2. Relapse Prevention G. Alan Marlatt, Ph.D. University of Washington Addictive Behaviors Research Center abrc@u.washington.edu http://depts.washington.edu/abrc

3. Contemporary Approaches to Substance 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

11. Brickman’s Model of Helping & Coping Applied to Addictive Behaviors Is the person responsible for the development of the addictive behavior? Is the person responsible for changing 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

15. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 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.

16. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

17. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

18. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

19. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive- behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

20. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission). # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

21. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 4Loss 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). # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

22. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 3Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA. # 4Loss 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). # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

23. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 2The ‘Father’ of the disease model of alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence) # 3Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA. # 4Loss 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). # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

25. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease … and the #1 reason why alcoholism is NOT a disease …

26. Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Disease # 1If 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) # 2The ‘Father’ of the disease model of alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence) # 3Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA. # 4Loss 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). # 6Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone). # 7There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated). # 8There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV). # 9Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker. # 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.

27. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors BIOLOGICAL 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.

28. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors PSYCHOLOGICAL 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.

29. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors SOCIOCULTURAL 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.

38. Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, and Heroin Addicts

40. “Let’s just go in and see what happens.”

43. Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and Overeaters

44. A Cognitive Behavioral Model of the Relapse Process

45. Relapse Prevention: Specific Intervention Strategies

46. Skill-Training with Alcoholics: One- Year Follow-Up Results p <.05 SD = 6.9 SD = 62.2 (Mean = 5.1) (Mean = 44.0) Days of Continuous Drinking

47. Skill-Training with Alcoholics: One- Year Follow-Up Results p <.05 SD = 2218.4 SD = 507.8 (Mean = 399.8) (Mean = 1592.8) Number of Drinks Consumed

48. Skill-Training with Alcoholics: One- Year Follow-Up Results p <.05 SD = 17.8 (Mean = 11.1) (Mean = 64.0) Days Drunk

49. Skill-Training with Alcoholics: One- Year Follow-Up Results SD = 17.8 SD = 2.6 P = N.S. Controlled Drinking (Mean = 4.9) (Mean = 1.2)

52. RELAPSE PREVENTION Empirical Support for the RP Model Narrative 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)

53. RELAPSE PREVENTION Empirical Support for the RP Model Meta-Analysis Review of 17 Controlled Studies Irvin, 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)

54. RELAPSE PREVENTION Empirical Support for the RP Model Meta-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.

56. The “Black and White” Model of Relapse

60. The Violation Effect The Abstinence Violation Effect  Emotional- guilt, blame, failure, etc.  Cognitive- Internal, stable,global, uncontrollable  Self-awareness increase  Comparison to Internalized Standards- greater difference, more guilt  Behavioral Reaction- dominant habitual response  Cognitive Reaction- resolve discrepancy

65. Relapse Prevention Specific 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

66. RELAPSE PREVENTION Specific 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?”

67. Decision Matrix

68. Stages of Change in Substance Abuse & Dependence: Intervention Strategies

69. Thank You.