Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors

432 Pages·2005·3.07 MB·English

by  G. Alan Marlatt PhD

RELAPSE PREVENTION

RELAPSE PREVENTION
Maintenance Strategies in the
Treatment of Addictive Behaviors
Second Edition
Edited by
G. ALAN MARLATT
DENNIS M. DONOVAN
THE GUILFORD PRESS
New York London
©2005TheGuilfordPress
ADivisionofGuilfordPublications,Inc.
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Relapseprevention:maintenancestrategiesinthetreatmentofaddictive
behaviors/editedbyG.AlanMarlattandDennisM.Donovan.—2nded.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN1-59385-176-6(alk.paper)
1. Substanceabuse—Relapse—Prevention. 2. Substanceabuse—Treatment. 3.
Behaviortherapy. I. Marlatt,G.Alan. II. Donovan,DennisM.(Dennis
Michael)
RC564.R452005
616.86′06—dc22
2005000834
AAbboouutt tthhee EEddiittoorrss
About the Editors
G. Alan Marlatt, PhD, Director of the Addictive Behaviors Research Cen-
ter and Professor of Psychology at the University of Washington, is re-
nowned for his innovative theoretical and clinical work in the addictions
field. Over the past two decades, he has made significant advances in de-
veloping programs for both relapse prevention and harm reduction for a
range of addictive behaviors. In addition to coediting the first editions of
Relapse Prevention: Maintenance Strategies in the Treatment of Addictive
Behaviors (1985) and Assessment of Addictive Behaviors (1988), Dr.
Marlatt is the editor of Harm Reduction: Pragmatic Strategies for Man-
agingHigh-RiskBehaviors(1998),coeditorofChangingAddictiveBehav-
ior:BridgingClinicalandPublicHealthStrategies(1999),andcoauthorof
BriefAlcoholScreeningandInterventionforCollegeStudents(BASICS):A
Harm Reduction Approach (1999), all published by The Guilford Press.
He is a Fellow of both the American Psychological Association and the
American Psychological Society, and is a former president of the Associa-
tionforAdvancementofBehaviorTherapy. Heservedasamemberofthe
National Advisory Council on Drug Abuse at the National Institute on
Drug Abuse from 1996 to 2002, and served on the National Advisory
Council on Alcohol Abuse and Alcoholism Subcommittee on College
Drinking from 1998 to 2001. Dr. Marlatt currently holds a Senior Re-
search Scientist Award from the National Institute on Alcohol Abuse and
Alcoholism, and received the Innovators Combating Substance Abuse
AwardfromtheRobertWoodJohnsonFoundationin2001. Previously,he
was presented with the Jellinek Memorial Award for Alcohol Studies
(1990), the Distinguished Scientist Award from the American Psychologi-
cal Association’s Society of Clinical Psychology (2000), the Visionary
Award by the Network of Colleges and Universities Committed to the
EliminationofDrugandAlcoholAbuse(2002),andtheDistinguishedRe-
searcher Award from the Research Society on Alcoholism (2004).
v
vi About the Editors
Dennis M. Donovan, PhD, was affiliated with the Addictions Treatment
Center at the Seattle Department of Veterans Affairs Medical Center for
over 20 years, while engaging in clinical, administrative, training, and re-
searchactivities.Duringthattimehewasalsoinstrumentalinthedevelop-
ment of, and served as the Associate Director of, the first Center of Excel-
lence in Substance Abuse Treatment and Education (CESATE) within the
nationalDepartmentofVeteransAffairs. HecurrentlyservesastheDirec-
tor of the University of Washington’s Alcohol and Drug Abuse Institute
and holds the faculty ranks of Professor in the Department of Psychiatry
and Behavioral Sciences, and Adjunct Professor in the Department of Psy-
chology at the University of Washington in Seattle. He has written over
120journalarticles,30bookchapters,and3booksintheareaofalcohol-
ism and addictive behaviors, with emphases on social learning theory and
biopsychosocialapproachestotheetiology,maintenance,andtreatmentof
addictions; the clinical assessment process and assessment measures; treat-
ment of entrance and engagement; evaluation of treatment process and
outcome; relapse prevention; and patient–treatment matching. Dr. Dono-
van’sresearchhasbeenfundedbytheNationalInstituteonAlcoholAbuse
and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA),
and the Center for Substance Abuse Treatment (CSAT). He has served as
AssociateEditorandasamemberoftheeditorialboardsfortheJournalof
StudiesonAlcohol,PsychologyofAddictiveBehaviors,andAddiction.He
has also been a member of the Clinical and Treatment Research Review
CommitteeofNIAAAandtheBehavioralAIDSResearchReviewCommit-
tee of NIDA. Dr. Donovan is a member of a number of national profes-
sionalorganizationsandservedasPresidentoftheSocietyofPsychologists
in Addictive Behaviors. He has also been elected a Fellow of Division 50
(Division on Addictions) of the American Psychological Association.
CCoonnttrriibbuuttoorrss
Contributors
Arthur W. Blume, PhD, Department of Psychology, University of Texas at El
Paso, El Paso, Texas
Kathleen M. Carroll, PhD, Department of Psychiatry, Division of Substance
Abuse, Yale University School of Medicine, New Haven, Connecticut,
and VA Connecticut Healthcare Center, West Haven, Connecticut
R. Lorraine Collins, PhD, Research Institute on Addictions, University at
Buffalo, State University of New York, Buffalo, New York
Ned L. Cooney, PhD, Yale University School of Medicine, New Haven,
Connecticut, and VA Connecticut Healthcare Center, West Haven,
Connecticut
Jessica M. Cronce, BS, Department of Psychology, Yale University, New Haven,
Connecticut
Berenice García de la Cruz, MA, Department of Special Education, University
of Texas at Austin, Austin, Texas
Dennis M. Donovan, PhD, Department of Psychiatry and Behavioral Sciences
and the Alcohol and Drug Abuse Institute, University of Washington
School of Medicine, Seattle, Washington
William H. George, PhD, Department of Psychology, University of Washington,
Seattle, Washington
Valerie A. Gruber, PhD, MPH, Department of Psychiatry, University of
California, San Francisco, San Francisco, California
Chad Gwaltney, PhD, Center for Alcohol and Addiction Studies, Brown
University, Providence, Rhode Island
Nancy A. Haug, PhD, Department of Psychiatry, University of California,
San Francisco, San Francisco, California
Ronald M. Kadden, PhD, Department of Psychiatry, University of Connecticut
School of Medicine, Farmington, Connecticut
vii
viii Contributors
Jon Kassel, PhD, Department of Psychology, University of Illinois at Chicago,
Chicago, Illinois
Jason R. Kilmer, PhD, Addictive Behaviors Specialist, Evergreen State College,
Olympia, Washington, and Saint Martin’s College, Lacey, Washington
Debi A. LaPlante, PhD, Division on Addictions, Harvard Medical School,
Boston, Massachusetts
G. Alan Marlatt, PhD, Department of Psychology and Addictive Behaviors
Research Center, University of Washington, Seattle, Washington
Dennis McChargue, PhD, Department of Psychology, University of Illinois at
Chicago, Chicago, Illinois
Rebekka S. Palmer, PhD, Department of Psychiatry, Division of Substance
Abuse, Yale University School of Medicine, New Haven, Connecticut
Richard A. Rawson, PhD, UCLA Integrated Substance Abuse Programs,
Department of Psychiatry and Biobehavioral Sciences, David Geffen
School of Medicine, Los Angeles, California
Roger A. Roffman, DSW, School of Social Work, University of Washington,
Seattle, Washington
Howard J. Shaffer, PhD, CAS, Division on Addictions, Harvard Medical
School, Boston, Massachusetts
Saul Shiffman, PhD, Smoking Research Group, University of Pittsburgh,
Pittsburgh, Pennsylvania
Yong S. Song, PhD, Department of Psychiatry, University of California, San
Francisco, at San Francisco Veterans Affairs Medical Center, San Francisco,
California
James L. Sorensen, PhD, Department of Psychiatry, University of California,
San Francisco, San Francisco, California
Robert S. Stephens, PhD, Department of Psychology, Virginia Polytechnic
Institute and State University, Blacksburg, Virginia
Susan A. Stoner, PhD, Department of Psychology and the Alcohol and Drug
Abuse Institute, University of Washington, Seattle, Washington
Jennifer G. Wheeler, PhD, Sex Offender Treatment Program, Department
of Corrections, Office of Correctional Operations, Monroe, Washington
Katie Witkiewitz, PhD, Department of Psychology and Addictive Behaviors
Research Center, University of Washington, Seattle, Washington
Tina M. Zawacki, PhD, Department of Psychology, University of Texas at
San Antonio, San Antonio, Texas
PPrreeffaaccee
Preface
In the two decades since the first edition of this book was published in
1985, much has happened in the relapse prevention field. Many of these
new developments and areas of application are described in this new edi-
tion.Intheopeningparagraphofthefirstedition,westatedthat“Relapse
Prevention (RP) is a self-management program designed to enhance the
maintenance stage of the habit-change process. The goal of RP is to teach
individuals who are trying to change their behavior how to anticipate and
copewiththeproblemofrelapse.Inaverygeneralsense,relapsereferstoa
breakdownorsetbackinaperson’sattempttochangeormodifyanytarget
behavior.” This definition of RP still applies and is consistent with the
book’ssubtitle,“MaintenanceStrategiesintheTreatmentofAddictiveBe-
haviors.”Ascanbeseeninthecontentsofthisedition,therangeofappli-
cation has expanded beyond substance use problems to include disorders
associated with eating, gambling, and high-risk sexual behavior. Broadly
conceived, RP is a cognitive-behavioral treatment (CBT) with a focus on
the maintenance stage of addictive behavior change that has two main
goals: to prevent the occurrence of initial lapses after a commitment to
changehasbeenmade,andtopreventanylapsethatdoesoccurfromesca-
lating into a full-blown relapse (relapse management).
This new edition differs from the original 1985 volume in several im-
portant ways. The first edition consisted of two main sections: Part I,
whichprovidedageneraltheoreticaloverviewoftheRPmodel(Chapters1
to 5), including coverage of high-risk situations for relapse, cognitive and
behavioral coping skills, and lifestyle modification; and Part II, which
contained four chapters describing application of RP with specific target
behaviors (alcoholism, problem drinking, smoking, and weight manage-
ment). The current edition contains chapters that extend the coverage of
thisapproachtootheraddictivebehaviors.Thefirstchapterisdesignedto
ix
x Preface
provide a summary of the RP approach in the treatment of alcohol and
otherdrugproblems,toprovideanoverviewoftreatmentoutcomestudies
that have evaluated the effectiveness of RP, and to describe recent updates
inthetheoreticalunderpinningsofthemodel.Thesecondchapterprovides
an important discussion of issues that need to be considered when using
RP programs with diverse client populations. The remaining 10 chapters
aredevotedtoapplicationsofRPandrelatedCBTinterventionsforavariety
ofhigh-riskbehaviors.Sixchaptersaredevotedtosubstanceuseproblems
associated with the use of alcohol, tobacco/nicotine, stimulants, opioids,
cannabis, and other substances (club drugs, hallucinogens, inhalants, and
steroids).Thefinalfourchapterscovernon-substanceuseproblembehaviors,
including eating disorders/obesity, gambling disorders, sexual offending,
and sexually risky behaviors.
Themostimportantchangeforreaderstonoteisthatthisnewedition
of the RP book is designed to be used in conjunction with the second edi-
tionofourcompanionvolume,AssessmentofAddictiveBehaviors(Dono-
van & Marlatt, 2005). Originally published in 1988, the new edition of
Assessmentcontainschaptersthatarematchedwithcontentareascovered
intheRPbook.Forexample,readerswhoareseekinginformationonboth
assessmentandRPinterventionmethodsforalcoholproblemscanconsult
parallel chapters in both books. The same authors were invited to provide
boththeassessmentandRPchapters,soastoenhancecongruenceofcov-
erage and cross-referenced materials.
ThereareadditionalchangesandupdatesinthecurrentRPbookthat
are also noteworthy. As described in Chapter 1, the original cognitive-
behavioral model of the relapse process has been updated with the recent
development of a dynamic model that incorporates both distal and proxi-
mal risk factors for relapse. This first chapter also describes the recent
addition of mindfulness meditation as a metacognitive coping strategy to
enhanceclientawarenessofrelapseriskandtofacilitatecopingwithurges
andcravings.Anothernewtopicthatisdiscussedinmanychaptersishow
to develop an integrated RP intervention program for the treatment of co-
occurring disorders (e.g., working with clients who have problems with
bothdepressionandexcessivealcoholuse).Sincerelapseisapotentialrisk
for clients with both mental health and substance use problems, therapists
whocanprovideanintegratedRPassessmentandtreatmentapproachwill
benefit from this material.
Many chapters also describe how RP methods can be integrated with
other intervention programs to enhance treatment effectiveness. Since the
advent and influence of the motivational “stages of change” model, many
treatment experts have recommended matching treatment interventions to
the client’s current stage of change. Based on this perspective, clients who
are unmotivated (precontemplation stage) or ambivalent about changing
theirproblembehavior(contemplationstage)maybenefitmostfrommoti-