ABSTRACT." This article examines relapse by integrating Wainwright, Mills, & Kirkland, in press; Gilbert, 1979;
knowledge from the addictive disorders of alcoholism, Myers, 1978; Pomerleau & Pomerleau, 1984), and food
smoking, and obesity. Commonalities across these areas abuse fits even less neatly with concepts of physical de-
suggest at least three basic stages of behavior change: mo- pendency, withdrawal, and tolerance. Treatment goals
tivation and commitment, initial change, and mainte- also vary, with abstinence the target in some cases and
nance. A distinction is made between lapse and relapse, moderation in others.
with lapse referring to the process (slips or mistakes) that Individual differences within the addictions are also
may or may not lead to an outcome (relapse). The natural impressive. Variable treatment responses are an example.
history of relapse is discussed, as are the consequences of There are also striking differences in patterns of use. Some
relapse for patients and the professionals who treat them. smokers, alcoholics, and overeaters engage in steady sub-
Information on determinants and predictors of relapse is stance use, whereas others binge. Combinations of phys-
evaluated, with the emphasis on the interaction of indi- iological, psychological, social, and environmental factors
vidual environmental, and physiological factors. Methods may addict different people to the same substance. Finally,
of preventing relapse are proposed and are targeted to the different processes may govern the initiation and mainte-
three stages of change. Specific research needs in these nance of the disorders.
areas are discussed. 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
The problem of relapse remains an important challenge patterns of relapse in alcoholics, heroin addicts, and
in the fields dealing with health-related behaviors, par- smokers. The picture is the same today (Marlatt & Gor-
ticularly the addictive disorders. This is true for areas of don, 1985). There may also be common determinants of
obesity (Brownell, 1982; Rodin, 198 l; Stunkard & Pen- relapse (Cummings, Gordon, & Maflatt, 1980). These
ick, 1979; Wilson, 1980), smoking (Lando & McGovern, factors suggest important commonalities in the addictive
1982; Lichtenstein, 1982; Ockene, Hymowitz, Sexton, & disorders. Progress may be aided by viewing these dis-
Broste, 1982; Pechacek, 1979; Shiffman, 1982) and al- orders from multiple perspectives (Levison, Gerstein, &
coholism (Marlatt, 1983; Miller & Hester, 1980; Nathan, Maloff, 1983; Maflatt & Gordon, 1985; Miller, 1980; Na-
1983; Nathan & Goldman, 1979). than, 1980).
The purpose of this article is to focus on relapse by The notion of commonalities gained support from
integrating the perspectives of four researchers and eli- expert panels assembled by two government agencies. The
nicians who have worked with one or more of the addictive National Institute on Drug Abuse (NIDA) convened a
disorders (Brownell, 1982; Lichtenstein, 1982; Marlatt, panel of researchers in alcoholism, obesity, smoking, and
1983; Wilson, 1980). We will discuss the natural history drug abuse and found both conceptual and practical sim-
of relapse, its determinants and effects, and methods for ilarities in the areas (NIDA, 1979). Similar conclusions
prevention. We hope that our collective experience and appeared in a more extensive report by the National
different perspectives will aid in developing a model for Academy of Sciences (Levison et al., 1983). Both reports
evaluating and preventing relapse. noted the importance of relapse and suggested the utility
of combining perspectives from different areas of the ad-
Commonalities and Differences in the dictions.
Addictions The question of whether the addictions are more
Compelling arguments can be marshaled for both com- similar than different is difficult to answer. It may be the
monalities and differences in the addictive disorders. case, for example, that there are common psychological
Many differences exist, both among the disorders and adaptations to different physiological pressures. Nicotine
among persons afflicted with the same disorder. For ex- dependence may be the central issue for a smoker, ex-
ample, genetic contributions to both alcoholism (Mc- cessive fat cells for a dieter, and disordered alcohol me-
Clearn, 1981; Schuckitt, 1981) and obesity (Stunkard et tabolism for an alcoholic, but there may be common social
al., 1986) suggest separate pathways for their development. or psychological provocations for relapse, emotional re-
There may be key differences in the pharmacology of actions to initial slips, and problems in reestablishing
nicotine and alcohol (Ashton & Stepney, 1982; Best, control. Our hope is to expand the information to be
Note. Reprinted from Relapse Prevention: Maintenance Strategies in Addictive Behavior Change (p. 54) by G. A. Marlatt and J. R. Gordon, 1985, New York:
Guilford Press. Copyright 1985 by Guilford Press. Reprinted by permission. The boxes represent the stages in the process and the circles represent examples
of interventions targeted at each stage.
actually influence relapse may depend on the nature of cation can be substituted for the absence of the addictive
the contact and the type of material presented. disorder. This notion is consistent with clinical experience,
Marlatt and Gordon (1985) proposed social support but little research has been done. Likely candidates are
as a component of relapse prevention. Social support is relaxation training, meditation, and exercise. Of these,
a predictor of long-term success, but attempts to intervene exercise has several intriguing possibilities, as we will dis-
in the social environment have produced inconsistent re- CUSS.
sults (Brownell, 1982; Brownell, Heckerman, Westlake, A controversial but thus far ineffective approach to
Hayes, & Monti, 1978; Lichtenstein, 1982). We believe maintenance is programmed lapse. This approach in-
that social factors are crucial in the behavior change pro- volves a planned lapse in a therapeutic setting and might
cess (Cohen & Syme, 1985) but that variations in social include an eating binge for a dieter, smoking for an ex-
relationships make it unlikely that any single approach smoker, or drinking for a problem drinker. This would
will work consistently. For instance, attempts to enlist the be done only after the person has received extensive in-
aid of a spouse may have positive effects in some marriages struction in the cognitive and behavioral coping skills
and negative effects in others. It is not surprising that mentioned above. The purpose is to have the inevitable
parametric studies with groups show no effects for such lapse occur under supervision and to demonstrate that
programs. This is also an area where developmental work self-management skills can be used to prevent the lapse
is needed so that the potential of social support can be from becoming a relapse. It may also be a useful para-
exploited. doxical technique; because the therapist controls the lapse,
General life-style change may also be helpful (Marlatt perceptions about lack of control may change.
& Gordon, 1985). The theory is that a source of gratifi- Cooney and colleagues tested this approach with
J u l y 1986 9 A m e r i c a n P s y c h o l o g i s t 781
calorie diets: Their efficacy, safety, and future. Annals of Internal Wilson, G. T. (1985). Psychological prognostic factors in the treatment
Medicine, 99, 675-684. of obesity. In J. Hirsch & T. B. Van ItaUie (Eds.), Recent advances in
Wilkinson, D. A., & Sanchez-Cralg, M. (1981). Relevance ofbrain dys- obesity research (Vol. 4, pp. 301-311). London: Libbey.
functionto treatment objectives: Should alcohol,related cognitive def-
icits influence the way we think about treatment? Addictive Behaviors, Wilson, G. T., & Brownell, K. D. (1980). Behavior therapy for obesity:
6, 253-260. An evaluation of treatment .outcome. Advancesin BehaviourResearch
Wilson, G. T. (1978). Methodological considerations in treatment out- and Therapy, 3, 49-86.
come research on obesity. Journal of Consulting and Clinical Psy-
chology, 46, 687-702. Wooley, S. C., Wooley, O. W., & Dyrenforth, S. R. (1979). Theoretical,
Wilson, G. T. (1980). Behavior therapy for obesity. In A. J. Stunkard practical, and social issues in behavioral treatments of ob~ity. Journal
(Ed.), Obesity (pp. 325-344). Philadelphia: Saunders. of Applied Behavior Analysis, 12, 3-26.