses of substance abuse [12], later reviewsfound some support for the greater effectivenessof relapse prevention when applied to alcoholor polydrug use disorders in combination withmedication treatment [30].

In terms of comparative efficacy, relapse pre-vention has been found to be superior to no-treatment control groups , and equally effectiveas other treatments, such as supportive ther-apy, social support groups, and interpersonalpsychotherapy [12]. Another review of relapseprevention [30] found that relapse prevention

has a greater impact on improving psychoso-cial functioning than on reducing substanceuse. Relapse prevention also was more effectivewhen combined with use of prescribed medi-cation. Although results were based on a smallnumber of studies and should be interpretedwith caution, Irvin et al. [30] concluded thatindividual, group, and marital modalities wereequally effective in preventing relapse in cohortsof substance abusers. What follows is a briefreview of the literature on the efficacy and useof relapse prevention strategies with differenttypes of addictive behaviors. A detailed pre-sentation of the standard elements is includedon the section entitled Strategies for RelapsePrevention.

Effectiveness Studies AcrossAddictive Behaviors

More research has been done on the effective-ness of relapse prevention for alcoholism andnicotine addiction than in any other area ofaddiction. The recent second edition of RelapsePrevention by Marlatt and Donovan [38] pro-vides a detailed chapter on relapse preventionfor each of the addictive behaviors. For mostdrugs of abuse, relapse prevention constructsand strategies have been applied in clinical set-tings. However, there is limited literature on spe-cific relapse prevention treatments separate frommore generic cognitive-behavioral approaches,and the research consists mainly of trials focus-ing on the Abstinence Violation Effect or otherdimensions of the model. It is disappointing thatthere have not been more studies of the entiremodel and its efficacy specifically in prevent-ing relapse across multiple behaviors. However,since cognitive behavior therapy approacheshave incorporated many aspects of the relapseprevention strategies and evaluations of the cog-nitive behavioral approaches in addictions havebeen favorable in terms of effectiveness and effi-cacy in trials [12], there is some empirical sup-port for many of the constructs and the strategiesthat are described later in this chapter.


Relapse Prevention has been found to bemost effective in treating alcohol and poly-substance use compared with other substancesalone (cocaine, marijuana, cigarettes, etc.) orabusive behaviors [30]. Reviews of alcoholand drug treatment studies generally reporta broad, multidimensional range of outcomesthat include reductions in use, increased timebefore relapse, and improvement in funct-ioning [12].

A comprehensive review of relapse preven-tion interventions for smoking cessation con-ducted by the Cochrane Collaborative foundinsufficient evidence to support use of inter-ventions designed specifically to prevent smok-ing relapse in those who already successfullyquit [27]. Nevertheless, many relapse preven-tion strategies have been included in stan-dard tobacco dependence treatment (knowingpersonal and environmental cues for smok-ing, delaying and urge management, relax-ation, rewards, etc.) and are incorporated intoself-help, and internet-assisted programs [59].Thus, relapse prevention has become a corecomponent of intervention for smoking cessa-tion, rather than a separate and independentintervention specifically designed to preventrelapse. The advent of pharmacotherapies thatcan be used to promote smoking cessation andenhance long-term success (Chantix R©, nico-tine replacement products, Zyban R©) have madethem part of the standard empirically supportedapproaches to quitting and maintaining smokingcessation.

Critical Mechanisms for RelapsePrevention

An increasing number of studies indicate that theprevention of relapse or promotion of its inverse,successful maintenance of change, involves sev-eral overarching constructs. The key dimensionsare motivation, coping, and self-efficacy. Thesethree elements are critical to the long-term suc-cess of recovery and are important componentsto address in any program attempting to prolongabstinence and prevent relapse.

Motivation

Motivation plays an important role in relapseprevention. There is ample evidence that moti-vation for change as well as treatment outcomeexpectancy and client goals of abstinence arerelated to successful treatment outcomes [55,56]. Motivation at the beginning of treatment andthe attitudes and intentions that individuals bringinto treatment are related to early cessation ofdrinking and drug use as well as long-term suc-cess [46]. Individuals who enter treatment aftermaking a decision to change and taking stepstoward change have a better prognosis comparedwith those who enter treatment not have yetmade a decision or taken steps [31]. Those whoappear more committed to change and demon-strate this in the treatment sessions by statementsthat indicate a determination to change (labeled“commitment language”) also have better out-comes [1]. In addition, studies have found thatrelapse prevention is less effective for individu-als who have low initial readiness [24].

How motivation and expectancies affect suc-cessful change and prevent relapse are not com-pletely understood. Motivation is clearly multi-dimensional and involves different mechanismsof change [22]. If motivation is viewed as aseries of tasks outlined by the stages of change,there are multiple elements that are necessary forthe success of recovery and the prevention ofrelapse. For example, in order to avoid relapse,addicted individuals need to have some con-tinuing, compelling reasons to abstain, a firmdecision based on realistic expectations, com-mitment to follow through despite difficulties, aneffective set of strategies and plans on how tomanage triggers, and the ability to problem solveeffectively when the plan is not working. Thesetasks outlined in the five stages of change have tobe accomplished in a “good enough” manner tobe able to sustain change and overcome the diffi-cult challenges presented to anyone stopping ormodifying an addictive behavior [20]. As indi-viduals begin to have some success at changingthe addictive behavior, their motivation to makean attempt to change has to shift to motivationto sustain the change over time in the face ofthe multiple personal and environmental barriers


that could undermine the decision, the commit-ment, the determination, and the plan. Triggershave to be met successfully and the centrifu-gal forces that bring one back to the addictivebehavior, be they physiological, behavioral, orsocial/environmental, must be countered.

One way to understand the function of relapsein recovery is to see it as a sign that the motiva-tional tasks involved in the stages have not beenadequately addressed or successfully mastered.So relapse serves to indicate that the process ofchange has not been done well enough to sup-port success. Recycling through the stages thenserves to help the addicted individual “get itright” in terms of accomplishing these tasks toa degree that enables change to be maintainedand relapse to be avoided. Much of the workof relapse prevention has focused on the cuesand triggers that precipitate relapse. While thoseprecipitants are important, they do not explainrelapse [59]. Looking more broadly at the entireprocess of change and successful completion ofmultiple tasks of the stages can help cliniciansexplore a range of challenges and topics thatspan the entire motivational process instead offocusing only on the moment of the slip, lapse,or relapse.

Coping

Strong support has been found for a relation-ship between coping and relapse prevention [51].Those who fail to use any coping response ina crisis have been found to be more likely torelapse [18]. There are two main theoreticalaspects of coping responses: (1) the focus of cop-ing and (2) the methods of coping [51]. In bothof these areas there is an important distinctionbetween active coping and avoidant coping. Interms of focus, active coping strategies are thosewhich are oriented toward the problem, whereasavoidant coping strategies rely on avoidance ofthe problem. Active strategies are most appropri-ate when an individual has some control over thesituation; whereas avoidant coping may be moreuseful when dealing with situations or events inwhich there is little or no control [48]. Methodsof coping involve strategies and coping activities

that involve both cognitive and behavioralstrategies.

An individual’s inability to utilize an effectivecoping behavior when he or she is experiencinga high-risk situation results in decreased self-efficacy and increased use of a substance as acoping mechanism [39]. However, differentialeffects have not been found for cognitive cop-ing skills versus behavioral coping skills. Rather,actively engaging either type of coping skillsseems to facilitate positive outcomes [9, 18]. Insummary, it appears that in preventing relapsethere is an important role for the addicted indi-vidual’s response to any threats to abstinence orrecovery. However, it is not only the actual effec-tiveness of the response but also the sense ofconfidence that the individuals have in their abil-ity to perform the behaviors critical to recoveryand to sustain change.

Self-Efficacy

Confidence in one’s ability to perform behaviorsseems a critical mechanism in intentional behav-ior change. Bandura [5] defined self-efficacy asthe degree to which an individual feels confidentand capable of performing a certain behavior inspecific situations. The self-evaluation of one’sconfidence to remain abstinent has been associ-ated with lower rates of relapse for both men andwomen, in inpatient and outpatient settings, andfor both short-term and long-term follow-ups[10, 26, 55].

Deficits in abstinence self-efficacy have beenfound to be a significant predictor of relapsein a number of studies [29, 65]. Moreover, thelonger an individual stays abstinent, the strongertheir self-efficacy and sense of personal con-trol becomes. Higher levels of self-efficacy havebeen found to be predictive of improved alco-hol treatment outcomes in a variety of contexts[2, 55].

In a study that investigated abstinence self-efficacy of inpatient alcoholics in predictingtheir ability to remain abstinent after treatment,the level of abstinence self-efficacy measuredat discharge from the residential center wasthe strongest predictor of abstinence at 1-year


follow-up [29]. Additional support has beenfound for the predictive power of abstinenceself-efficacy using the Alcohol ConfidenceQuestionnaire [65]. Higher levels of confidenceto resist the urge to drink in high-risk situationswere associated with greater likelihood to main-tain abstinence 6 months after treatment. Also,lower levels of confidence in situations relatedto urges and testing control were found to predictrelapse to heavy drinking during a 12-week treat-ment period [7]. Greenfield and colleagues [26]found that those who relapsed to alcohol the yearafter hospitalization had lower overall confi-dence scores than those who did not relapse. Thislater relapse onset for the group with higher self-efficacy indicates a relation between efficacyto abstain and duration of abstinent behaviorfollowing treatment.

A large clinical treatment trial for match-ing participants to optimal alcohol treatmentsbased on a number of client characteristics,Project MATCH, considered abstinence self-efficacy to be an important variable for deter-mining appropriate treatment. Levels of absti-nence self-efficacy were measured at the startof the study (baseline) and at the end of treat-ment (post-treatment). For the outpatient arm ofthe study, baseline abstinence self-efficacy waspredictive of drinking outcomes during treat-ment, throughout the 1-year follow-up, and at a3-year follow-up [23, 56]. However, for after-care clients, baseline self-assessment of absti-nence self-efficacy did not predict post-treatmentdrinking, suggesting that efficacy was a morepowerful predictor for those individuals whowere just beginning therapy, compared withthose who were continuing treatment and mayhave already experienced changes to their levelsof abstinence self-efficacy or who evaluated theirself-efficacy in a residential setting.

Strategies for Relapse Prevention

The challenge of preventing relapse is oneof trying to find strategies that can supportand increase motivation, can teach or imple-ment appropriate coping activities when internal

or external cues trigger a desire or tempta-tion to drink or use drugs, and can encourageand strengthen the self-efficacy of the addictedindividual. Proper motivation, coping and effi-cacy would then support recovery and preventrelapse. Most programs and models of treat-ment and mutual help provide activities andsupport that target these variables. AlcoholicsAnonymous, for example, encourages continuedself-reevaluation (e.g., moral inventories, read-ing supportive literature), active coping bothin avoiding high-risk situations, and turning tomeetings and a sponsor to support sobriety, andsupports efficacy with a focus on one day at atime and messages of empowerment based onsupport from a higher power. However, the mostextensive discussion of relapse prevention strate-gies comes from the social learning and relapseprevention models.

Relapse prevention is best used with clientswho have finished an initial detoxification roundof treatment and/or may be coming to theend of initial phases of treatment since theyare the ones who have been able to achievesome measure of abstinence or change. In addi-tion, rates of relapse are highest in the ini-tial phases of the action stage and once initialtreatment has been completed. Relapse preven-tion would also be appropriate for individualswho have experienced a slip after a period ofsustained abstinence, and as a follow-up treat-ment for individuals in the maintenance stage ofchange [42].

Relapse prevention treatment strategies havebeen divided into five specific categoriesof activities: (1) assessment, (2) increasinginsight/awareness, (3) skills trainings, (4) cog-nitive strategies, and (5) lifestyle interventions.Each of these activities will be described indetail below. The activities are interconnectedand there is a logical flow beginning with theinitial strategy of behavioral assessment, whichoften starts with self-monitoring by the client.The goal of this behavioral assessment is toget a clear and complete picture of the cir-cumstances surrounding potential substance use,and the client’s reactions to each of those sit-uations or cues. If the client is still actively


using substances, it is critical to obtain accurateinformation about the amount, environment sur-rounding the use, and the events that precededand followed the use. The next step is to identifyhigh-risk situations, coping skills, and the effec-tiveness of both cognitive and behavioral copingstrategies being used to address the cues [32].

Once key skill deficits are identified, cop-ing skills training can be conducted using eithergroup or individual sessions. An advantage ofthe group format is that peers are natural part-ners for role plays, and can provide examplesof coping or scenarios for group brainstorm-ing. Including significant others in sessions canalso potentially assist in cue reduction and cop-ing training and have a comprehensive impacton a client’s recovery [32]. Finally, the focusturns to the lifestyle of the individual to seehow overall patterns of life activities can helpof hinder continued recovery and the mainte-nance of change. We will review each of thesecomponents in greater detail and then discusstwo newer strategies that have been added tothe relapse prevention tool box: mindfulnessstrategies and medications.

Assessment

Behavioral assessments can be conducted usingdirect observation by a therapist (when cues areavailable or presented), role plays, interviewswith family members or peers, self-report ques-tionnaires (Alcohol or Drug Abstinence Self-Efficacy; Alcohol Confidence Questionnaire,Situational Confidence Questionnaire), and self-monitoring [34, 64, 66]. In fact, self-monitoringserves not only as a means of gathering informa-tion, but also as an intervention. While clientsmay initially be resistant to self-monitoring asa homework assignment, frequently after com-pleting it, they report it is a positive experi-ence. In addition to the insight gained thoughthe self-assessment, monitoring often acts asa catalyst for behavior change and leads to areduction of the monitored behavior [35]. Self-monitoring can also be an effective tool to

combat denial, challenge cognitive distortions,and identify substance-related automatic pro-cesses and negative thoughts, by which a clientis on “autopilot” during a sequence of behaviorsthat lead to using [66].

If the individual is still engaging in theaddictive behavior then using self-monitoring toassess the factors surrounding use is important.If the client has been able to achieve abstinence,a self-assessment of cravings is appropriate toidentify their personal high-risk situations. A fre-quently used type of self-assessment is assigninga drinking diary or craving diary to identifyhabit patterns, potential triggers, high-risk sit-uations, consequences of use to themselves aswell as others, and the physical, emotional,and financial costs of using. It is important forthe individual to understand the social, situa-tional, emotional, cognitive, and physiologicalprecipitants of relapse that make up a high-risksituation [66].

High-risk situations are any situation thatthreatens an individual’s abstinence self-efficacyand poses a strong potential for relapse backto the addictive behavior. High-risk situationsinclude both intra-personal determinants aswell as inter-personal determinants. The intra-personal determinants include both positive andnegative emotional states as potential risk fac-tors. Negative emotional states such as anger,depression, anxiety, boredom, and frustrationcan be triggering particularly if substances wereused as a way of dealing with the emotionalstates. Clients may need additional treatmentsuch as anger management or therapy for depres-sion in addition to drug counseling to give themthe coping skills to deal with such negative emo-tions [32]. Positive emotional states such as feel-ing good, confident, or celebrating can bolsteroverconfidence in being able to handle “just one”use of the substance [34]. Interpersonal deter-minants include conflicts with friends, spouses,family members, and co-workers. Another inter-personal determinant is social pressure thatcan either be overt encouragement to use, orcovert pressure to conform in a situation whereeveryone else may be smoking, drinking, ordrugging [66].


Once the self-assessment has been completed,this information can be used to create a deci-sional balance sheet that helps to concretelylay out the pros and cons of using in partic-ular situations. Such a worksheet can clarifythe specific reasons for maintaining abstinenceand increase motivation particularly for individ-uals who are not fully committed to treatmentor recovery. Assessments can not only iden-tify high-risk situations but also examine thecommitment, self-efficacy, and coping skills thatthe individual may use to address challengingsituations.

Insight and Awareness

Increasing insight and awareness assists clientsin understanding the processes that triggera relapse including social pressure, physio-logical mechanisms, or emotion management.Understanding these mechanisms is an impor-tant part of preparing for high-risk situations andunexpected triggers and urges. This can be mademore concrete by creating an ongoing road mapto relapse by which clients identify upcominghigh-risk situations, as well as potential unex-pected risks and emergency situations. They canalso identify early warning signs that predict ahigh-risk situation [25]. The road map can alsoidentify ways they can refrain from using withan effective coping strategy for a particular situa-tion [34]. The next challenge is to make sure thatthey have access to the types of skills and self-management strategies that would be needed toeffectively address their risk situations that couldprovoke a return to the substance use or addictivebehavior.

Behavioral Coping Skills

The behavioral skills training componentinvolves training in a number of skills andstrategies in different life domains to assistclients in resisting relapse. Skills training is

designed to develop specific skills needed tocope with situations and to increase the client’ssense of self-efficacy to sustain recovery andovercome risks for relapse. For example, relaxa-tion training can be particularly helpful withclients who used substances to alleviate anxietyor to cope with stressful situations. Progressiverelaxation training or mindfulness meditationcan assist in decreasing anxiety in a high-risksituation enough that an alternative coping strat-egy can then be employed [67]. Assertivenesstraining can assist clients with poor social skillsin navigating interpersonal pressures to use,as well as encouraging use of social supportfor continued abstinence. Practicing ways torefuse substances, deal with criticism, andappropriately express feelings of frustration,anger or anxiety can assist clients in buildingtheir repertoire of coping skills [66].

Cue exposure is another cognitive behavioraltechnique that is used to build up client’s absti-nence self-efficacy through gradually exposingthem to substance-related cues. It is a counterconditioning procedure in which clients are pro-gressively desensitized to the stimuli associatedwith the addictive behavior in controlled con-ditions. Clients practice using coping skills asthey are gradually exposed to different high-risksituations. In order to avoid iatrogenic effectsfrom putting clients in potentially very unset-tling conditions, exposure should always endwith adequate processing of the experience anddebriefing such as a relaxation exercise or medi-tation [3, 67].

There are numerous skills that can be devel-oped and there are manuals for various typesof addictive behaviors that contain modulesfor specific skills training in effective com-munication, anger management, coping withnegative emotions, depression, assertiveness,handling rejection, meditation, and managingfamily members who use substances. Thesemodules can be used depending on the typesof situations that are identified by the addictedindividual so that the relapse prevention strate-gies can be personalized to the types of situ-ations and cues that are most salient for thatindividual [47].


Cognitive Strategies

In addition to behavioral skills, there are alsoa number of cognitive strategies that can betaught and used to combat relapse. Often relapseis precipitated not just by the external cuesbut by the interpretations and self-statementsfrom within the individual when confrontedwith a high-risk situation. Cognitive strategiesare designed to challenge and change waysthat individuals process information and prob-lematic self-statements that undermine copingand efficacy. These cognitive strategies includecognitive restructuring, relapse rehearsal, label-ing and detachment, and coping imagery.Cognitive restructuring is the process of correct-ing addiction-related cognitive distortions andfrequent patterns of thinking such as seeminglyirrelevant decisions and the abstinence violationeffect. Seemingly irrelevant decisions are deci-sions which are not inherently related to theactual substance use, but can put the client in ahigh-risk situation. An example would be a clientgetting his car fixed at a mechanic one blockfrom his favorite bar (alcohol-associated cues).Doing so could prompt him to go in to see if anyfriends (interpersonal pressure) were around as away to alleviate the boredom (negative emotion)of waiting for his car to be fixed [34]. The goalof cognitive interventions is to help individualsexamine and prevent such seemingly irrelevantdecisions that put individuals in harm’s way andcan lead to relapse.

As was previously noted, the abstinence vio-lation effect is a potential reaction to initial useor reengagement in the addictive behavior. Ifafter a lapse clients feel they failed and expe-rience a significant decrease in abstinence self-efficacy, they are more likely to go back to usingas much as they used to rather than attempt toregain abstinence. It is important to put a lapseinto proper perspective so that clients can returnto the recovery process rather than returning totheir prior habits. Recovery from a slip seemsto require an interpretation and attribution ofthe lapse as caused by external or environmentalfactors, a continuing commitment to the change

goal, a confidence in the ability to recover froma lapse, and a reactivation of active coping toavoid or manage the triggering situations orcues [34].

Relapse rehearsal and relapse fantasies are ameans of associating the coping skills learnedin treatment with a crisis situation. By imagin-ing a high-risk situation and using an effectivecoping skill to avoid substance use, the clientis able to prepare for a variety of high-risksituations and evaluate the expected effective-ness of different coping strategies. Labeling anddetachment are coping strategies aimed at help-ing clients experience urges and cravings with-out succumbing to them. This strategy reframescravings as temporary sensations of desire asopposed to unending compulsions that dictatea client’s behavior. Helping clients view crav-ings as coming from environmental cues, andnot coming from within themselves, can assistin decreasing the subjective strength of thecravings [66].

Other coping strategies to deal with urgesinclude challenging the urges, recalling negativeconsequences of using, thinking of the bene-fits of not using, thought stopping, distraction,delaying a decision of whether to use or not,leaving the situation, and getting support fromothers [32]. Coping imagery is another cognitivetechnique that can assist with combating high-risk situations. Making use of guided fantasy, thetherapist and client can make use of personallyrelevant imagery that can bolster the individual’sself-efficacy to avoid relapse [66].

Seeking support for abstinence and recov-ery from a slip involves both cognitive andbehavioral strategies. Individuals that have socialnetworks filled with drinking or drug use thatthey cannot leave are more prone to relapseand need to recognize the need to change thecomposition of the network and build anotherone that is supportive of recovery [37]. Mutualhelp groups like Alcoholics Anonymous andSmart Recovery offer opportunities to listenand understand the perspectives and experiencesof others and offer both cognitive and behav-ioral coping activities for the addicted indi-vidual [53].


Lifestyle Interventions

The final stage of the process of change is tointegrate the new behavior into the lifestyle ofthe individual [20]. Replacing dependence withabstinence or excess with moderation gener-ally involves a change not only in one behav-ior but in the addict’s overall way of life.Lifestyle interventions for relapse preventioninclude lifestyle balance, substitute indulgences,positive addictions, and stimulus control tech-niques. Lifestyle balance is a global strategy toameliorate stressful situations, promote appro-priate coping, improve problem solving, andincrease pleasurable activities such as hobbies orspending time with friends and family that werereplaced by substance use. It is also important forclients to understand that their desires not to bedepressed or to be social, which can lead to high-risk situations, are reasonable desires. However,they need to find alternative ways of fulfillingthese needs without using substances or turningto other problematic, addictive behaviors [34].Mutual help groups and activities can play animportant role in offering a venue and a series ofactivities that can support the lifestyle changes.

Substitute indulgences are activities that areimmediately gratifying and can serve as a sub-stitute for the addictive behavior when a clientexperiences an urge or craving. One example isto take a hot shower or bubble bath instead ofgoing to a bar to relax after a difficult day atwork. It is important however, that the pleasur-able activities are not harmful in the long term.Positive addictions have a similar function in thatthey replace the activity of substance use, buthave more long-term rewards and value, ratherthan immediate gratification. Examples of posi-tive addiction include taking up a sport, regularexercise, or a new hobby. It is important that pos-itive addictions be practical and something thatthe client is able to perform and sustain on theirown [34].

Stimulus control techniques attempt toaddress the physical cues for relapse. A frequentexample is the strong association of drinkingand smoking, either of which could serve as

a cue for the other. While experiencing somecues is inevitable, it is an important step for aclient to eliminate the cues under their controlby changing their routine as much as possible.An example for a client who is quitting smokingwould be to throw out all cigarettes, ashtrays,and lighters, rearrange the furniture so that afavorite smoking area is not present, and changethe morning routine so that it does not revolvearound the first cigarette of the day [34].

Mindfulness-Based Strategies forRelapse Prevention

Recently another set of strategies has been addedto relapse prevention treatment called mindful-ness based relapse prevention. The basic struc-ture and goals of relapse prevention remain thesame but there is an emphasis on the use of mind-fulness techniques throughout the interventionprocess. Mindfulness meditation is a metacogni-tive skill learned through practice of meditationthat allows the individual to achieve perspec-tive, patience, and inner peacefulness that canreduce relapse cues and create lifestyle changesto promote recovery [8].

Mindfulness is a state of detached awarenessof emotions, cognitions, and physical sensations.It is a state of attentional focus which can beused to change client’s attitudes towards theirthoughts, feelings, and sensations. Mindfulnessbased relapse prevention uses development ofthe mindfulness state to disrupt maladaptive cog-nitions by heightening awareness of cravingswithout identifying with, judging, or reactingto them. The mindfulness state interrupts thechain of cognitions and emotions that follow anurge or craving thus decreasing the likelihoodof an action based on them [67]. Mindfulnessappears to work differently than thought sup-pression, which prior studies have found to bean ineffective coping technique [8]. There havebeen promising initial findings regarding theusefulness of mindfulness in relapse preven-tion with incarcerated substance abusers, thoughmore thorough investigation is necessary [8].


Medications for Relapse Prevention

Medications have also been found to be usefuladjunct to promote change and prevent relapsein treatments for nicotine, alcohol, and opi-ate addiction. Since the 1990s both Naltrexoneand Acamprosate (Campral R©), have been addedto disulfiram (Antabuse R©) as approved medi-cations in the United States to be prescribedfor alcoholism treatment [36]. Use of disulfiramcauses a flushing or sick reaction when alcoholis ingested, which results in extremely low com-pliance, and as a result has not been found to besuperior to placebo. Meta-analyses have shownthat both acamprosate and naltrexone can helpreduce cravings and increase days abstinent [42].Acamprosate may be more effective in promot-ing complete abstinence, while naltrexone maybe more effective when the treatment goal isreduced drinking, though there have been mixedclinical outcomes [57].

Methadone, buprenorphine, levo-alpha-acetylmethadol, and naltrexone have beenused to treat heroin addiction. Opiate main-tenance using methadone, buprenorphine, orlevo-alpha-acetylmethadol assist in decreasingthe extremely high rates of relapse in treatmentfor opiate addiction, although the medicationsthemselves can be addictive at high doses aswell as have negative side effects [62].

Medications for nicotine cessation includea variety of nicotine replacement products,varenicline tartrate (Chantix R©), and the anti-depressant bupropion (Zyban R©). In an analysisof over 6,000 articles, researchers found thatuse of medications for nicotine replacement ther-apy including gums, inhalers, patches, and nasalsprays, as well as the antidepressant bupropion atleast doubles the likelihood of quitting comparedwith placebo. In addition, the effects of medica-tions are substantially increased when added tobehavioral interventions [16].

Although there have been studies of med-ications to treat cocaine addiction, they havenot resulted in improved treatment outcomeswith any consistency [42]. It is generally rec-ommended that medications be administered in

addition to a psychosocial intervention suchas relapse prevention for opiate and nicotinetreatment [15, 16, 62], though investigations ofcombined therapy and medication have showedmixed results compared with either alone fortreating alcoholism [4, 57].

When Relapse Prevention Fails

All of the above strategies are designed to helpthe addicted individual achieve and maintainchange once initiated. However, as many of thestudies demonstrated, these strategies are helpfulto some but not others [9, 28]. Even individu-als who have been taught coping strategies andacknowledge the critical cues or triggers thatmake them vulnerable to relapse have not beensuccessful in preventing relapse. This is whensuccessful recycling promotion has to be sub-stituted for relapse prevention. Clinicians andresearchers working in addictions have to takea life course perspective, abandon the singleattempt, linear model of success, and see the pro-cess of successful change as better representedby a cyclical process that in the long run yieldssuccess change [54]. We will discuss the lifecourse perspective and the cyclical model below.

A Life Course Perspective on Recovery

Alcoholism and drug addictions are chronic con-ditions that can span decades and numerousperiods of treatment, remission from drinkingor drug use, relapse to uncontrolled drinking,and treatment re-entry. Treatment providers havea comparatively small amount of contact withclients in their overall treatment and recoverycareers. It is important to understand the factorsand context outside of treatment that are relatedto clients’ entry into treatment and that pre-cipitate relapse episodes. Taking the life courseperspective of recovery is an important step forresearchers in order to truly appreciate the fullcontext in which a particular treatment episode“succeeds” or “fails” [21].


Some individuals with less severe dependenceare able to avoid the cycle of relapse and main-tain either continued abstinence or a lower levelof non-harmful substance use [41]. However, therecovery process of many addicted individuals ismarked by multiple transitions in their treatmentcareer. In long-term follow-up studies spanningup to 16 years, researchers have consistentlyfound that individuals who received treatmentsooner and spent more time in treatment hadlonger periods of remission from alcohol depen-dence. Greater use of alcohol was predicted byless self-efficacy, greater use of avoidance cop-ing, and less of a perception that drinking was asignificant problem [49, 50].

Successive Approximations,Recycling, and Learning from the Past

As described earlier, learning how to overcomean addiction and to avoid relapse is essentiallya process of successive approximations wherebyaddicted individuals try to modify the addictivebehavior, fail to complete the change, then tryagain until they are successful or until death, dis-ability, or prison intervenes. There is no guaran-tee of success even after multiple attempts sincethe learning may not be complete or the physi-ological or environmental barriers are too greatfor this individual to overcome. However, largenumbers of individuals who have been classifiedas dependent on a substance have been success-ful in significantly changing addictive behaviorsafter multiple attempts. Half of the “ever smok-ers” in the U.S. have quit smoking successfullyand we have over 40 million of these suc-cess stories [13]. A recent epidemiological studyby Dawson and colleagues [19] examined over4,000 individuals who had had a lifetime diag-nosis of alcohol dependence. Based on past yeardrinking, they estimated that approximately 47%could be considered in full remission and wereclassified as either abstinent (18.2%), low-riskdrinker (17.7%) or asymptomatic risk drinker(11.8%) with only 25% meeting the criteria

for being dependent during the past year. Thisstudy highlights once again that the definition ofrelapse determines whether you consider some-one in recovery or relapsed. Nevertheless, recov-ery does happen for many addicted individuals,demonstrating that over time there is signifi-cant change and successful self-management ofaddictive behaviors.

Relapse represents a problem in the prepara-tion, planning, or implementation of the actionplan. As such, it highlights some deficit or bar-rier that needs remediation or a different solu-tion. Relapse then, should be viewed from apragmatic and learning perspective. Trial anderror are an integral part of psychological prin-ciples and medical practice. If one strategy ormedication does not seem to help the individ-ual completely manage the problem or beginsto cause more problems than it solves (e.g.,side effects), practitioners would quickly tryanother strategy or medication. However, oftenwith addictions the inability to succeed has beenviewed as a deficit of motivation, will, or charac-ter. A learning perspective that views the relapseas an opportunity to learn from the past and dosomething differently accurately reflects longi-tudinal research and would be critical to creatingeffective relapse prevention activities that reflectthe reality of recycling.

Promoting recycling represents a valid relapseprevention strategy that accepts the occurrenceof relapse. Recycling engages individuals whohave relapsed in a review of past success andfailure with a view of finding what went rightor wrong and when or where it occurred so thatthe deficits in motivation, coping, or self-efficacycan be remediated and the types of barriers thatled to the relapse surmounted. In longitudinalstudies, many individuals get stuck in the pro-cess of change and remain in precontemplationor contemplation for months or years [11, 63].The goal of recycling is to help individuals makeanother more successful attempt to change theaddictive behavior more quickly and effectively.Policies and practices that limit access to ser-vices after a relapse or interpret relapse as afailure of the treatment undermine the recyclingprocess.


Treatment Recommendations

There are several important considerations thatsummarize this review of relapse prevention andrecycling in the addictions. Each of these consid-erations has important implications for treatmentand research. We will highlight below the keyconsiderations and implications.

1. Relapse is part of the process of successfulbehavior change. Partial success and outrightfailure offer opportunities for learning thatare critical for long-term successful recov-ery. As in other areas of life, the importantreality is not that you have fallen down,but that you get back up and try again,hopefully having learned important lessonsabout how to achieve the goal without fallingdown again. Relapse prevention begins at thestart of the change process and should bean integral part of all treatment programs.However, addicted individuals may not beable to avoid and practitioners may not beable to prevent all relapse. In their effortsto promote maintenance and prevent relapse,treatments and treatment providers shouldconcentrate on helping individuals managemotivation, engage in critical coping activ-ities and support and increase their self-efficacy to perform the behaviors needed toachieve abstinence and recovery. In addition,special attempts should be made to engage orreengage individuals who relapse in a conver-sation and collaboration to promote recyclingto remedy the problems in the process ofchange that contributed to the relapse.

2. Maintaining change is the goal of relapseprevention. A number of elements havebeen identified as important maintenanceenhancers that also act to prevent relapse.Commitment fueled by solid decision-making leading to adequate planning, skillsacquisition and implementation, and along-term goal and perspective seem to becritical to sustaining significant modificationof addictive behaviors. A comprehensiveperspective on the process of change and a

life course perspective appear to be essentialwhen addressing and comprehending relapse.

3. Support sustains success. Support from fam-ily, friends and peers seems to play an impor-tant role in prevention relapse. Individualswho seek support and engage in mutual helpgroups have better outcomes [60]. Creating orsupporting existing support groups and help-ing individuals access and utilize the supportcan assist in relapse prevention. Integratingthe relapse prevention model perspective withthe mutual help perspective offers socialinteractions and support that can enhance per-sonal coping, motivation, and self-efficacy.

4. Multiple problems complicate maintenanceof change. Pay attention to complicating lifeproblems be they financial, family, social,medical, legal, and psychiatric in origin thatcan have an impact on successful recoveryfrom addictions [44]. Psychiatric illness andemotional distress are risk factors for becom-ing addicted and act as barriers to begin-ning and remaining in recovery. Integrationof treatment efforts across multiple problemsseems to offer the best potential for success-ful change of the addiction as well as the otherproblems.

5. Stigma stifles success. Viewing relapse as afailure and relapsers as “defective people”who cannot change promotes the stigmatiza-tion of addictions in general, and relapsers inparticular. Relapse is a problem of behaviorchange and not a unique problem of addic-tions. Addressing and managing relapse ispart and parcel of all efforts to change estab-lished patterns of behavior and to managechronic illnesses.

References

1. Amrhein PC, Miller WR, Yahne CE, Palmer M,Fulcher L (2003) Client commitment language dur-ing motivational interviewing predicts drug use out-comes. J Consult Clin Psych 71(5):862–878

2. Annis HM, Davis CS (1988) Self-efficacy and theprevention of alcoholic relapse: initial findings froma treatment trial. In: Baker TB, Cannon DS (eds)


Assessment and treatment of addictive disorders.Praeger, New York, pp 88–112

3. Annis HM, Schober R, Kelly E (1996) Matchingaddiction outpatient counseling to client readinessfor change: the role of structured relapse preven-tion counseling. Exp Clin Psychopharmacol 4(1):37–45

4. Anton RF et al (2006) Combined pharmacother-apies and behavioral interventions for alcoholdependence: the COMBINE study: a random-ized controlled trial. JAMA: J Am Med Assoc295(17):2003–2017

5. Bandura A (1977) Self-efficacy: toward a unify-ing theory of behavior change. Psychol Rev 84:191–215

6. Bandura A (1997) Self-efficacy: the exercise of con-trol. WH Freeman/Times Books/Henry Holt & Co.,New York, NY, pp ix, 604

7. Blomquist O, Hernandez-Avila CA, Berleson JA,Ashraf A, Kranzler HR (2003) Self-efficacyas a predictor of relapse during treatment foralcohol dependence. Addict Disorders Treat 2:135–145

8. Bowen S et al (2007) The role of thought sup-pression in the relationship between mindfulnessmeditation and alcohol use. Addict Behav 32(10):2324–2328

9. Brownell KD et al (1986) Understanding andpreventing relapse. Am Psychologist 41(7):765–782

10. Burling TA et al (1989) Self-efficacy and relapseamong inpatient drug and alcohol abusers: apredictor of outcome. J Studies Alcohol 50(4):354–360

11. Carbonari JP, DiClemente CC, Sewell KB(1999) Stage transitions and the transtheoreti-cal ‘stages of change’ model of smoking cessation.Swiss J Psychol/Schweizerische Zeitschrift fürPsychologie/Revue Suisse de Psychologie 58(2):134–144

12. Carroll KM (1996) Relapse prevention as a psy-chosocial treatment: a review of controlled clinicaltrials. Exp Clin Psychol 4(1):46–54

13. CDC (2007) Cigarette smoking among adults –United States, 2006. MMWR 2006. 56:1157–1161

14. Childress AR, Miller WR, Carroll KM (2006) Whatcan human brain imaging tell us about vulnera-bility to addiction and to relapse? In: Rethinkingsubstance abuse: what the science shows, and whatwe should do about it. Guilford, New York, NY,pp 46–60

15. Copenhaver MM, Bruce RD, Altice FL (2007)Behavioral counseling content for optimizing theuse of buprenorphine for treatment of opioid depen-dence in community-based settings: a review ofthe empirical evidence. Am J Drug Alcohol Abuse33(5):643–654

16. Corelli RL, Hudmon KS (2002) Medications forsmoking cessation. West J Med 176(2):131–135

17. Cummings C, Gordon JR, Marlatt GA (1980)Relapse: prevention and prediction. In: Miller WR(ed) Addictive behaviors. Pergamon, New York,pp 291–321

18. Curry SG, Marlatt GA (1985) Unaided quitters’strategies for coping with temptations to smoke. In:Wills TA, Shiffman S (eds) Coping and substanceuse. Academic, Orlando, FL, pp 243–265

19. Dawson DA et al (2006) Recovery from DSM-IV alcohol dependence: United States, 2001–2002.Alcohol Res Health 29(2):131–142

20. DiClemente CC (2003) Addiction and change: howaddictions develop and addicted people recover.Guilford substance abuse series. Guilford, NewYork, NY, pp xviii, 317

21. DiClemente CC (2006) Natural change and the trou-blesome use of substances: a life-course perspective.In: Miller WR, Carroll KM (eds) Rethinking sub-stance abuse: what the science shows, and whatwe should do about it. Guilford, New York, NY,pp 81–96

22. DiClemente CC (2007) Mechanisms, determinantsand process of change in the modification of drink-ing behavior. Alcholoism: Clin Exp Res 31(S3):8

23. DiClemente CC, Daniels JW, Carbonari JP (1997)Determinants of alcohol abstinence self-efficacy: atest of Bandura’s model. Poster at Association forAdvancement of Behavior Therapy

24. Gonzalez VM, Schmitz JM, DeLaune KA (2006)The role of homework in cognitive-behavioral ther-apy for cocaine dependence. J Consult Clin Psychol74(3):633–637

25. Gorski TT (1993) Relapse prevention: a state of theart overview. Addiction Recovery 13(2):25

26. Greenfield S, Hufford M, Vagge L, Muenz L,Costello M, Weiss R (2000) The relationship ofself-efficacy expectancies to relapse among alcoholdependent men and women: a prospective study. JStudies Alcohol 61:345–351

27. Hajek P, Stead LF, West R, Jarvis M, Lancaster T(2005) Relapse prevention interventions for smok-ing cessation. Cochrane Database Syst Rev 1:1–40

28. Hunt WA, Barnett LW, Branch LG (1971) Relapserates in addiction programs. J Clin Psychol 27:455–456

29. Ilgen M, McKellar J, Tiet Q (2005) Abstinenceself-efficacy and abstinence 1 year after substanceuse disorder treatment. J Consult Clin Psychol73(6):1175–1180

30. Irvin JE, Bowers CA, Dunn ME, Wang MC (1999)Efficacy of relapse prevention: a meta-analyticreview. J Consult Clin Psychol 67(4):563–570

31. Isenhart C (1997) Pretreatment readiness for changein male alcohol dependent subjects: predictorsof one-year follow-up status. J Studies Alcohol58:351–357

32. Kadden RM, Cooney NL (2005) Treating alcoholproblems. In: Marlatt GAD, Dennis M (eds) Relapseprevention: maintenance strategies in the treatment


of addictive behaviors, 2nd edn. Guilford, NewYork, NY, pp 65–91

33. Koob GF et al (2007) Neurobiology of addiction:a neuroadaptational view relevant for diagnosis.In: Diagnostic issues in substance use disorders:refining the research agenda for DSM-V. AmericanPsychiatric Association, Washington, DC, pp 31–43

34. Larimer ME, Palmer RS, Marlatt GA (1999)Relapse prevention: an overview of Marlatt’scognitive-behavioral model. Alcohol Res Health23(2):151–160

35. Lichtenstein E, Danaher BG (1976) Modificationof smoking behavior: a critical analysis of theory,research and practice. In: Advances in behaviormodification. Academic, New York, pp 79–132

36. Litten RZ, Allen J, Fertig J (1996)Pharmacotherapies for alcohol problems: areview with focus on developments since 1991.Alcoholism: Clin Exp Res 20(5):859–876

37. Longabaugh R et al (1993) The effect of socialinvestment on treatment outcome. J Studies Alcohol54:465–478

38. Marlatt GA, Donovan DM (2005) Relapse pre-vention: maintenance strategies in the treatment ofaddictive behaviors, 2nd edn. Guilford, New York,p 416

39. Marlatt GA, Gordon JR (1985) Relapse prevention:maintenance strategies in the treatment of addictivebehaviors. Guilford, New York

40. Marlatt GA, Gordon JR (1980) Determinants ofrelapse: implications for the maintenance of behav-ior change. In: Davidson PODSM (ed) Behaviormedicine: chaning health lifestyles. Brunner/Mazel,New York

41. Marlatt GA, Witkiewitz K (2002) Harm reductionapproaches to alcohol use: health promotion, pre-vention, and treatment. Addict Behav 27(6):867

42. Marlatt GA, Witkiewitz K (2005) Relapse preven-tion for alcohol and drug problems. In: Marlatt GA,Donovan, DM (eds) Relapse prevention: mainte-nance strategies in the treatment of addictive behav-iors, 2nd edn. Guilford, New York, NY, pp 1–44

43. McClelland DC (1987) Human motivation.Cambridge University, New York

44. McLellan AT et al (1983) Predicting responseto alcohol and drug abuse treatment. Arch GenPsychiatry 40:620–625

45. Miller WR, Carroll KM (2006) Rethinking sub-stance abuse: what the science shows, and whatwe should do about it. Guilford, New York, NY,pp xvi, 320

46. Miller WR, Westerberg VS, Harris RJ, ToniganJS (1996) What predicts relapse? Prospective test-ing of antecedent models. Addiction 91(Suppl):S155–S171

47. Monti PM et al (1989) Treating alcohol dependence:a coping skills training guide. Guilford, New York

48. Moos RH (1993) Coping responses inventory.Psychological Assessment Resources, Odessa, FL

49. Moos RH, Moos BS (2006) Treated and untreatedindividuals with alcohol use disorders: rates and pre-dictors of remission and relapse. Int J Clin HealthPsychol 6(3):513–526

50. Moos RH, Moos BS (2007) Treated and untreatedalcohol-use disorders: course and predictors ofremission and relapse. Evaluation Rev 31(6):564–584

51. Moser AE, Annis HM (1996) The role of coping inrelapse crisis outcome: a prospective study of treatedalcholics. Addiction 91(8):1101–1113

52. Niaura R (2000) Cognitive social learning andrelated perspective on drug craving. Addiction95(Suppl 2):S155–S163

53. Nowinski J, Baker S, Carroll K (1992) Twelve stepfacilitation therapy manual: a clinical research guidefor therapists treating indivduals with alcohol abuseand dependence. NIAAA, Rockville MD

54. Prochaska JO, DiClemente CC, Norcross JC (1992)In search of how people change: applicationsto addictive behaviors. Am Psychologist 47(9):1102–1114

55. Project MATCH Research Group (1997) Matchingalcoholism treatments to client heterogeneity:project MATCH Posttreatment drinking outcomes.J Studies Alcohol Drugs 58(1):7–29

56. Project MATCH Research Group (1998) Matchingalcoholism treatments to client heterogeneity:project MATCH three-year drinking outcomes.Alcoholism: Clin Exp Res 22(6):1300–1311

57. Rosenthal RN (2006) Current and futuredrug therapies for alcohol dependence. J ClinPsychopharmacol 26:S20–S29

58. Sheehan T, Owen P (1999) The disease model.In: Epstein BSMEE (ed) Addictions: a compre-hensive guidebook. Oxford University, New York,pp 268–286

59. Shiffman S (2005) Relapse prevention for smok-ing. In: Gordon GAMJ (ed) Relapse prevention:maintenance strategies in the treatment of addictivebehaviors. Guilford, New York

60. Tonigan JS, Connors G, Miller WR (1996) Thealcoholics anonymous involvement scale (AAI):reliability and norms. Psych Addict Behav 10:75–80

61. Vaillant GE (1983) The natural history of alco-holism: causes, patterns, and paths to recovery.Harvard University, Cambridge, MA

62. van den Brink W, Haasen C (2006) Evidence-based treatment of opioid-dependent patients. CanJ Psychiatry 51(10):635–646

63. Velicer W et al (1990) Patterns of change: dynamictypology applied to smoking cessation. MultivariateBehav Res 25:587–611

64. Velicer WF et al (1990) Relapse situations andself-efficacy: an integrative model. Addict Behav15(3):271–283

65. Vielva I, Iraurgi I (2001) Cognitive and behaviouralfactors as predictors of abstinence following


treatment for alcohol dependence. Addiction96(2):297–303

66. Wanigaratne S, Wallace W, Pullin J, Keaney F(1990) Relapse prevention for addictive behaviors:a manual for therapists. Mosby, Chicago

67. Witkiewitz K, Marlatt GA, Walker D (2005)Mindfulness-based relapse prevention for alcoholand substance use disorders. J Cogn Psychother.

Special Issue: State-of-the-Art in BehavioralInterventions for Substance Use Disorders19(3):211–228

68. Zywiak WH, Connors GJ, Maisto SA, WesterbergVS (1996) Relapse research and the reasonsfor drinking questionnaire: a factor analysis ofMarlatt’s relapse taxonomy. Addiction 91(Suppl):S121–S130

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