Therapist's Guide to Evidence-Based Relapse Prevention

Katie A. Witkiewitz, G. Alan Marlatt

• Publisher: Academic Press
• Year: 2011
• ISBN:
  9780080471044
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Describes the evidence-based approaches to preventing relapse of major mental and substance-related disorders. Therapist's Guide to Evidence-based Relapse Prevention combines the theoretical rationale, empirical data, and the practical "how-to" for intervention programs.

The first section will serve to describe the cognitive-behavioral model of relapse and provide a general introduction to relapse prevention techniques. While Section II will focus on specific problem areas, Section III will focus on diverse populations and treatment settings.

• Incorporates theoretical and empirical support
• Provides step-by-step strategies for implementing relapse prevention techniques
• Includes case studies that describe application of relapse prevention techniques

Section II

Application of Relapse Prevention to Specific Problem Areas

3 RELAPSE PREVENTION: CLINICAL STRATEGIES FOR SUBSTANCE USE DISORDERS

ANTOINE DOUAIHY, KEITH R. STOWELL, AND TAE WOO PARK

Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

DENNIS C. DALEY

University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

INTRODUCTION

Overall, an estimated 22.5 million Americans aged 12 and older in 2004 were classified with substance dependence or abuse (9.4% of the population) according to the 2003 data from the National Survey on Drug Use and Health (SAMSHA, 2004). Including the cost of healthcare, productivity loss, and crime, the yearly costs associated with illicit drug use and alcohol use disorders was estimated at $180 billion and $185 billion, respectively (Harwood, 2004). Of course, the economic costs cannot completely capture the heavy emotional and psychological burden that substance use disorders (SUDs) can have on individuals, their families, and significant others.

Existing data indicate that individuals with SUDs face the possibility of relapse once they stop using alcohol or other drugs even if they have a successful treatment episode (NIAAA, 2000). For many individuals with SUDs, substance use leads to a chronic cycle of relapse, treatment reentry, and recovery, often lasting for decades. Therefore, greater emphasis has been placed on identifying clinical strategies to reduce the likelihood of a relapse and to manage actual relapse in order to minimize adverse effects in cases in which an individual returns to substance use following a period of recovery.

Relapse prevention (RP) is a cognitive-behavioral approach that combines behavioral skills training procedures with cognitive intervention techniques to assist persons in maintaining desired behavioral changes. Based in part upon the principles of health psychology and social-cognitive theory, the typical treatment goal of RP in SUDs is either to refrain totally from using substances or to reduce the harm of or risk of ongoing lapse, therefore preventing further relapse. RP strategies often are incorporated into individual and group treatment approaches (see NIAAA and NIDA treatment manuals on psychosocial treatments). In addition, RP programs are sometimes offered as part of a rehabilitation, partial hospital, intensive outpatient, or outpatient program. For example, the MATRIX model of treatment provides numerous RP groups in addition to individual sessions, early recovery skills groups, family education, and a social support group (Rawson, Obert, McCann & Ling, 2005). Both the Individual Drug Counseling (NIDA, 1999) and Group Drug Counseling (NIDA, 2002) models of treatment focus considerable attention on RP issues in the context of individual and group treatment sessions. Many structured residential and ambulatory programs incorporate a RP track into their group program to educate clients and help them learn coping skills to reduce relapse risk as well as to intervene early in a lapse or relapse.

This chapter summarizes the major tenets of RP including the concepts of lapse, relapse, and recovery, and the hypothesized common relapse precipitants and determinants. We also provide a discussion on treatment outcome literature and empirical data incorporating RP techniques. Models of RP are reviewed. We also present highlights of RP assessment and intervention strategies representing the most common principles espoused in the RP models. Finally, we propose future research initiatives and their relevance to clinical settings.

OVERVIEW OF LAPSE, RELAPSE, AND RECOVERY

One of the most difficult issues that continues to create an ongoing debate is the way relapse is defined. So what really constitutes relapse? As Einstein (1994) stated: “At what point is a return to a defined pattern of single/multiple substance use relapse as well as what are the coping/adaptational and treatment implications of the definition(s)?” The complexity of this issue has evolved throughout the years and multiple definitions and meanings of the term relapse were suggested (Litman et al., 1983; Miller, 1996; Saunders et al., 1989; Wilson, 1992). Marlatt has identified a conceptual distinction between lapse, which he described as the initial episode of alcohol or other drug use after a period of abstinence (Marlatt & Gordon, 1985), and a relapse, as continued use after the initial lapse, “a breakdown or setback in the person’s attempt to change or modify any target behavior” (Marlatt, 1985a, p. 3). Other definitions have included: (1) a process that slowly and gradually leads to the initiation of substance use or engagement in the behavior after a period of abstinence; (2) descriptive presence or absence of the behavior, the behavior exceeding a certain threshold, and a judgment about the behavior in the context of individual and societal standards (Miller, 1996); (3) a consequence of substance use resulting in the need for subsequent treatment (e.g., recidivism) (Donovan, 1996); (4) an “unfolding process in which the resumption of substance use is the last event in a long series of maladaptive responses to internal or external stressors or stimuli” (NIDA’s Cue Extinction (CE) model; NIDA, 1993, p. 39); (5) a complex multidimensional composite indices of outcome / relapse, taking into account the different aspects of return to problematic behavior and the presence or absence of related consequences that go beyond the simple concept of abstinence-lapse-relapse and fit more into the concept of a harm reduction approach (Marlatt & Witkiewitz, 2002; Zweben & Cisler, 2003).

It has been shown that a lapse does not necessarily herald a full-blown relapse in users of opiates (Gossop et al., 1989) and tobacco (Gwantley et al., 2005). Milby et al. (2004) compared behavioral day treatment (DT) with the same day treatment plus abstinent-contingent housing and work (DT+) in cocaine users and found that the DT+ subjects who lapsed were actually less likely to relapse. This indicates that the lapse event could be perceived as a crossroads. Based on different rates of relapse using different definitions and diverse conceptual and methodological approaches involved in understanding the process of relapse, it is clear that relapse is better understood as both a dichotomous outcome and a process involving a series of prior related events and the predictors of these events interfering with behavior change (Daley & Marlatt, 2005, 2006a; Wang et al., 2002). Therefore a dynamic, not static, conceptual and clinical assessment model would potentially capture all the elements of relapse as it unfolds across time (Donovan, 1996a; Hufford, Witkiewitz et al., 2003; Shiffman et al., 2000; Witkiewitz & Marlatt, 2004). Determining and addressing both the immediate variables and the distal variables remain essential to the process of preventing a lapse episode from evolving into a full-blown relapse (Miller et al., 1996; Moser & Annis et al., 1996; Vielva & Iraurgi et al., 2001). In addition, a recent review exploring gender differences in alcohol and substance use relapse showed that for women, marriage and marital stress were risk factors for alcohol relapse and among men, marriage lowered relapse risk (Walitzer & Dearing, 2006). In contrast to the lack of gender differences in alcohol relapse rates, this review also showed that women appear to be less likely to experience relapse to substance use, relative to men.

Multiple epidemiological studies of people with lifetime substance dependence suggest that 58 percent eventually enter sustained recovery (i.e., no symptoms for the past year), a rate that is considerably better than the 39 percent average rate of recovery across psychiatric disorders (Kessler, 1994; McLellan, Lewis & O’Brien, 2000; Robins & Rigier, 1991). Of the people who eventually achieved a state of sustained recovery, the majority did so after participating in treatment (Cunningham, Lin, Ross & Walsh, 2000).

Recovery is defined as a long-term and ongoing process rather than an endpoint (Dimeff & Marlatt, 1995; NIDA, 1999). Specific areas of change during the process of recovery include physical, psychological, behavioral, interpersonal, spiritual, socio-cultural, familial, and financial (Daley & Marlatt, 2006a, 2006b). Recovery tasks depend on the stage and recovery the individual is in (Washton, 2001, 2002). Recovering from SUD involves psychoeducation, focusing on involvement in a program of change including learning coping skills, and staying engaged in treatment for long enough to benefit from it. The program of change may also incorporate psychotherapy, pharmacotherapy, case management, participation in self-help groups, and self-management goals. As recovery progresses, clients rely more on themselves after initially utilizing support from family, significant others, and health care professionals, with the goal of improving their overall quality of life. In fact, Flynn et al. (2003) studied a group of opiate users five years after treatment and compared those who were in recovery and those who were not. The subjects in recovery were more likely to benefit from family and friends as a support group and were more likely to agree that their social network did not include people with SUDs. The subjects in recovery were nearly four times more likely to perceive themselves as improving their overall personal growth and ability to lead a constructive and fulfilling lifestyle.

TREATMENT OUTCOMES AND RELAPSE RATES

Despite the fact that longitudinal studies have repeatedly demonstrated that substance abuse treatment is associated with major reductions in substance abuse, other studies demonstrated that after discharge from treatment, relapse and eventual readmission are also common, particularly when addiction is coexisting with psychiatric disorders (Godley, Godley et al., 2002; Lash, Petersen et al., 2001). In addition, co-occurring psychiatric disorders are associated with higher substance use severity, more intensive level of care placements, lower treatment participation, and worse outcomes (American Society of Addiction Medicine, 2003; Angst, Sellaro et al., 2002; Daley & Moss, 2002; Grella, 2003; Mueser et al., 2003).

Miller and Hester (1980) reviewed more than 500 alcoholism outcome studies and reported that three-quarters of subjects relapse within one year. More recently, McLellan and colleagues (2000) reviewed more than 100 clinical trials of drug addiction treatments and noted that in one-year post-discharge follow-up studies, 40 to 60 percent of individuals discharged from treatment were continuously abstinent and 15 to 30 percent had not used substances addictively. Several publications by the Center for Substance Abuse Treatment (CSAT, 1999, 2000a, 2000b) describe positive outcomes for substance abusers who have received professional treatment including reduced rates of substance use, reduced rates of criminal behaviors, improved psychological functioning, and family productivity. Most relapses occur within the first year of treatment, with two-thirds occurring within the first 90 days (Daley, 2003). Though this may be the case, the risk of relapse may be present even after a long period of abstinence.

The cycle of relapse, treatment reentry, and recovery has been evident in statistics for people admitted to the U.S. public treatment system in 1999, in which 60 percent were reentering treatment, including 23 percent for the second time, 13 percent for third time, 7 percent for the fourth time, 4 percent for the fifth time, and 13 percent for six or more times (Office of Applied Studies, ...

Table of contents

• Cover
• Title Page
• Copyright
• Contributors
• Preface
• Table of Contents
• Section I: Introduction and Overview
• Section II: Application of Relapse Prevention to Specific Problem Areas
• Section III: Specific Populations and Treatment Settings
• Index
• Instructions for online access