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An Overview of Marlatt’s
Cognitive-Behavioral Model
R
elapse, or the return to heavy cess, a series of events that unfold over
alcohol use following a period of time (Annis 1986; Litman et al. 1979; MARY E. LARIMER, PH.D., is a research
abstinence or moderate use, occurs Marlatt and Gordon 1985). According assistant professor of psychology, REBEKKA S.
in many drinkers who have undergone to these models, the relapse process PALMER is a graduate student in clinical
alcoholism treatment. Traditional alco- begins prior to the first posttreatment psychology, and G. ALAN MARLATT,
holism treatment approaches often alcohol use and continues after the initial PH.D., is a professor of psychology at the
conceptualize relapse as an end-state, a use. This conceptualization provides Addictive Behaviors Research Center,
negative outcome equivalent to treatment a broader conceptual framework for Department of Psychology, University of
failure. Thus, this perspective considers intervening in the relapse process to Washington, Seattle, Washington.
only a dichotomous treatment out- prevent or reduce relapse episodes and
come—that is, a person is either absti- thereby improve treatment outcome. Preparation of this manuscript was sup-
nent or relapsed. In contrast, several This article presents one influential ported by National Institute on Alcohol
models of relapse that are based on model of the antecedents of relapse and Abuse and Alcoholism grants R3A–AA–
social-cognitive or behavioral theories the treatment measures that can be 05591 to G. Alan Marlatt and 5RO1–
emphasize relapse as a transitional pro- taken to prevent or limit relapse after AA–10772–03 to Mary E. Larimer.
Decreased
Effective coping Increased
probability of
response self-efficacy
relapse
High-risk
situation
Decreased
self-efficacy Abstinence
and violation
Ineffective Lapse (initial effect and Increased
positive
coping use of perceived probability
outcome
response alcohol) positive of relapse
expectancies
for effects of effects of
alcohol alcohol
Figure 1 The cognitive-behavioral model of the relapse process posits a central role for high-risk situations and for the drinker’s
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.
maintain the change. Certain situations (i.e., using “willpower” to limit con- an initial lapse) and a return to uncon-
or events, however, can pose a threat sumption), and nonspecific cravings trolled drinking or abandonment of
to the person’s sense of control and, also were identified as high-risk situ- the abstinence goal (i.e., a full-blown
consequently, precipitate a relapse cri- ations that could precipitate relapse. relapse). Although research with vari-
sis. Based on research on precipitants of ous addictive behaviors has indicated
relapse in alcoholics who had received Coping. Although the RP model con- that a lapse greatly increases the risk of
inpatient treatment, Marlatt (1996) siders the high-risk situation the imme- eventual relapse, the progression from
categorized the emotional, environmen- diate relapse trigger, it is actually the lapse to relapse is not inevitable.
tal, and interpersonal characteristics of person’s response to the situation that Marlatt and Gordon (1980, 1985)
relapse-inducing situations described determines whether he or she will expe- have described a type of reaction by the
by study participants. According to this rience a lapse (i.e., begin using alco- drinker to a lapse called the abstinence
taxonomy, several types of situations hol). A person’s coping behavior in a violation effect, which may influence
can play a role in relapse episodes, as high-risk situation is a particularly criti- whether a lapse leads to relapse. This
follows: cal determinant of the likely outcome. reaction focuses on the drinker’s emo-
Thus, a person who can execute effec- tional response to an initial lapse and
• Negative emotional states, such as tive coping strategies (e.g., a behavioral on the causes to which he or she attributes
anger, anxiety, depression, frustra- strategy, such as leaving the situation, the lapse. People who attribute the lapse
tion, and boredom, which are also or a cognitive strategy, such as positive to their own personal failure are likely
referred to as intrapersonal high-risk self-talk) is less likely to relapse com- to experience guilt and negative emo-
situations, are associated with the pared with a person lacking those skills. tions that can, in turn, lead to increased
highest rate of relapse (Marlatt and Moreover, people who have coped suc- drinking as a further attempt to avoid
Gordon 1985). These emotional cessfully with high-risk situations are or escape the feelings of guilt or failure.
states may be caused by primarily assumed to experience a heightened Furthermore, people who attribute the
intrapersonal perceptions of certain sense of self-efficacy (i.e., a personal lapse to stable, global, internal factors
situations (e.g., feeling bored or lonely perception of mastery over the specific beyond their control (e.g., “I have no
after coming home from work to an risky situation) (Bandura 1977; Marlatt willpower and will never be able to stop
empty house) or by reactions to envi- et al. 1995, 1999; Marlatt and Gordon drinking”) are more likely to abandon
ronmental events (e.g., feeling angry 1985). Conversely, people with low the abstinence attempt (and experience
about an impending layoff at work). self-efficacy perceive themselves as lack- a full-blown relapse) than are people
ing the motivation or ability to resist who attribute the lapse to their inability
• Situations that involve another person drinking in high-risk situations. to cope effectively with a specific high-
or a group of people (i.e., interper- risk situation. In contrast to the former
sonal high-risk situations), particu- Outcome Expectancies. Research group of people, the latter group real-
larly interpersonal conflict (e.g., an among college students has shown that izes that one needs to “learn from one’s
argument with a family member), those who drink the most tend to have mistakes” and, thus, they may develop
also result in negative emotions and higher expectations regarding the posi- more effective ways to cope with simi-
can precipitate relapse. In fact, intra- tive effects of alcohol (i.e., outcome lar trigger situations in the future.
personal negative emotional states and expectancies) and may anticipate only
interpersonal conflict situations served the immediate positive effects while
as triggers for more than one-half ignoring or discounting the potential
Covert Antecedents of High-Risk
of all relapse episodes in Marlatt’s negative consequences of excessive
Situations
(1996) analysis. drinking (Carey 1995). Such positive Although high-risk situations can be
outcome expectancies may become conceptualized as the immediate deter-
• Social pressure, including both direct particularly salient in high-risk situa- minants of relapse episodes, a number
verbal or nonverbal persuasion and tions, when the person expects alcohol of less obvious factors also influence the
indirect pressure (e.g., being around use to help him or her cope with nega- relapse process. These covert antecedents
other people who are drinking), con- tive emotions or conflict (i.e., when include lifestyle factors, such as overall
tributed to more than 20 percent of drinking serves as “self-medication”). stress level, as well as cognitive factors
relapse episodes in Marlatt’s (1996) In these situations, the drinker focuses that may serve to “set up” a relapse,
study. primarily on the anticipation of imme- such as rationalization, denial, and a
diate gratification, such as stress reduc- desire for immediate gratification (i.e.,
• Positive emotional states (e.g., cele- tion, neglecting possible delayed nega- urges and cravings) (see figure 2).
brations), exposure to alcohol- tive consequences. These factors can increase a person’s
related stimuli or cues (e.g., seeing vulnerability to relapse both by increas-
an advertisement for an alcoholic The Abstinence Violation Effect. A crit- ing his or her exposure to high-risk sit-
beverage or passing by one’s favorite ical difference exists between the first uations and by decreasing motivation
bar), testing one’s personal control violation of the abstinence goal (i.e., to resist drinking in high-risk situations.
Self-monitoring
and behavior
assessment
Revised (e.g., situational
decision competency
matrix test)
Decreased self-
Urges efficacy; Initial Abstinence
Rationalization, Lack of
Lifestyle Desire for High-risk positive substance violation
and denial, and coping
imbalance indulgence situation outcome use (i.e., effect
craving AIDs response
expectancies lapse)
Education about
warning signals of Analysis of Eliminating myths
relapse (e.g., AIDs, relapse fantasies and placebo effects
positive expectancies, and descriptions (e.g., education about
lifestyle imbalances) of past relapses 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 episode—rationalization and denial—as
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 person’s 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 situa-
tions. White boxes indicate steps in the relapse process and intervention strategies that are related to the client’s general
lifestyle and coping skills. High-risk situations are related to both the client’s general and specific coping abilities.
anyone expect me not to drink when RP Intervention Strategies relapse episodes and relapse dreams or
there’s a bottle of liquor in the house?”). fantasies in order to identify situations
The RP model includes a variety of in which the client has or might have
Lifestyle Factors. Marlatt and Gordon cognitive and behavioral approaches difficulty coping. Several self-report
(1985) have proposed that the covert designed to target each step in the relapse questionnaires also can help assess the
antecedent most strongly related to process (see figure 2). These approaches situations in which clients have been
relapse risk involves the degree of balance include specific intervention strategies prone to drinking heavily in the past
in the person’s life between perceived that focus on the immediate determinants as well as the clients’ self-efficacy for
external demands (i.e., “shoulds”) and of relapse as well as global self-manage- resisting future drinking in these situa-
internally fulfilling or enjoyable activi- ment strategies that focus on the covert tions (Annis and Davis 1988; Annis
ties (i.e., “wants”). A person whose life antecedents of relapse. Both the specific 1982a). Furthermore, clients who have
is full of demands may experience a and global strategies fall into three main not yet initiated abstinence are encour-
constant sense of stress, which not only categories: skills training, cognitive aged to self-monitor their drinking
can generate negative emotional states, restructuring, and lifestyle balancing. behavior—for example, by maintaining
thereby creating high-risk situations, an ongoing record of the situations,
but also enhances the person’s desire for emotions, and interpersonal factors asso-
pleasure and his or her rationalization
Specific Intervention Strategies ciated with drinking or urges to drink.
that indulgence is justified (“I owe myself The goal of the specific intervention Such a record allows clients to become
a drink”). In the absence of other non- strategies—identifying and coping with more aware of the immediate precipitants
drinking pleasurable activities, the person high-risk situations, enhancing self- of drinking. Even in clients who have
may view drinking as the only means efficacy, eliminating myths and placebo already become abstinent, self-monitor-
of obtaining pleasure or escaping pain. effects, lapse management, and cogni- ing can still be used to assess situations
tive restructuring—is to teach clients to in which urges are more prevalent.
Urges and Cravings. The desire for imme- anticipate the possibility of relapse and Once a person’s high-risk situations
diate gratification can take many forms, to recognize and cope with high-risk have been identified, two types of
and some people may experience it as a situations. These strategies also focus intervention strategies can be used to
craving or urge to use alcohol. Although on enhancing the client’s awareness of lessen the risks posed by those situations.
many researchers and clinicians consider cognitive, emotional, and behavioral The first strategy involves teaching the
urges and cravings primarily physiolog- reactions in order to prevent a lapse client to recognize the warning signals
ical states, the RP model proposes that from escalating into a relapse. The first associated with imminent danger—that
both urges and cravings are precipitated step in this process is to teach clients is, the cues indicating that the client is
by psychological or environmental stim- the RP model and to give them a “big about to enter a high-risk situation.
uli. Ongoing cravings, in turn, may picture” view of the relapse process. Such warning signals to be recognized
erode the client’s commitment to main- For example, the therapist can use the may include, for example, AIDs, stress
taining abstinence as his or her desire metaphor of behavior change as a jour- and lack of lifestyle balance, and strong
for immediate gratification increases. ney that includes both easy and diffi- positive expectances about drinking. As
This process may lead to a relapse set- cult stretches of highway and for which a result of identifying those warning
up or increase the client’s vulnerability various “road signs” (e.g., “warning sig- signals, the client may be able to take
to unanticipated high-risk situations. nals”) are available to provide guidance. some evasive action (e.g., escape from
Although they are often used inter- According to this metaphor, learning to the situation) or possibly avoid the
changeably, the terms “urges” and “crav- anticipate and plan for high-risk situa- high-risk situation entirely.
ings” can be associated with distinct tions during recovery from alcoholism The second strategy, which is possi-
meanings. Thus, Marlatt and Gordon is equivalent to having a good road map, bly the most important aspect of RP,
(1985) have defined an urge as a rela- a well-equipped tool box, a full tank of involves evaluating the client’s existing
tively sudden impulse to engage in an gas, and a spare tire in good condition motivation and ability to cope with
act such as alcohol consumption, whereas for the journey. specific high-risk situations and then
craving is defined as the subjective desire helping the client learn more effective
to experience the effects or consequences Identifying and Coping With High- coping skills. Relevant coping skills can
of such an act. Nevertheless, the same Risk Situations. To anticipate and plan be behavioral or cognitive in nature
processes may mediate both urges and accordingly for high-risk situations, the and can include both strategies to cope
cravings. Two such processes have been person first must identify the situations
proposed: (1) conditioning1 elicited by in which he or she may experience dif- 1
Classical or Pavlovian conditioning occurs when an
stimuli associated with past gratifica- ficulty coping and/or an increased desire originally neutral stimulus (e.g., the sight of a beer
tion and (2) cognitive processes associ- to drink. These situations can be identi- bottle) is repeatedly paired with a stimulus (e.g., alco-
hol consumption) that induces a certain physiological
ated with anticipated gratification (i.e., fied using a variety of assessment strate- response. After the two stimuli have been paired
the expectancies for the immediate gies. For example, the therapist can repeatedly, the neutral stimulus becomes a conditioned
pleasurable effects of alcohol). interview the client about past lapses or stimulus that elicits the same physiological response.
to view them not as failures or indicators strategies are designed to modify the and friends) have gradually been replaced
of a lack of willpower but as mistakes client’s lifestyle to increase balance as by drinking as a source of entertain-
or errors in learning that signal the need well as to identify and cope with covert ment and gratification. Therefore,
for increased planning to cope more antecedents of relapse (i.e., early warn- one global self-management strategy
effectively in similar situations in the ing signals, cognitive distortions, and involves encouraging clients to pursue
future. This perspective considers lapses relapse set-ups). again those previously satisfying, non-
key learning opportunities resulting from drinking recreational activities. In addi-
an interaction between coping and sit- Balanced Lifestyle and Positive tion, specific cognitive-behavioral skills
uational determinants, both of which Addiction. Assessing lifestyle factors training approaches, such as relaxation
can be modified in the future. This associated with increased stress and training, stress-management, and time
reframing of lapse episodes can help decreased lifestyle balance is an important management, can be used to help clients
decrease the clients’ tendency to view first step in teaching global self-manage- achieve greater lifestyle balance.
lapses as the result of a personal failing ment strategies. This assessment can be Helping the client to develop “posi-
or moral weakness and remove the self- accomplished through approaches in tive addictions” (Glaser 1976)—that is,
fulfilling prophecy that a lapse will which clients self-monitor their daily activities (e.g., meditation, exercise, or
inevitably lead to relapse. activities, identifying each activity as a yoga) that have long-term positive
“want,” “should,” or combination of effects on mood, health, and coping—
both. Clients also can complete stan- is another way to enhance lifestyle bal-
Global Lifestyle Self-Control dardized assessment measures, such as ance. Self-efficacy often increases as a
Strategies the Daily Hassles and Uplifts Scale result of developing positive addictions,
Although specific intervention strategies (Delongis et al. 1982), to evaluate the largely caused by the experience of suc-
can address the immediate determi- degree to which they perceive their life cessfully acquiring new skills by per-
nants of relapse, it is also important to stressors to be balanced by pleasurable forming the activity.
modify individual lifestyle factors and life events.
covert antecedents that can increase Many clients report that activities Stimulus-Control Techniques.
exposure or reduce resistance to high- they once found pleasurable (e.g., hob- Although achieving a more balanced
risk situations. Global self-control bies and social interactions with family lifestyle may reduce the risk of cravings
Resume Automatic pleasure, Feel weak from Maintain friendships Possible loss of
Alcohol Use reduced stress drinking, risk of with drinking family and job,
and anxiety, not accidents and buddies, able deterioration of
feel pain, not worry embarrassment, to drink while health and early
about one’s problems, anger of wife watching sports, death, loss of
able to enjoy sports and family, arrive not have to nondrinking or
and drink with buddies late to or miss cope with wife light-drinking
work, hangovers, and family by friends, ridicule
waste money staying out drinking 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 client’s decisionmaking process regarding his or her future alcohol consumption.
that is, whether different researchers ing an initial lapse. Specifically, those • RP is associated with “delayed emer-
coded a given relapse episode in an participants who had a greater belief in gence effects”—that is, significant
identical or similar manner. the disease model of alcoholism and a effects favoring RP as compared
higher commitment to absolute absti- with other treatment approaches are
• It evaluated whether the key relapse nence (who were most likely to experi- often found only at later followup
episodes predicted the types of relapse ence feelings of guilt over their lapse) points (i.e., 1 year or more after
episodes that study participants were most likely to experience relapse treatment) (Carroll 1996). This
reported after undergoing treatment in that study. In a recent review of the delayed effectiveness may result
(Maisto et al. 1996; Stout et al. 1996). literature on relapse precipitants, Dimeff from the fact that it takes time to
and Marlatt (1998) also concluded that learn new skills and that conse-
• It extended research on the RP model considerable support exists for the notion quently RP effects become more
beyond the taxonomy by evaluating that an abstinence violation effect can obvious as patients acquire addi-
alternative methods for assessing precipitate a relapse. tional practice.
high-risk situations as well as evalu- Several recent review articles and
ating the relative contribution of meta-analyses have examined the effec- • Although RP has been applied with
negative affect, abstinence violation tiveness of treatments based on the RP some success to various addictive
effect, coping, and expectancies on model in preventing relapse (Dimeff behaviors, the effects of RP-based
the likelihood of relapse. and Marlatt 1998; Rawson et al. 1993; approaches are greatest in the treat-
Carroll 1996; Irvin et al. 1999). The ment of alcoholism or multiple drug
The results reported in the RREP RP-based treatments included in those use (Irvin et al. 1999).
study indicate that the original relapse analyses were delivered both as stand-
taxonomy of the RP model has only alone treatments for initiating abstinence • Combining RP with medications
moderate inter-rater reliability at the and as adjuncts to other treatment pro- (e.g., disulfiram or naltrexone) to
highest level of specificity, although grams. Although the reviews differ in treat alcoholism leads to improved
reliability of the more general categories their methodology and in their criteria outcomes as compared with either
(e.g., negative affect and social pres- for including or excluding certain treat- RP or medication alone (Irvin et al.
sure) was better. The model’s predictive ments, the conclusions regarding over- 1999).
validity also was modest; however, the all effectiveness of the RP approach are
definition of the key relapse episodes similar. The findings can be summa-
utilized in these studies failed to clarify rized as follows: Summary
whether these were voluntary change
episodes or simply a return to drinking The RP model of relapse is centered
following a short period of abstinence • The studies conducted to date tend around a detailed taxonomy of emo-
that did not represent a serious attempt to support the effectiveness of cogni- tions, events, and situations that can
to quit drinking. Therefore, the RREP tive-behavioral RP-based approaches precipitate both lapses and relapses to
studies do not represent a good test of in reducing the frequency of relapse drinking. This taxonomy includes both
the predictive validity of the taxonomy. episodes as well as the intensity of immediate relapse determinants and
Nevertheless, the study provides rel- lapse and/or relapse episodes among covert antecedents, which indirectly
atively good support for other aspects of people who resumed alcohol use increase a person’s vulnerability to relapse.
the RP model. For example, Miller and after treatment (Irvin et al. 1999). Based on the classification of relapse
colleagues (1996) found that although The effectiveness of RP was particu- determinants and high-risk situations
mere exposure to specific high-risk larly great in studies that compared proposed in the RP model, numerous
situations did not predict relapse, the relapse rates in patients before and treatment components have been
manner in which people coped with after treatment or that compared developed that are aimed at helping the
those situations strongly predicted sub- patients receiving RP-based treatment recovering alcoholic cope with high-risk
sequent relapse or continued abstinence. with controls receiving no treatment. situations. The results of recent research,
Furthermore, in that study the major- particularly the RREP study, likely will
ity of relapse episodes after treatment • Despite its benefits, RP-based treat- lead to modifications of the original RP
occurred during situations involving ment is not associated with higher model, particularly with regard to the
negative emotional states, a finding abstinence rates compared with other assessment of high-risk situations as
that has been replicated in other studies valid treatment approaches (Carroll well as the conceptualization of covert
(Cooney et al. 1997; McKay 1999; 1996; Irvin et al. 1999). RP-based and immediate antecedents of relapse.
Shiffman 1992). Finally, the results of treatment is, however, often associ- Overall, however, research findings
Miller and colleagues (1996) support ated with lower drinking rates and support both the overall model of the
the role of the abstinence violation effect fewer drinking problems among relapse process and the effectiveness
in predicting which participants would patients who have experienced a of treatment strategies based on the
experience a full-blown relapse follow- relapse (e.g., Chaney et al. 1978). model. ■