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Marlatt's Model of RPC
Marlatt's Model of RPC
An Overview of Marlatts
Cognitive-Behavioral Model
Mary E. Larimer, Ph.D., Rebekka S. Palmer, and G. Alan Marlatt, Ph.D.
Relapse prevention (RP) is an important component of alcoholism treatment. The RP model
proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk
situations, coping skills, outcome expectancies, and the abstinence violation effect) and
covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse.
The RP model also incorporates numerous specific and global intervention strategies that
allow therapist and client to address each step of the relapse process. Specific interventions
include identifying specific high-risk situations for each client and enhancing the clients skills
for coping with those situations, increasing the clients self-efficacy, eliminating myths
regarding alcohols effects, managing lapses, and restructuring the clients perceptions of the
relapse process. Global strategies comprise balancing the clients lifestyle and helping him or
her develop positive addictions, employing stimulus control techniques and urgemanagement techniques, and developing relapse road maps. Several studies have provided
theoretical and practical support for the RP model. KEY WORDS: AODD (alcohol and other
drug dependence) relapse; relapse prevention; treatment model; cognitive therapy; behavior
therapy; risk factors; coping skills; self efficacy; expectancy; AOD (alcohol and other drug)
abstinence; lifestyle; AOD craving; intervention; alcohol cue; reliability (research methods);
validity (research methods); literature review
treatment completion. This relapse prevention (RP) model, which was developed by Marlatt and Gordon (1985) and
which has been widely used in recent
years, has been the focus of considerable
research. This article reviews various
immediate and covert triggers of relapse
proposed by the RP model, as well as
numerous specific and general intervention strategies that may help patients
avoid and cope with relapse-inducing
situations. The article also presents
studies that have provided support for
the validity of the RP model.
Effective coping
response
Decreased
probability of
relapse
Increased
self-efficacy
High-risk
situation
Ineffective
coping
response
Decreased
self-efficacy
and
positive
outcome
expectancies
for effects of
alcohol
Lapse (initial
use of
alcohol)
Abstinence
violation
effect and
perceived
positive
effects of
alcohol
Increased
probability
of relapse
Figure 1 The cognitive-behavioral model of the relapse process posits a central role for high-risk situations and for the drinkers
response to those situations. People with effective coping responses have confidence that they can cope with the situation
(i.e., increased self-efficacy), thereby reducing the probability of a relapse. Conversely, people with ineffective coping
responses will experience decreased self-efficacy, which, together with the expectation that alcohol use will have a positive
effect (i.e., positive outcome expectancies), can result in an initial lapse. This lapse, in turn, can result in feelings of guilt
and failure (i.e., an abstinence violation effect). The abstinence violation effect, along with positive outcome expectancies,
can increase the probability of a relapse.
NOTE: This model also applies to users of drugs other than alcohol.
152
Self-monitoring
and behavior
assessment
(e.g., situational
competency
test)
Revised
decision
matrix
Increasing lifestyle balance
(e.g., developing positive
addictions [jogging,
meditation, "body time"]
and substitute indulgences
[e.g., recreational activities,
massage])
Lifestyle
imbalance
Desire for
indulgence
Stimulus control
techniques (e.g.,
removing all
items associated
with alcohol use)
Urges
and
craving
Efficacy-enhancing
strategies (e.g., viewing
change process as
skills acquisition,
breaking down overall
task into subtasks)
Rationalization,
denial, and
AIDs
Urge management
(e.g., coping
imagery, such as
"urge surfing")
Avoidance
strategies
Education about
warning signals of
relapse (e.g., AIDs,
positive expectancies,
lifestyle imbalances)
Decreased selfefficacy;
positive
outcome
expectancies
Lack of
coping
response
High-risk
situation
Lapse management
(e.g., contract to limit
alcohol use, reminder
cards with instructions
on how to cope with
a lapse)
Coping-skills
training (e.g.,
relaxation training,
stress management,
and assertiveness
training) and relapse
rehearsal
Analysis of
relapse fantasies
and descriptions
of past relapses
Initial
substance
use (i.e.,
lapse)
Abstinence
violation
effect
Cognitive
restructuring (e.g.,
considering lapse a
mistake, not a
result of personal
failure)
Eliminating myths
and placebo effects
(e.g., education about
immediate vs.
delayed effects of
alcohol, use of
decision matrix)
Figure 2 Covert antecedents and immediate determinants of relapse and intervention strategies for identifying and preventing or
avoiding those determinants. Lifestyle balance is an important aspect of preventing relapse. If stressors are not balanced
by sufficient stress management strategies, the client is more likely to use alcohol in an attempt to gain some relief or
escape from stress. This reaction typically leads to a desire for indulgence that often develops into cravings and urges.
Two cognitive mechanisms that contribute to the covert planning of a relapse episoderationalization and denialas
well as apparently irrelevant decisions (AIDs) can help precipitate high-risk situations, which are the central determinants
of a relapse. People who lack adequate coping skills for handling these situations experience reduced confidence in their
ability to cope (i.e., decreased self-efficacy). Moreover, these people often have positive expectations regarding the effects
of alcohol (i.e., outcome expectancies). These factors can lead to initial alcohol use (i.e., a lapse), which can induce an
abstinence violation effect that, in turn, influences the risk of progressing to a full relapse. Self-monitoring, behavior
assessment, analyses of relapse fantasies, and descriptions of past relapses can help identify a persons high-risk situations.
Specific intervention strategies (e.g., skills training, relapse rehearsal, education, and cognitive restructuring) and general
strategies (e.g., relaxation training, stress management, efficacy-enhancing imagery, contracts to limit the extent of alcohol
use, and reminder cards) can help reduce the impact of relapse determinants. Shaded boxes indicate steps in the relapse
process and intervention measures that are specific to each client and his or her ability to cope with alcohol-related situations. White boxes indicate steps in the relapse process and intervention strategies that are related to the clients general
lifestyle and coping skills. High-risk situations are related to both the clients general and specific coping abilities.
154
RP Intervention Strategies
The RP model includes a variety of
cognitive and behavioral approaches
designed to target each step in the relapse
process (see figure 2). These approaches
include specific intervention strategies
that focus on the immediate determinants
of relapse as well as global self-management strategies that focus on the covert
antecedents of relapse. Both the specific
and global strategies fall into three main
categories: skills training, cognitive
restructuring, and lifestyle balancing.
Negative
Delayed Consequences
Positive
Negative
Remain
Abstinent
Frustration and
anxiety, denied
pleasures of
drinking, unable
to go to bars,
anger at not
being able to
do what one
wants without
paying the price
Greater control
over ones life,
better health
and longevity,
learn about ones
self and others
without being
intoxicated, more
respect from others
Not able to
enjoy drinking
while watching
sports, bored
and depressed,
not able to remain
friends with heavydrinking buddies
Resume
Alcohol Use
Automatic pleasure,
reduced stress
and anxiety, not
feel pain, not worry
about ones problems,
able to enjoy sports
and drink with buddies
Maintain friendships
with drinking
buddies, able
to drink while
watching sports,
not have to
cope with wife
and family by
staying out drinking
Possible loss of
family and job,
deterioration of
health and early
death, loss of
nondrinking or
light-drinking
friends, ridicule
by others, low
self-esteem
*In such a matrix, the client lists both the positive and negative immediate and delayed consequences of remaining abstinent versus resuming drinking. This list can facilitate
the clients decisionmaking process regarding his or her future alcohol consumption.
157
Summary
The RP model of relapse is centered
around a detailed taxonomy of emotions, events, and situations that can
precipitate both lapses and relapses to
drinking. This taxonomy includes both
immediate relapse determinants and
covert antecedents, which indirectly
increase a persons vulnerability to relapse.
Based on the classification of relapse
determinants and high-risk situations
proposed in the RP model, numerous
treatment components have been
developed that are aimed at helping the
recovering alcoholic cope with high-risk
situations. The results of recent research,
particularly the RREP study, likely will
lead to modifications of the original RP
model, particularly with regard to the
assessment of high-risk situations as
well as the conceptualization of covert
and immediate antecedents of relapse.
Overall, however, research findings
support both the overall model of the
relapse process and the effectiveness
of treatment strategies based on the
model.
159
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