relapse prevention g. alan marlatt, ph.d. university of washington addictive behaviors research...
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Relapse PreventionRelapse Prevention
G. Alan Marlatt, Ph.D.
University of WashingtonAddictive Behaviors Research Center
[email protected] http://depts.washington.edu/abrc
Contemporary Approaches to Contemporary Approaches to Substance Abuse TreatmentSubstance Abuse Treatment
12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA Traditional Minnesota Model Inpatient Treatment - Detox,
medical supervision, disease model, AA, group, drug education Intensive Outpatient Minnesota Model Treatment - Medical
supervision, individual sessions, disease model, AA, groups Therapeutic Communities for Substance Abuse - 24-hour
residential setting, norms, responsibility, encounter groups Pharmacological Therapy – Antabuse, methadone, LAMM,
buprenorphine, naltrexone, etc Psychological Therapies – Group, couple, and individual
therapy Behavior Therapy – Aversion therapy, cue exposure, skills
training, contingency management, community reinforcerment Cognitive-Behavioral Therapy – Relapse Prevention, coping
skills training, cognitive therapy, lifestyle modification
Brickman’s Model of Helping & Coping Applied to Addictive
Behaviors
Is the person
responsiblefor the
development
of theaddictive behavior?
Is the person responsible forchanging the addictive behavior?
YES
NO
COMPENSATORY MODEL
(Cognitive-Behavioral)
Relapse = Mistake, Error, or Temporary Setback
YES NO
MORAL MODEL(War on Drugs)
Relapse = Crime or Lack of Willpower
SPIRITUAL MODEL(AA & 12-Steps)
Relapse = Sin or Loss of Contact with Higher Power
DISEASE MODEL(Heredity & Physiology)
Relapse = Reactivation of the Progressive Disease
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 10Drinking is a risk behavior, not a disease.
Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 9 Unlike biological disease, alcoholism can be
eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 8 There is no official medical diagnosis of
“Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 7 There is no known single biological or
genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 6 Effective treatments for alcoholism are
almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 5 Unlike with most diseases, many people
resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 4 Loss of control drinking in alcoholics is
triggered more by psychological factors (expectancy) than by the biological effects of alcohol.# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).
# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 3 Belief in the disease model of alcoholism
predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.
# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.
# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).
# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 2 The ‘Father’ of the disease model of
alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence)# 3 Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.
# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.
# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).
# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease
… and the #1 reasonwhy alcoholism
is NOT a disease …
Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a
DiseaseDisease# 1 If alcoholism is not a disease, what is it? It
is an Addictive Behavior (with multiple biopsycho-social causes and consequences) that increases the risk of physical disease (i.e. cirrhosis)# 2 The ‘Father’ of the disease model of alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence)
# 3 Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.
# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.
# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).
# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).
# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).
# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).
# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.
# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.
Biopsychosocial Factors in Development and Maintenance of
Addictive BehaviorsBIOLOGICAL FACTORS
Biological vulnerability and genetic predisposition in interaction with certain facilitating environments create problems and eventually disease.
Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body.
Tolerance – Increased frequency of use and higher doses over time.
Withdrawal – Negative effects of cessation of addictive behaviors.
Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances.
Biopsychosocial Factors in Development and Maintenance of
Addictive BehaviorsPSYCHOLOGICAL FACTORS
Motivation – Stages of habit initiation and stages of habit change.
Expectancies – Positive outcomes of drug use and self-efficacy.
Attributions – Effects of substance use and reasons for relapse.
Sensation-Seeking – Excessive need for stimulation Impulsivity – Inability to effectively control or restrain
behavior. Negative Affect – Dysphoric moods such as anxiety &
depression. Poor Coping – Deficits in cognitive and behavioral skills or
inhibitions in the ability to perform behaviors due to the effects of anxiety.
Biopsychosocial Factors in Biopsychosocial Factors in Development and Maintenance of Development and Maintenance of
Addictive BehaviorsAddictive BehaviorsSOCIOCULTURAL FACTORS
Family History – Dysfunctional family settings especially parental alcohol and drug problems and parental abuse or neglect of children.
Peer Influences – Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership.
Culture and Ethnic Background – Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the body’s rate and efficiency of metabolizing drugs and alcohol.
Media/Advertising – Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use.
Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, and Heroin Addicts
RELAPSE SITUATION (Risk Factor)
Alcoholics (N=70)
Smokers (N=35)
Heroin Addicts (N=32)
TOTAL Sample (N=137)
Negative Emotional States 38% 43% 28% 37%
Negative Physical States 3% - 9% 4%
Positive Emotional States - 8% 16% 6%
Testing Personal Control 9% - - 4%
Urges and Temptations 11% 6% - 8%
TOTAL 61% 57% 53% 59%
Interpersonal Conflict 18% 12% 13% 15%
Social Pressure 18% 25% 34% 24%
Positive Emotional States 3% 6% - 3%
TOTAL 39% 43% 47% 42%
INTRAPERSONAL DETERMINANTS
INTERPERSONAL DETERMINANTS
“Let’s just go in and see what happens.”
Analysis of High-Risk Situations for RelapseAlcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and
OvereatersRELAPSE SITUATION (Risk Factor)
Alcoholics (N=70)
Smokers (N=64)
Heroin Addicts (N=129)
Gamblers (N=29)
Overeaters (N=29)
TOTAL Sample (N=311)
Negative Emotional States 38% 37% 19% 47% 33% 35%
Negative Physical States 3% 2% 9% - - 3%
Positive Emotional States - 6% 10% - 5% 4%
Testing Personal Control 9% - 2% 16% - 5%
Urges and Temptations 11% 5% 5% 16% 10% 9%
TOTAL 61% 50% 45% 79% 48% 56%
Interpersonal Conflict 18% 15% 14% 16% 14% 16%
Social Pressure 18% 32% 36% 5% 10% 20%
Positive Emotional States 3% 3% 5% - 28% 8%
TOTAL 39% 50% 55% 21% 52% 44%
INTRAPERSONAL DETERMINANTS
INTERPERSONAL DETERMINANTS
High-Risk Situation
Effective coping response
Increased self-efficacy
Decreased probability of
relapse
Ineffective coping response
Lapse (initial use of the
substance)
Increased probability of
relapse
Abstinence Violation Effect
¤ Perceived effects of the substance
Decreased Self-efficacy
¤ Positive outcome
Expectancies (for initial effects of
the substance)
A Cognitive Behavioral Model of
the Relapse Process
Relapse Prevention: Specific Intervention Strategies
High-Risk Situation
Abstinence Violation Effect
Ineffective Coping
Response
Lapse
Decreased Self-Efficacy
¤ Positive Outcome
Expectancies
Self-Monitoring ¤
Inventory of Drug-Taking Situations
¤ Drug Taking Confidence
Questionnaire
Mediation, Relaxation Training, Stress Management
¤ Efficacy-Enhancing
Imagery
Contract to limit extent of use
¤ Reminder Card (what to do if you have slip)
Description of Past Relapses
¤ Relapse Fantasies
Situational Competency Test
¤ Coping-Skill
Training ¤
Education about immediate vs. delayed effects
¤ Decision Matrix
Cognitive Restructuring
(a lapse is a mistake: coping vs.
Skill-Training with Alcoholics:
One- Year Follow-Up Results
0
20
40
60
Skill training Combined Controls
p < .05
SD = 6.9
SD = 62.2
(Mean = 5.1) (Mean = 44.0)
Days of Continuous Drinking
Skill-Training with Skill-Training with Alcoholics: Alcoholics:
One- Year Follow-Up ResultsOne- Year Follow-Up Results
0
500
1000
1500
2000
Skill training Combined Controls
p < .05
SD = 2218.4SD = 2218.4
SD = 507.8
(Mean = 399.8) (Mean = 1592.8)
Number of Drinks Consumed
Skill-Training with Skill-Training with Alcoholics: Alcoholics:
One- Year Follow-Up ResultsOne- Year Follow-Up Results
0
20
40
60
80
Skill training Combined Controls
p < .05
SD = 17.8
SD = 17.8
(Mean = 11.1) (Mean = 64.0)
Days Drunk
Skill-Training with Skill-Training with Alcoholics: Alcoholics:
One- Year Follow-Up ResultsOne- Year Follow-Up Results
0
2
4
6
Skill training Combined Controls
SD = 17.8
SD = 2.6SD = 2.6
P = N.S.
Controlled Drinking
(Mean = 4.9) (Mean = 1.2)
RELAPSE PREVENTIONEmpirical Support for the RP
ModelNarrative Review of 24 Randomized Controlled Trials
Kathleen M. Carroll (1996)1. While RP usually does not prevent a lapse better than
other active treatments, RP is more effective at “Relapse Management,” i.e. delaying the first lapse longer and reducing the duration and intensity of lapses that do occur before abstinence is regained.
2. RP is particularly effective at maintaining treatment effects over long-term follow-up measurements of one to two years or more.
3. RP treatment outcomes often demonstrate “delayed emergence effects” in which greater improvement in coping occurs over time.
4. RP may be most effective for “more impaired substance abusers including those with more severe levels of substance abuse, greater levels of negative affect, and greater perceived deficits in coping skills.” (Carroll, 1996, p.52)
RELAPSE PREVENTIONEmpirical Support for the RP Model
Meta-Analysis Review of 17 Controlled StudiesIrvin, Bowers, Dunn & Wang (1999)
Irvin, Bowers, Dunn, & Wang (1999) selected 17 controlled studies to evaluate the overall effectiveness of the RP model as a substance abuse treatment and to statistically identify moderator variables that may reliably impact the outcome of RP treatment. In their discussion, they conclude that their “Results indicate that RP is highly effective for both alcohol-use and substance-use disorders” (p.3)
RELAPSE PREVENTIONEmpirical Support for the RP
ModelMeta-Analysis Review of 17 Controlled Studies
Irvin, Bowers, Dunn, & Wang (1999)
Moderator Variables with Significant Impact on RP Effectiveness
1. Group therapy formats were more effective than individual therapy formats.
2. RP is more effective as a “stand alone” than as aftercare.3. Inpatient settings yielded better treatment outcomes
than outpatient settings.4. Stronger treatment effects on self-reported use than on
physiological measures.5. While RP was effective across all categories of substance
use disorders, stronger treatment effects were found for substance abuse than alcohol abuse.
The “Black and White” Model of Relapse
Abstinence
Relapse
Thin Line
The The Abstinence Violation Violation EffectEffect
Emotional- guilt, blame, failure, etc.
Cognitive- Internal, stable,global, uncontrollable
Self-awareness increaseComparison to Internalized
Standards- greater difference, more guilt
Behavioral Reaction- dominant habitual response
Cognitive Reaction- resolve discrepancy
Relapse PreventionSpecific Intervention Strategies
What to do if a lapse occurs Stop, Look, and Listen Keep Calm Renew Your Commitment Implement your Relapse
Prevention plan Ask For Help Review the situation leading-up to
the lapse
RELAPSE PREVENTIONSpecific Intervention Strategies
Coping with Lapses(Initial Use of a Substance)
Relapse Plan with Emergency Procedures
Relapse Contract to limit extent of use Relapse Reminder Card “What do I do in case of a lapse?”
POSITIVE
Improved self-efficacy, confidence
and esteem; family approval;
better health; financial gains;
continued success
Enhanced ability to control one’s life;
more money; more respect;
greater popularity
Frustration; denial of pleasure; anger at
oneself for not doing
what one wants
Denial of immediate
and seemingly easy
gratification
Immediate reduction of
anxiety; revenge against one’s spouse; better
feeling about work; immediate gratification
Feeling as though one is
caught in a fog, so one
doesn’t have to deal with
reality
Feeling that one has
lost control; anger at family and employer; financial loss;
weakness
Continued deterioration; loss of one’s family; loss of
one’s employment; poor health;
loss of friends; greater self-hatred
Delayed Consequences
ALCOHOL ABSTINENCE ALCOHOL USE
Immediate Consequences Immediate Consequences
Delayed Consequences
NEGATIVE NEGATIVE POSITIVE POSITIVE
Decision Matrix
Precontemplation Stage
Contemplation Stage
Preparation Stage
Action Stage
Maintenance Stage
Relapse Stage
Motivational Enhancement
Strategies Assessment & Treatment
Matching
Relapse Prevention & Relapse
Management
Stages of Change in Substance Abuse & Dependence: Intervention
Strategies
Thank You.Thank You.