Understanding and preventing relapse.

" This article examines relapse by integrating knowledge from the addictive disorders of alcoholism, smoking, and obesity. Commonalities across these areas suggest at least three basic stages of behavior change: motivation and commitment, initial change, and maintenance. A distinction is made between lapse and relapse, with lapse referring to the process (slips or mistakes) that may or may not lead to an outcome (relapse). The natural history of relapse is discussed, as are the consequences of relapse for patients and the professionals who treat them. Information on determinants and predictors of relapse is evaluated, with the emphasis on the interaction of individual environmental, and physiological factors. Methods of preventing relapse are proposed and are targeted to the three stages of change. Specific research needs in these areas are discussed. The problem of relapse remains an important challenge in the fields dealing with health-related behaviors, particularly the addictive disorders. This is true for areas of obesity (Brownell, 1982; Rodin, 198 l; Stunkard & Penick, 1979; Wilson, 1980), smoking (Lando & McGovern, 1982; Lichtenstein, 1982; Ockene, Hymowitz, Sexton, & Broste, 1982; Pechacek, 1979; Shiffman, 1982) and alcoholism (Marlatt, 1983; Miller & Hester, 1980; Nathan, 1983; Nathan & Goldman, 1979). The purpose of this article is to focus on relapse by integrating the perspectives of four researchers and elinicians who have worked with one or more of the addictive disorders (Brownell, 1982; Lichtenstein, 1982; Marlatt, 1983; Wilson, 1980). We will discuss the natural history of relapse, its determinants and effects, and methods for prevention. We hope that our collective experience and different perspectives will aid in developing a model for evaluating and preventing relapse. Commonalities and Differences in the Addictions Compelling arguments can be marshaled for both commonalities and differences in the addictive disorders. Many differences exist, both among the disorders and among persons afflicted with the same disorder. For example, genetic contributions to both alcoholism (McClearn, 1981; Schuckitt, 1981) and obesity (Stunkard et al., 1986) suggest separate pathways for their development. There may be key differences in the pharmacology of nicotine and alcohol (Ashton & Stepney, 1982; Best, Wainwright, Mills, & Kirkland, in press; Gilbert, 1979; Myers, 1978; Pomerleau & Pomerleau, 1984), and food abuse fits even less neatly with concepts of physical dependency, withdrawal, and tolerance. Treatment goals also vary, with abstinence the target in some cases and moderation in others. Individual differences within the addictions are also impressive. Variable treatment responses are an example. There are also striking differences in patterns of use. Some smokers, alcoholics, and overeaters engage in steady substance use, whereas others binge. Combinations of physiological, psychological, social, and environmental factors may addict different people to the same substance. Finally, different processes may govern the initiation and maintenance of the disorders. There is also increasing emphasis on commonalities. One reason is that rates for relapse appear so similar. In 1971, Hunt, Barnett, and Branch found nearly identical patterns of relapse in alcoholics, heroin addicts, and smokers. The picture is the same today (Marlatt & Gordon, 1985). There may also be common determinants of relapse (Cummings, Gordon, & Maflatt, 1980). These factors suggest important commonalities in the addictive disorders. Progress may be aided by viewing these disorders from multiple perspectives (Levison, Gerstein, & Maloff, 1983; Maflatt & Gordon, 1985; Miller, 1980; Nathan, 1980). The notion of commonalities gained support from expert panels assembled by two government agencies. The National Institute on Drug Abuse (NIDA) convened a panel of researchers in alcoholism, obesity, smoking, and drug abuse and found both conceptual and practical similarities in the areas (NIDA, 1979). Similar conclusions appeared in a more extensive report by the National Academy of Sciences (Levison et al., 1983). Both reports noted the importance of relapse and suggested the utility of combining perspectives from different areas of the addictions. The question of whether the addictions are more similar than different is difficult to answer. It may be the case, for example, that there are common psychological adaptations to different physiological pressures. Nicotine dependence may be the central issue for a smoker, excessive fat cells for a dieter, and disordered alcohol metabolism for an alcoholic, but there may be common social or psychological provocations for relapse, emotional reactions to initial slips, and problems in reestablishing control. Our hope is to expand the information to be July 1986 ~ American Psychologist Copyright 1986 by the American Psychological Association, Inc. 0003-066X/86/$00.75 Vol. 41, No. 7, 765-782 765 focused on relapse by considering both similarities and differences. In so doing, both conceptual'and practical ideas may emerge that would not be suggested by the knowledge available in any one area. Rates and Definition Relapse rates for the addictions are assumed to be in the range of 50% to 90% (Hunt et al., 1971; Hunt & Matarazzo, 1973; Marlatt & Gordon, 1980, 1985). This underscores the importance of the problem. However; defining specific rates is difficult. Hidden within these averages is large variability. The rates depend on characteristics of the addiction, individual variables, the success of treatment, and so forth. The figures generally cited for relapse could overestimate or underestimate actual rates. Most data are from clinical programs, so rates are based on those who have received formal treatment. These figures could overstate the problem because only difficult cases are seen and because only one attempt to change is studied (Schachter, 1982). persons attempting to change on their own may be more successful and may relapse less frequently (Schachter, 1982). The vast majority o f persons who change do so on their own (Ockene, 1984). These data could understate the case because clinical programs are most likely to provide effective treatments. In addition, #arious criteria are used to define relapse. For example, relapse in alcohol studies could be defined as days intoxicated, days hospitalized o r jailed, days drinking out of control, or the use of any alcohol. This points to the need for standard definitions and for the study of the natural history of relapse. Lapse and Relapse--Process Versus Outcome There are two common definitions of relapse, each refleeting a bias regarding its nature and severity (Marlatt & Gordon, 1985). Webster's New Collegiate Dictionary of 1983 gives both definitions. The first is "a recurrence of symptoms of a disease after a period of improvement." This refers to an outcome and implies a dichotomous view because a person is either ill and has symptoms or is well and does not. The second definition is "the act or instance of backsliding, worsening, or subsiding." This focuses on a process and implies something less serious, perhaps a slip or mistake. The choice of the process or outcome definition has important implications for conceptualizing, preventing, and treating relapse. We suggest that lapse may best describe a process, behavior, or event (Marlatt & Gordon, rhis article had its origins in a symposium on relapse at the World Congress on Behavior Therapy, Washington, I)(2, 1983. This work was supported in part by Research SCientist Development Award MH00319 from NIMH and by a grant from the MacArthur Foundation to Kelly D. BrowneU, grant HL29547 to Edward Lichtenstein from NHLBI, grant AA00259 to G. Terence Wilson from NIAAA, and grant AA05591 to G. Alan Marlatt from NIAAA. Correspondence concerning this article should be addressed to Kelly D. Brownell, Department of Psychiatry, University of Pennsylvania, 133 South 36th St., Philadelphia, Pennsylvania 19104. 1985). Webster's defines lapse as "a slight error or slip 9 . . a temporary fall esp. from a higher to a lower state." A lapse is a single event, a reemergence of a previous habit, which may or may not lead to the state of relapse. When a slip or mistake is defined as a lapse, it implies that corrective action can be taken, not that control is lost completely. There is support for this distinction in smokers (Coppotelli & Orleans, 1985; Mermelstein & Lichtenstein, 1983) and in dieters (Dubbert & Wilson, 1984). In these cases, different determinants were found for lapses (slips) and relapses. The challenge with this approach is defining when one or more lapses become a relapse. One former smoker may lose control with the first transgression, whereas another may smoke one cigarette each month and never lose control. A lapse, therefore, could be defined concretely as use of the substance in the case of smoking and alcoholism or violation of program guidelines for a dieter. The individual's response to these lapses determines whether relapse has occurred. This varies from person to person and may be best defined by perceived loss of control. Reliable measures do not yet exist for this assessment. Research in this area is important for the field. The Nature and Process of R e l a p s e Surprisingly little is known about relapse in its natural state. Most data are from clinical programs where different treatments are used with different populations, so it is difficult to isolate the factors that influence relapse. In addition, few researchers have done careful evaluations of patients when they are most likely to relapse, that is, after treatment has ended. Periodic follow-ups in groups are the only contacts with patients in most studies, so repeated, intensive assessments are needed. There would be great value in learning more about the nature and process of relapse. The Need for a Natural History A metaphor that describes traditional thought on relapse is of a person existing perilously close to the edge of a cliff. The slightest disruption can precipitate a fall from which there is no return'. A person is always on the brink of relapse, ready to fall at any disturbance. There may be physiological, psychological, or social causes of the disturbance, but the outcome is just as final. The first slip creates momentum so that a complete relapse is certain. This metaphor may be inadequate.. It does not explain why a relapse occurs under the same circumstances that the person managed before. An eating binge may precipitate relapse in a dieter, but such an individual has probably recovered from similar binges in the past. A smoker may relapse after being offered a cigarette, but there are cases where this same person refused the cigarette or prevented the lapse from becoming a relapse. Also, the metaphor is based on observations of people who have relapsed, not those who have not, therefore, successful recovery is seldom seen. Information on natural history could address the question of whether the probability of relapse increases 766 July 1986 9 American Psychologist or decreases with time. If relapse occurs when treatment "wears off," the probability should increase with time. If the metaphor used above is valid, the chance of relapse should increase with time simply because more disturbances could occur. One can speculate, however, that a person learns to cope effectively as time passes and that those who "survive" beyond the initial period are those who will succeed. To the extent withdrawal symptoms precipitate relapse, particularly in smoking and alcoholism, the likelihood of relapse should decrease as the body adapts to the absence of the addictive substance. It is in this context that the concept of a "safe" point arises. This is a point in time before which relapse is likely and beyond which relapse is unlikely. In the work of Hunt et al. (1971) on heroin addiction, smoking, and alcoholism, relapse curves stabilized after the first three months. It is appealing to conclude that individuals who abstain for three months are likely to succeed thereafter, but more recent evidence does not support a specific safe point (Lichtenstein & Rodrigues, 1977; Wilson & Brownell, 1980). Defining such a point would have important conceptual and practical implications, so more study on this topic could pay high dividends. Interpreting relapse curves may be the first step. Relapse curves are one type of survival curve. As such, the figures must be interpreted with several facts in mind (Elandt-Johnson & Johnson, 1980; Marlatt & Gordon, 1985; Sutton, 1979). Group averages do not represent individuals. Madatt, Goldstein, and Gordon (1984) found that abstinence rates for smokers after quitting on the basis of a New Year's resolution were 21% both 4 and 12 months later, implying that relapse rates stabilize and show a safe point at 4 months. However, different individuals formed the 21% these two times; some persons moved from abstinence to relapse whereas equal numbers moved in the opposite direction. Second, the cumulative nature of the curves implies that a person who relapses will remain so; survival curves are negatively accelerating by their nature. Schachter (1982) noted that cure for many persons follows several relapses. Third, the probability of survival for the entire group increases with time because the persons at highest risk are most likely to leave the sample. Life table analyses have been designed to deal with these issues (Elandt-Johnson & Johnson, 1980). Therefore, it may be possible in future research to develop a time line for the relapse process and to determine whether there are "safe" points. Some information does exist on the natural history of the addictions. Vaillant's (1983) report on the longterm progress of 110 alcohol abusers, 71 of whom were "alcohol dependent," shows the complexity of the issue. Vaillant's book, and an article by Vaillant and Milofsky (1982), showed the importance of cultural and ethnic factors in alcoholism. Many personal and environmental factors influenced the propensity to drink excessively. It was clear from these data that a lapse does not necessarily become a relapse and that this transition has many determinants. Schachter (1982) interviewed 161 persons from the Psychology Department at Columbia University and from a resort community. In their retrospective accounts, they reported much higher rates of success at dieting and smoking cessation than suggested by the literature. Almost all successes were achieved without professional aid. Although Schachter's methods have been questioned (Jeffery & Wing, 1983; Prochaska, 1983), he made several important points. He noted that cure rates are based on clinical samples and that self-quitters may differ from therapy-assisted quitters, a notion supported by DiClemente and Prochaska (1982). Second, he found that many of the successful quitters had made numerous attempts to change before finally succeeding. Marlatt and Gordon (1980, 1985) have examined the natural history of the relapse itself. Beginning with a high-risk situation, their cognitive-behavioral model addresses the coping process (Figure 1). The absence of a coping response leads to decreased self-efficacy (Bandura, 1977a, 1977b), then use of the substance, and then the cognitive phenomenon they label the "abstinence violation effect." This phenomenon involves the loss of control that follows violation of self-imposed rules. The end result of this process is increased probability of relapse. Recent data from an analysis of relapse episodes in smokers showed a significant difference in attributions for slips between subjects who slipped (smoked at least 1 cigarette) and regained abstinence and those who relapsed (Goldstein, Gordon, & Marlatt, 1984). Persons who relapsed made more internal, characterological attributions for the slip. This model is useful in conceptualizing the relapse process from the point at which the person is in a highrisk situation. Marlatt and Gordon's (1985) model allows for multiple determinants of high-risk situations but emphasizes cognitive processes thereafter. Other factors of a physiological or environmental nature may also be important. Figure 1 A Cognitive-Behavioral Model of the Relapse Process Beginning With the Exposure to a High-Risk Situation Note. Reprinted from Relapse Prevention: Maintenance Strategies in Addictive Behavior Change (p. 38) by G. A. Marlatt and J. R. Gordon, 1985, New York: Guilford Press. Copyright 1985 by Guilford Press. Reprinted by permission. July 1986 9 American Psychologist 767 For example, the use of nicotine or alcohol after a period of abstinence may create a physiological demand for additional use. An environmental example is that of a smoker whose lapse occurs in a social setting where others are smoking. The resulting cues may provoke further use. Grunberg and colleagues have found powerful effects of nicotine on the regulation of body weight and food preferences in both humans and animals (Grunberg, 1982; Grunberg & Bowen, 1985; G-runberg~ Bowen, Maycock, & Nespor, 1985; Grunberg, Bowen, & Morse, 1984). Stopping smoking can create physiological pressure to change food intake and gain weight. This in turn has psychological and environmental consequences that can precipitate relapse. Therefore, it is important to consider the interaction of individual, environmental, and physiological factors in all stages of the change process. There is much to be learned about the natural history of relapse. More descriptive information is needed on lapses and their associations with relapse. This research is not easy because the work must be prospective and because qualitative and quantitative work must be combined. AS an example, Lichtenstein (1984)followed treated smokers at 1-, 2-, 3-, 6-, and 12-month intervals with telephone calls. Relapses were preceded by slips for 41 subjects; 19 subjects reported slips but did not relapse. More information of this nature would be useful.