Preventing Relapse: A Look at Marlatt's Cognitive-Behavioral Model

Relapse prevention is an important topic in the training of any counselor, irrespective of her or his ultimate specialty. That said, any consideration of relapse need at least consider Marlatt's cognitive-behavioral therapy approach – see Larimer, Palmer, & Marlatt’s 1999 article in Alcohol Research & Health, “Relapse Prevention: An Overview of Marlatt’s Cognitive-Behavioral Model.” As for a text for a relapse prevention course, I recommend Marlatt and Donovan’s edited text, Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors  (link to book on Amazon). Be sure to review the table of contents as you will quickly see this text truly considers the subject of relapse across ALL addictive disorders.

As an aside, an important aspects of Marlatt’s consideration of relapse is the role the “abstinence

violation effect” (AVE) plays in the onset of a true relapse. The AVE is essentially the guilt that is associated with having used after a period of abstinence. It is this guilt that plays a major role in turning the “slip” into a “fall off the wagon.” Marlatt argued that before one can relapse, the recovering individual must first “lapse.” The distinction between a “lapse” and a “relapse” being that a lapse is a temporary return to use whereas the relapse is a return to the lifestyle of the active user. It is important for counselor-ed students to recognize this difference as this concept—“lapse” precedes “relapse”—coupled with CBT enables the practitioner to “act on” the lapse rather than “react to” the relapse.

I have had individuals with whom I addressed a SUD (substance use disorder) contact me in a panic the day after a lapse, filled with guilt and shame about their use. I always begin the conversation by asking what they have done with the remainder of the alcohol, weed, cigarettes or “whatever.” Frequently, they tell me that they felt so bad about the use that they flushed the weed, dumped the alcohol down the drain, or discarded the remainder of “whatever.” I then suggest that while we can discuss the use later, “right now” what I am really interested in is the fact that they appear so committed to change that they threw away $X of product. I then suggest this shows how far they have come in their recovery and that their experience is what is called a lapse rather than a relapse. Obviously there is more to this approach than a simple 3-min conversation with a client. The point is, the practitioner follows a true “solution-focused” path; by concentrating on what the client has done well, we can move further away from the AVE and its associated guilt and shame. This guilt and shame then all but ensures the lapse progresses into the proverbial “full blown relapse.” This blending of harm reduction with CBT is a very effective strategy in “true” relapse prevention.

To put some closure on these comments, there is no distinct line of demarkation between recovery and relapse. Just as the 21-year-old at 12:01 AM on her 21st b-day has not magically become better able to drink safely than at 11:59 PM, neither does someone with a substance use disorder relapse upon taking the first sip/toke/drag. Now, do not misunderstand my comments to mean that it is “okay” to use “just a little” or we should not be concerned about that sip/toke/drag etc. Clearly, we need to be sensitive to any early indicators of someone who is skating on the proverbial thin ice as regards recovery; risk is risk and those who ignore this fact will fall through that ice. That said, Miller’s admonishment that we “dance” with clients rather than “wrestle” with them suggests that we teach our students the difference between a “lapse” and a "relapse” so that as practitioners they can proffer the guidance and support necessary to get the “train back on the tracks.”

What do you think?

Dr. Robert