This document reviews the evolution and updates of the Relapse Prevention (RP) model, which has been integral to addiction treatment for over 30 years, focusing on developments from 2000-2010. Key advancements include the reformulated cognitive-behavioral model of relapse, mindfulness-based relapse prevention, and the integration of advanced statistical methods in research. Despite its widespread application, the historical tendency to merge RP within other treatment frameworks has complicated systematic evaluations, although RP remains a vital framework in addiction studies.

1. REVIEW Open Access
Relapse prevention for addictive behaviors
Christian S Hendershot1,2*, Katie Witkiewitz3, William H
George4 and G Alan Marlatt4
Abstract
The Relapse Prevention (RP) model has been a mainstay of
addictions theory and treatment since its introduction
three decades ago. This paper provides an overview and update
of RP for addictive behaviors with a focus on
developments over the last decade (2000-2010). Major treatment
outcome studies and meta-analyses are
summarized, as are selected empirical findings relevant to the
tenets of the RP model. Notable advances in RP in
the last decade include the introduction of a reformulated
cognitive-behavioral model of relapse, the application of
advanced statistical methods to model relapse in large
randomized trials, and the development of mindfulness-
based relapse prevention. We also review the emergent
literature on genetic correlates of relapse following
pharmacological and behavioral treatments. The continued
influence of RP is evidenced by its integration in most
cognitive-behavioral substance use interventions. However, the
tendency to subsume RP within other treatment
modalities has posed a barrier to systematic evaluation of the
RP model. Overall, RP remains an influential
cognitive-behavioral framework that can inform both theoretical
and clinical approaches to understanding and
facilitating behavior change.

2. Keywords: Alcohol, cognitive-behavioral skills training,
continuing care, drug use, psychosocial intervention, sub-
stance use treatment
Introduction
Relapse poses a fundamental barrier to the treatment of
addictive behaviors by representing the modal outcome
of behavior change efforts [1-3]. For instance, twelve-
month relapse rates following alcohol or tobacco cessa-
tion attempts generally range from 80-95% [1,4] and evi-
dence suggests comparable relapse trajectories across
various classes of substance use [1,5,6]. Preventing
relapse or minimizing its extent is therefore a prerequi-
site for any attempt to facilitate successful, long-term
changes in addictive behaviors.
Relapse prevention (RP) is a tertiary intervention strat-
egy for reducing the likelihood and severity of relapse
following the cessation or reduction of problematic
behaviors. Three decades since its introduction [7], the
RP model remains an influential cognitive-behavioral
approach in the treatment and study of addictions. The
aim of this paper is to provide readers with an update
on empirical and applied developments related to RP,
with a primary focus on events spanning the last decade
(2000-2010). We begin with a concise overview of the
historical and theoretical foundations of the RP model
and a brief summary of clinical intervention strategies.
Next, we review the major theoretical, methodological
and applied developments related to RP in the last dec-
ade. Specific emphasis is placed on the reformulated
cognitive-behavioral model of relapse [8] as a basis for
hypothesizing and studying dynamic aspects of the
relapse process. In reviewing empirical findings we focus
on major treatment outcome studies, meta-analyses, and

3. selected results that coincide with underlying tenets of
the RP model. We conclude by noting critiques of the
RP model and summarizing current and future direc-
tions in studying and preventing relapse.
This paper extends recent reviews of the RP literature
[1,8-10] in several ways. Most notably, we provide a
recent update of the RP literature by focusing primarily
on studies conducted within the last decade. We also
provide updated reviews of research areas that have
seen notable growth in the last few years; in particular,
the application of advanced statistical modeling techni-
ques to large treatment outcome datasets and the devel-
opment of mindfulness-based relapse prevention.
Additionally, we review the nascent but rapidly growing
literature on genetic predictors of relapse following sub-
stance use interventions. In focusing exclusively on
* Correspondence: [email protected]
1Centre for Addiction and Mental Health, 33 Russell St.,
Toronto, ON, M5S
2S1, Canada
Full list of author information is available at the end of the
article
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Policy 2011, 6:17
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© 2011 Hendershot et al; licensee BioMed Central Ltd. This is
an Open Access article distributed under the terms of the
Creative
Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and
reproduction in any medium, provided the original work is

4. properly cited.
mailto:[email protected]
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addictive behaviors (for which the RP model was initially
conceived) we forego a discussion of RP as it relates to
various other behavioral domains (e.g., sexual offending,
depression, diet and exercise) and refer readers to other
sources for updates on the growing range of RP applica-
tions [8,11].
Definitions of relapse and relapse prevention
The terms “relapse” and “relapse prevention” have seen
evolving definitions, complicating efforts to review and
evaluate the relevant literature. Definitions of relapse are
varied, ranging from a dichotomous treatment outcome
to an ongoing, transitional process [8,12,13]. Overall, a
large volume of research has yielded no consensus
operational definition of the term [14,15]. For present
purposes we define relapse as a setback that occurs dur-
ing the behavior change process, such that progress
toward the initiation or maintenance of a behavior
change goal (e.g., abstinence from drug use) is inter-
rupted by a reversion to the target behavior. We also
take the perspective that relapse is best conceptualized
as a dynamic, ongoing process rather than a discrete or
terminal event (e.g., [1,8,10]).
Definitions of RP have also evolved considerably, due
largely to the increasingly broad adoption of RP
approaches in various treatment contexts. Though the
phrase “relapse prevention” was initially coined to denote
a specific clinical intervention program [7,16], RP strate-
gies are now integral to most psychosocial treatments for

5. substance use [17], including many of the most widely dis-
seminated interventions (e.g., [18-20]). The National Reg-
istry of Evidence-based Programs and Practices,
maintained by the U.S. Substance Abuse and Mental
Health Services Administration (SAMHSA), includes list-
ings for numerous empirically supported interventions
with “relapse prevention” as a descriptor or primary treat-
ment objective (http://www.nrepp.samhsa.gov). Thus, RP
has in many ways evolved into an umbrella term encom-
passing most skills-based treatments that emphasize cog-
nitive-behavioral skills building and coping responses.
While attesting to the broad influence of the RP model,
the diffuse application of RP approaches also tends to
complicate efforts to define RP-based treatments and eval-
uate their overall efficacy (e.g., [21]). In the present review
we emphasize Marlatt’s RP model [7,16] and its more
recent iteration [8] when discussing the theoretical basis
of RP. By necessity, our literature review also includes stu-
dies that do not explicitly espouse the RP model, but that
are relevant nonetheless to its predictions.
Marlatt’s relapse prevention model: Historical foundations
and overview
The RP model developed by Marlatt [7,16] provides
both a conceptual framework for understanding relapse
and a set of treatment strategies designed to limit
relapse likelihood and severity. Because detailed
accounts of the model’s historical background and theo-
retical underpinnings have been published elsewhere (e.
g., [16,22,23]), we limit the current discussion to a con-
cise review of the model’s history, core concepts and
clinical applications.
Based on the cognitive-behavioral model of relapse,
RP was initially conceived as an outgrowth and augmen-

6. tation of traditional behavioral approaches to studying
and treating addictions. The evolution of cognitive-beha-
vioral theories of substance use brought notable changes
in the conceptualization of relapse, many of which
departed from traditional (e.g., disease-based) models of
addiction. For instance, whereas traditional models often
attribute relapse to endogenous factors like cravings or
withdrawal–construed as symptoms of an underlying
disease state–cognitive-behavioral theories emphasize
contextual factors (e.g., environmental stimuli and cog-
nitive processes) as proximal relapse antecedents. Cogni-
tive-behavioral theories also diverged from disease
models in rejecting the notion of relapse as a dichoto-
mous outcome. Rather than being viewed as a state or
endpoint signaling treatment failure, relapse is consid-
ered a fluctuating process that begins prior to and
extends beyond the return to the target behavior [8,24].
From this standpoint, an initial return to the target
behavior after a period of volitional abstinence (a lapse)
is seen not as a dead end, but as a fork in the road.
While a lapse might prompt a full-blown relapse,
another possible outcome is that the problem behavior
is corrected and the desired behavior re-instantiated–an
event referred to as prolapse. A critical implication is
that rather than signaling a failure in the behavior
change process, lapses can be considered temporary set-
backs that present opportunities for new learning to
occur. In viewing relapse as a common (albeit undesir-
able) event, emphasizing contextual antecedents over
internal causes, and distinguishing relapse from treat-
ment failure, the RP model introduced a comprehensive,
flexible and optimistic alternative to traditional
approaches.
Marlatt’s original RP model is depicted in Figure 1. A
basic assumption is that relapse events are immediately

7. preceded by a high-risk situation, broadly defined as any
context that confers vulnerability for engaging in the
target behavior. Examples of high-risk contexts include
emotional or cognitive states (e.g., negative affect,
diminished self-efficacy), environmental contingencies
(e.g., conditioned drug cues), or physiological states (e.
g., acute withdrawal). Although some high-risk situa-
tions appear nearly universal across addictive behaviors
(e.g., negative affect; [25]), high-risk situations are likely
to vary across behaviors, across individuals, and within
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http://www.nrepp.samhsa.gov
the same individual over time [10]. Whether a high-risk
situation culminates in a lapse depends largely on the
individual’s capacity to enact an effective coping
response–defined as any cognitive or behavioral com-
pensatory strategy that reduces the likelihood of lapsing.
Central to the RP model is the role of cognitive factors
in determining relapse liability. For example, successful
navigation of high-risk situations may increase self-effi-
cacy (one’s perceived capacity to cope with an impending
situation or task; [26]), in turn decreasing relapse prob-
ability. Conversely, a return to the target behavior can
undermine self-efficacy, increasing the risk of future
lapses. Outcome expectancies (anticipated effects of sub-
stance use; [27]) also figure prominently in the RP model.
Additionally, attitudes or beliefs about the causes and

8. meaning of a lapse may influence whether a full relapse
ensues. Viewing a lapse as a personal failure may lead to
feelings of guilt and abandonment of the behavior change
goal [24]. This reaction, termed the Abstinence Violation
Effect (AVE; [16]), is considered more likely when one
holds a dichotomous view of relapse and/or neglects to
consider situational explanations for lapsing. In sum, the
RP framework emphasizes high-risk contexts, coping
responses, self-efficacy, affect, expectancies and the AVE
as primary relapse antecedents.
Implicit in the RP approach is that the initiation and
maintenance of behavior change represent separate pro-
cesses governed by unique contingencies [12,28]. Thus,
specific cognitive and behavioral strategies are often
necessary to maintain initial treatment gains and mini-
mize relapse likelihood following initial behavior change.
RP strategies fall into two broad categories: specific
intervention techniques, often designed to help the
patient anticipate and cope with high-risk situations,
and global self-control approaches, intended to reduce
relapse risk by promoting positive lifestyle change. An
essential starting point in treatment is a thorough
assessment of the client’s substance use patterns, high-
risk situations and coping skills. Other important assess-
ment targets include the client’s self-efficacy, outcome
expectancies, readiness to change, and concomitant fac-
tors that could complicate treatment (e.g., comorbid dis-
orders, neuropsychological deficits). Using high-risk
situations as a starting point, the clinician works back-
ward to identify immediate precipitants and distal life-
style factors related to relapse, and forward to evaluate
coping responses [16,24]. Ideally, this approach helps
clients to recognize high-risk situations as discriminative
stimuli signaling relapse risk, as well as to identify cog-

9. nitive and behavioral strategies to obviate these situa-
tions or minimize their impact. Examples of specific
intervention strategies include enhancing self-efficacy (e.
g., by setting achievable behavioral goals) and eliminat-
ing myths and placebo effects (e.g., by challenging mis-
perceptions about the effects of substance use).
The client’s appraisal of lapses also serves as a pivotal
intervention point in that these reactions can determine
whether a lapse escalates or desists. Establishing lapse
management plans can aid the client in self-correcting
soon after a slip, and cognitive restructuring can help
clients to re-frame the meaning of the event and mini-
mize the AVE [24]. A final emphasis in the RP approach
is the global intervention of lifestyle balancing, designed
to target more pervasive factors that can function as
relapse antecedents. For example, clients can be encour-
aged to increase their engagement in rewarding or
stress-reducing activities into their daily routine. Success
in these areas may enhance self-efficacy, in turn redu-
cing relapse risk. Overall, the RP model is characterized
by a highly ideographic treatment approach, a contrast
to the “one size fits all” approach typical of certain tradi-
tional treatments. Moreover, an emphasis on post-treat-
ment maintenance renders RP a useful adjunct to
various treatment modalities (e.g., cognitive-behavioral,
twelve step programs, pharmacotherapy), irrespective of
the strategies used to enact initial behavior change.
Developments in Relapse Prevention: 2000-2010
The last decade has seen numerous developments in the
RP literature, including the publication of Relapse
Figure 1 Original cognitive-behavioral model of relapse
(Marlatt & Gordon, 1985)

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Prevention, Second Edition [29] and its companion text,
Assessment of Addictive Behaviors, Second Edition [30].
The following sections provide an overview of major
theoretical, empirical and applied advances related to RP
over the last decade.
The reformulated cognitive-behavioral model of relapse
Efforts to develop, test and refine theoretical models are
critical to enhancing the understanding and prevention
of relapse [1,2,14]. A major development in this respect
was the reformulation of Marlatt’s cognitive-behavioral
relapse model to place greater emphasis on dynamic
relapse processes [8]. Whereas most theories presume
linear relationships among constructs, the reformulated
model (Figure 2) views relapse as a complex, nonlinear
process in which various factors act jointly and interac-
tively to affect relapse timing and severity. Similar to the
original RP model, the dynamic model centers on the
high-risk situation. Against this backdrop, both tonic
(stable) and phasic (transient) influences interact to
determine relapse likelihood. Tonic processes include
distal risks–stable background factors that determine an
individual’s “set point” or initial threshold for relapse
[8,31]. Personality, genetic or familial risk factors, drug
sensitivity/metabolism and physical withdrawal profiles
are examples of distal variables that could influence
relapse liability a priori. Tonic processes also include

11. cognitive factors that show relative stability over time,
such as drug-related outcome expectancies, global self-
efficacy, and personal beliefs about abstinence or
relapse. Whereas tonic processes may dictate initial sus-
ceptibility to relapse, its occurrence is determined lar-
gely by phasic responses–proximal or transient factors
that serve to actuate (or prevent) a lapse. Phasic
responses include cognitive and affective processes that
can fluctuate across time and contexts–such as urges/
cravings, mood, or transient changes in outcome expec-
tancies, self-efficacy, or motivation. Additionally,
momentary coping responses can serve as phasic events
that may determine whether a high-risk situation culmi-
nates in a lapse. Substance use and its immediate conse-
quences (e.g., impaired decision-making, the AVE) are
additional phasic processes that are set into motion
once a lapse occurs. Thus, whereas tonic processes can
determine who is vulnerable for relapse, phasic pro-
cesses determine when relapse occurs [8,31].
A key feature of the dynamic model is its emphasis on
the complex interplay between tonic and phasic pro-
cesses. As indicated in Figure 2, distal risks may influ-
ence relapse either directly or indirectly (via phasic
Figure 2 Revised cognitive-behavioral model of relapse
(Witkiewitz & Marlatt, 2004)
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12. processes). The model also predicts feedback loops
among hypothesized constructs. For instance, the return
to substance use can have reciprocal effects on the same
cognitive or affective factors (motivation, mood, self-effi-
cacy) that contributed to the lapse. Lapses may also
evoke physiological (e.g., alleviation of withdrawal) and/
or cognitive (e.g., the AVE) responses that in turn deter-
mine whether use escalates or desists. The dynamic
model further emphasizes the importance of nonlinear
relationships and timing/sequencing of events. For
instance, in a high-risk context, a slight and momentary
drop in self-efficacy could have a disproportionate
impact on other relapse antecedents (negative affect,
expectancies) [8]. Furthermore, the strength of proximal
influences on relapse may vary based on distal risk fac-
tors, with these relationships becoming increasingly
nonlinear as distal risk increases [31]. For example, one
could imagine a situation whereby a client who is rela-
tively committed to abstinence from alcohol encounters
a neighbor who invites the client into his home for a
drink. Feeling somewhat uncomfortable with the offer
the client might experience a slight decrease in self-effi-
cacy, which cascades into positive outcome expectancies
about the potential effects of having a drink as well as
feelings of shame or guilt about saying no to his neigh-
bor’s offer. Importantly, this client might not have ever
considered such an invitation as a high-risk situation,
yet various contextual factors may interact to predict a
lapse.
The dynamic model of relapse assumes that relapse
can take the form of sudden and unexpected returns to
the target behavior. This concurs not only with clinical
observations, but also with contemporary learning mod-
els stipulating that recently modified behavior is inher-
ently unstable and easily swayed by context [32]. While

13. maintaining its footing in cognitive-behavioral theory,
the revised model also draws from nonlinear dynamical
systems theory (NDST) and catastrophe theory, both
approaches for understanding the operation of complex
systems [10,33]. Detailed discussions of relapse in rela-
tion to NDST and catastrophe theory are available else-
where [10,31,34].
Empirical findings relevant to the RP model
The empirical literature on relapse in addictions has
grown substantially over the past decade. Because the
volume and scope of this work precludes an exhaustive
review, the following section summarizes a select body
of findings reflective of the literature and relevant to RP
theory. The studies reviewed focus primarily on alcohol
and tobacco cessation, however, it should be noted that
RP principles have been applied to an increasing range
of addictive behaviors [10,11].
Systematic reviews and large-scale treatment
outcome studies
The first comprehensive review of RP treatment out-
come studies was Carroll’s [35] descriptive account of
24 interventions focusing on substance use. This review
found consistent support for the superiority of RP over
no treatment, inconsistent support for its superiority
over discussion control conditions, and consistent sup-
port that RP was equally efficacious to other active
treatments. Carroll concluded that RP, though not con-
sistently superior to other active treatments, showed
particular promise in three areas: reducing relapse sever-
ity, enhancing durability of treatment gains, and match-
ing treatment strategies to client characteristics. RP also
showed delayed emergence effects in some studies, sug-
gesting that it may outperform other treatments during
the maintenance stage of behavior change [35].

14. Subsequently, a meta-analysis evaluated 26 RP treat-
ment outcome studies totaling 9,504 participants [36].
The authors examined two primary outcomes (substance
use and psychosocial functioning) and several treatment
moderators. Effect sizes indicated that RP was generally
successful in reducing substance use (r = .14) and
improving psychosocial functioning (r = .48), consistent
with its purpose as both a specific and global interven-
tion approach. Moderation analyses suggested that RP
was consistently efficacious across treatment modalities
(individual vs. group) and settings (inpatient vs. outpati-
ent). RP was most effective for reducing alcohol and
polysubstance use and less effective for tobacco and
cocaine use–a contrast to Carroll’s [35] finding of com-
parable efficacy across drug classes. In addition, RP was
more effective when delivered in conjunction with phar-
macotherapy, when compared to wait-list (vs. active)
comparison conditions, and when outcomes were
assessed soon after treatment. Though some findings
were considered tentative due to sample sizes, the
authors concluded that RP was broadly efficacious [36].
McCrady [37] conducted a comprehensive review of
62 alcohol treatment outcome studies comprising 13
psychosocial approaches. Two approaches–RP and brief
intervention–qualified as empirically validated treat-
ments based on established criteria. Interestingly, Miller
and Wilbourne’s [21] review of clinical trials, which
evaluated the efficacy of 46 different alcohol treatments,
ranked “relapse prevention” as 35th out of 46 treatments
based on methodological quality and treatment effect
sizes. However, many of the treatments ranked in the
top 10 (including brief interventions, social skills train-
ing, community reinforcement, behavior contracting,
behavioral marital therapy, and self-monitoring) incor-

15. porate RP components. These two reviews highlighted
the increasing difficulty of classifying interventions as
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specifically constituting RP, given that many treatments
for substance use disorders (e.g., cognitive behavioral
treatment (CBT)) are based on the cognitive behavioral
model of relapse developed for RP [16]. One of the key
distinctions between CBT and RP in the field is that the
term “CBT” is more often used to describe stand-alone
primary treatments that are based on the cognitive-
behavioral model, whereas RP is more often used to
describe aftercare treatment. Given that CBT is often
used as a stand-alone treatment it may include addi-
tional components that are not always provided in RP.
For example, the CBT intervention developed in Project
MATCH [18] (described below) equated to RP with
respect to the core sessions, but it also included elective
sessions that are not typically a focus in RP (e.g., job-
seeking skills, family involvement).
An increasing number of large-scale trials have
allowed for statistically powerful evaluations of psycho-
social interventions for alcohol use. Project MATCH
[18] evaluated the efficacy of three interventions–Moti-
vational Enhancement Therapy (MET), Twelve-Step
Facilitation (TSF), and Cognitive Behavioral Therapy
(CBT)–for treating alcohol dependence. The CBT inter-
vention was a skills-based treatment containing elements

16. of RP. Spanning nine data collection sites and following
over 1700 participants for up to three years, Project
MATCH was the largest psychotherapy trial conducted
to that point. Multiple matching hypotheses were pro-
posed in evaluating differential treatment efficacy as a
function of theoretically relevant client attributes. Pri-
mary analyses supported only one of sixteen matching
hypotheses: outpatients lower in psychiatric severity
fared better in TSF than in CBT during the year follow-
ing treatment [18]. Although primary analyses provided
relatively little support for tailoring alcohol treatments
based on specific client attributes, matching effects have
been identified in subsequent analyses (described in
more detail later).
Since 2005 an ongoing Cochrane review has evaluated
RP for smoking cessation [38,39]. As of 2009, meta-ana-
lyses had found no support for the efficacy of skills-
based RP approaches in preventing relapse to smoking
[38]. However, a recent re-analysis of these trials yielded
different results [40]. The re-analysis stratified beha-
vioral interventions based on specific intervention con-
tent while also imposing stricter analytic criteria
regarding the length of follow-up assessments. In these
analyses, CBT/RP-based self-help interventions showed
a significant overall effect in increasing long-term absti-
nence (pooled OR: 1.52, 95% CI: 1.15 - 2.01, based on 3
studies) and group counseling showed significant short-
term efficacy (pooled OR: 2.55, 95% CI: 1.58 - 4.11,
based on 2 studies). There was limited evidence for the
efficacy of other specific behavioral treatments, although
there was general support for the efficacy of pharmaco-
logical treatments [40].
Recently, Magill and Ray [41] conducted a meta-analy-

17. sis of 53 controlled trials of CBT for substance use dis-
orders. As noted by the authors, the CBT studies
evaluated in their review were based primarily on the
RP model [29]. Overall, the results were consistent with
the review conducted by Irvin and colleagues, in that
the authors concluded that 58% of individuals who
received CBT had better outcomes than those in com-
parison conditions. In contrast with the findings of Irvin
and colleagues [36], Magill and Ray [41] found that
CBT was most effective for individuals with marijuana
use disorders.
Recent findings in support of RP model
components
The following section reviews selected empirical findings
that support or coincide with tenets of the RP model.
Sections are organized in accordance with major model
constructs. Because the scope of this literature precludes
an exhaustive review, we highlight select findings that
are relevant to the main tenets of the RP model, in par-
ticular those that coincide with predictions of the refor-
mulated model of relapse.
Self-efficacy
Self-efficacy (SE), the perceived ability to enact a given
behavior in a specified context [26], is a principal deter-
minant of health behavior according to social-cognitive
theories. In fact, some theories view SE as the final com-
mon pathway to relapse [42]. Although SE is proposed
as a fluctuating and dynamic construct [26], most stu-
dies rely on static measures of SE, preventing evaluation
of within-person changes over time or contexts [43].
Shiffman, Gwaltney and colleagues have used ecological
momentary assessment (EMA; [44]) to examine tem-
poral variations in SE in relation to smoking relapse.
Findings from these studies suggested that participants’

18. SE was lower on the day before a lapse, and that lower
SE in the days following a lapse in turn predicted pro-
gression to relapse [43,45]. One study [46] reported
increases in daily SE during abstinent intervals, perhaps
indicating mounting confidence as treatment goals were
maintained [45].
In the first study to examine relapse in relation to
phasic changes in SE [46], researchers reported results
that appear consistent with the dynamic model of
relapse. During a smoking cessation attempt, partici-
pants reported on SE, negative affect and urges at ran-
dom intervals. Findings indicated nonlinear relationships
between SE and urges, such that momentary SE
decreased linearly as urges increased but dropped
abruptly as urges peaked. Moreover, this finding
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appeared attributable to individual differences in base-
line (tonic) levels of SE. When urge and negative affect
were low, individuals with low, intermediate or high
baseline SE were similar in their momentary SE ratings.
However, these groups’ momentary ratings diverged sig-
nificantly at high levels of urges and negative affect,
such that those with low baseline SE had large drops in
momentary SE in the face of increasingly challenging
situations. These findings support that higher distal risk
can result in bifurcations (divergent patterns) of beha-
vior as the level of proximal risk factors increase, consis-

19. tent with predictions from nonlinear dynamic systems
theory [31].
A recent meta-analysis evaluated the association of SE
with smoking relapse [47]. The review included 54 stu-
dies that assessed prospective associations of SE and
smoking during a quit attempt. A major finding con-
cerned differential effect sizes based on the timing of SE
assessments: the negative association of SE with likeli-
hood of future smoking represented a small effect (d =
-.21) when SE was assessed prior to the quit attempt,
but a medium effect (d = -.47) when SE was assessed
after the quit day. The authors concluded that, given the
centrality of SE to most cognitive-behavioral models of
relapse, the association of SE with cessation was weaker
than would be expected (i.e., SE accounted for roughly
2% of the variance in treatment outcome following
initial abstinence). The findings also suggested that SE
should ideally be measured after the cessation attempt,
and that controlling for concurrent smoking is critical
when examining SE in relation to prospective relapse
[47]. Finally, in analyses from a cross-national study of
the natural history of smoking cessation, researchers
examined self-efficacy in relation to relapse rates across
an extended time period [48,49]. Results indicated that
self-efficacy increased with cumulative abstinence and
correlated negatively with urges, consistent with RP the-
ory. Also, higher self-efficacy consistently predicted
lower relapse rates across time and partly mediated the
association of perceived benefits of smoking with relapse
events [48,49].
Outcome expectancies
Outcome expectancies (anticipated outcomes of a given
behavior or situation) are central to the RP model and
have been studied extensively in the domain of alcohol

20. use [27]. In theory, expectancies are shaped by various
tonic risk factors (e.g., environment, culture, personality,
genetics) and mediate these antecedent influences on
drinking [27]. Research supports that expectancies could
partly mediate influences such as personality factors
[50], genetic variations [51,52], and negative affect [53]
on drinking. Outcome expectancies could also be
involved as a phasic response to situational factors. In
the first study to examine how daily fluctuations in
expectancies predict relapse [45], researchers assessed
positive outcome expectancies for smoking (POEs)
among participants during a tobacco cessation attempt.
Lower POEs on the quit day were associated with
greater abstinence likelihood, and POEs decreased in the
days following the quit day. Lapses were associated with
higher POEs on the preceding day, and in the days fol-
lowing a lapse those who avoided a full relapse showed
decreases in POEs whereas those who relapsed did not
[45]. These results suggest that outcome expectancies
might play a role in predicting relapse as both a tonic
and phasic risk factor.
Expectancy research has recently started examining
the influences of implicit cognitive processes, generally
defined as those operating automatically or outside con-
scious awareness [54,55]. Recent reviews provide a con-
vincing rationale for the putative role of implicit
processes in addictive behaviors and relapse [54,56,57].
Implicit measures of alcohol-related cognitions can dis-
criminate among light and heavy drinkers [58] and pre-
dict drinking above and beyond explicit measures [59].
One study found that smokers’ attentional bias to
tobacco cues predicted early lapses during a quit
attempt, but this relationship was not evident among
people receiving nicotine replacement therapy, who

21. showed reduced attention to cues [60].
Initial evidence suggests that implicit measures of
expectancies are correlated with relapse outcomes, as
demonstrated in one study of heroin users [61]. In
another recent study, researchers trained participants in
attentional bias modification (ABM) during inpatient
treatment for alcohol dependence and measured relapse
over the course of three months post-treatment [62].
Relative to a control condition, ABM resulted in signifi-
cantly improved ability to disengage from alcohol-
related stimuli during attentional bias tasks. While inci-
dence of relapse did not differ between groups, the
ABM group showed a significantly longer time to first
heavy drinking day compared to the control group.
Additionally, the intervention had no effect on subjec-
tive measures of craving, suggesting the possibility that
intervention effects may have been specific to implicit
cognitive processes [62]. Overall, research on implicit
cognitions stands to enhance understanding of dynamic
relapse processes and could ultimately aid in predicting
lapses during high-risk situations.
Withdrawal
Withdrawal tendencies can develop early in the course
of addiction [25] and symptom profiles can vary based
on stable intra-individual factors [63], suggesting the
involvement of tonic processes. Despite serving as a
chief diagnostic criterion, withdrawal often does not
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22. predict relapse, perhaps partly explaining its de-empha-
sis in contemporary motivational models of addiction
[64]. However, recent studies show that withdrawal pro-
files are complex, multi-faceted and idiosyncratic, and
that in the context of fine-grained analyses withdrawal
indeed can predict relapse [64,65]. Such findings have
contributed to renewed interest in negative reinforce-
ment models of drug use [63].
Although withdrawal is usually viewed as a physiologi-
cal process, recent theory emphasizes the importance of
behavioral withdrawal processes [66]. Whereas physiolo-
gical withdrawal symptoms tend to abate in the days or
weeks following drug cessation, the unavailability of a
conditioned behavioral coping response (e.g., the ritual
of drug administration) may leave the former user ill-
equipped to cope with ongoing stressors, thus exacer-
bating and/or prolonging symptoms [66]. Current theory
and research indicate that physiological components of
drug withdrawal may be motivationally inert, with the
core motivational constituent of withdrawal being nega-
tive affect [25,66]. Thus, examining withdrawal in rela-
tion to relapse may only prove useful to the extent that
negative affect is assessed adequately [64].
Negative affect
A large literature attests to the role of negative affect
(NA) in the etiology and maintenance of addictive beha-
viors. NA is consistently cited as a relapse trigger in ret-
rospective reports (e.g., [67,68]), although participants
might sometimes misattribute lapses to negative mood
states[15]. In one study, individuals who were unable to
sustain a smoking cessation attempt for more than 24
hours (compared to those with a sustained quit attempt)

23. reported greater depressive symptoms and NA in
response to stress and displayed less perseverance dur-
ing experimental stress inductions [69]. Supporting the
dynamic influence of NA on relapse, Shiffman and
Waters [70] found that smoking lapses were not asso-
ciated with NA in the preceding days, but were asso-
ciated with rising NA in the hours leading up to a lapse.
Evidence further suggests that negative affect can pro-
mote positive outcome expectancies [53] or undermine
situational self-efficacy [71], outcomes which could in
turn promote a lapse. Moreover, Baker and colleagues
propose that high levels of negative affect can interfere
with controlled cognitive processes, such that adaptive
coping and decision-making may be undermined as
negative affect peaks [25]. Witkiewitz and Villarroel [72]
found that drinking rates following treatment were sig-
nificantly associated with current and prior changes in
negative affect and changes in negative affect were sig-
nificantly associated with current and prior changes in
drinking state (effect size range = 0.13 (small) to 0.33
(medium)). Overall, the results showed that individuals
who reported higher negative affect or increased nega-
tive affect over time had the highest probability of heavy
and frequent drinking following treatment, and had a
near-zero probability of transitioning to moderate drink-
ing. Heavier and more frequent alcohol use predicted a
greater probability of high negative affect and increased
negative affect over time.
Knowledge about the role of NA in drinking behavior
has benefited from daily process studies in which parti-
cipants provide regular reports of mood and drinking.
Such studies have shown that both positive and negative
moods show close temporal links to alcohol use [73].
One study [74] found evidence suggesting a feedback

24. cycle of mood and drinking whereby elevated daily levels
of NA predicted alcohol use, which in turn predicted
spikes in NA. These findings were moderated by gender,
social context, and time of week. Other studies have
similarly found that relationships between daily events
and/or mood and drinking can vary based on intraindi-
vidual or situational factors [73], suggesting dynamic
interplay between these influences.
Self-control and coping responses
Strengthening coping skills is a goal of virtually all cog-
nitive-behavioral interventions for substance use [75].
Several studies have used EMA to examine coping
responses in real time. One study [76] found that
momentary coping differentiated smoking lapses from
temptations, such that coping responses were reported
in 91% of successful resists vs. 24% of lapses. Shiffman
and colleagues [68] found that restorative coping follow-
ing a smoking lapse decreased the likelihood of a second
lapse the same day. Exactly how coping responses
reduce the likelihood of lapsing remains unclear. One
study found that momentary coping reduced urges
among smokers, suggesting a possible mechanism [76].
Some studies find that the number of coping responses
is more predictive of lapses than the specific type of
coping used [76,77]. However, despite findings that cop-
ing can prevent lapses there is scant evidence to show
that skills-based interventions in fact lead to improved
coping [75].
Some researchers propose that the self-control
required to maintain behavior change strains motiva-
tional resources, and that this “fatigue” can undermine
subsequent self-control efforts [78]. Consistent with this
idea, EMA studies have shown that social drinkers
report greater alcohol consumption and violations of

25. self-imposed drinking limits on days when self-control
demands are high [79]. Limit violations were predictive
of responses consistent with the AVE the following day,
and greater distress about violations in turn predicted
greater drinking [80]. Findings also suggested that these
relationships varied based on individual differences,
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suggesting the interplay of static and dynamic factors in
AVE responses. Evidence further suggests that practicing
routine acts of self-control can reduce short-term inci-
dence of relapse. For instance, Muraven [81] conducted
a study in which participants were randomly assigned to
practice small acts self-control acts on a daily basis for
two weeks prior to a smoking cessation attempt. Com-
pared to a control group, those who practiced self-con-
trol showed significantly longer time until relapse in the
following month.
Emerging topics in relapse and relapse
prevention
Using nonlinear methods to model relapse
A key contribution of the reformulated relapse model is
to highlight the need for non-traditional assessment and
analytic approaches to better understand relapse. Most
studies of relapse rely on statistical methods that assume
continuous linear relationships, but these methods may
be inadequate for studying a behavior characterized by
discontinuity and abrupt changes [33]. Consistent with

26. the tenets of the reformulated RP model, several studies
suggest advantages of nonlinear statistical approaches
for studying relapse.
In one study, researchers used catastrophe models to
examine proximal and distal predictors of post-treat-
ment drinking among individuals with alcohol use disor-
ders [31]. Catastrophe models accounted for more than
double the amount of variance in drinking than that
predicted by linear models. Similar results have been
found using the much larger Project MATCH dataset
[33]. Two additional recent analyses of the MATCH
dataset showed that nonlinear approaches can detect
processes that may go unobserved in the context of lin-
ear models. Witkiewitz and colleagues [34,82] used cata-
strophe modeling and latent growth mixture modeling
to re-assess two of the matching hypotheses that were
not supported in the original study–that individuals low
in baseline self-efficacy would respond more favorably
to cognitive-behavioral therapy (CBT) than motivational
enhancement therapy (MET) and that individuals low in
baseline motivation would respond more favorably to
MET than CBT [18]. In the first study [34], catastrophe
models provided the best fit to the data, and latent
growth analyses confirmed the predicted interaction: fre-
quent drinkers with low initial self-efficacy had better
outcomes in CBT than in MET, while those high in
self-efficacy fared better in MET. Similarly, a second
study [82] found that individuals in the outpatient arm
of Project MATCH with low motivation to change at
baseline who were assigned to MET had better out-
comes than those assigned to CBT. The authors also
found a treatment by gender by alcohol dependence
severity interaction in support of the matching
hypothesis, whereby females with low baseline motiva-

27. tion and males with lower levels of alcohol dependence
and low baseline motivation who received MET as an
aftercare treatment had better outcomes than those who
were assigned to receive CBT as an aftercare treatment.
Genetic influences on treatment response and relapse
The last decade has seen a marked increase in the num-
ber of human molecular genetic studies in medical and
behavioral research, due largely to rapid technological
advances in genotyping platforms, decreasing cost of
molecular analyses, and the advent of genome-wide
association studies (GWAS). Not surprisingly, molecular
genetic approaches have increasingly been incorporated
in treatment outcome studies, allowing novel opportu-
nities to study biological influences on relapse. Given
the rapid growth in this area, we allocate a portion of
this review to discussing initial evidence for genetic
associations with relapse. Specifically, we focus on
recent, representative findings from studies evaluating
candidate single nucleotide polymorphisms (SNPs) as
moderators of response to substance use interventions.
It is important to note that these studies were not
designed to evaluate specific components of the RP
model, nor do these studies explicitly espouse the RP
model. Also, many studies have focused solely on phar-
macological interventions, and are therefore not directly
related to the RP model. However, we review these find-
ings in order to illustrate the scope of initial efforts to
include genetic predictors in treatment studies that
examine relapse as a clinical outcome. These findings
may be informative for researchers who wish to incor-
porate genetic variables in future studies of relapse and
relapse prevention.
Broadly speaking, there are at least three primary con-
texts in which genetic variation could influence liability

28. for relapse during or following treatment. First, in the
context of pharmacotherapy interventions, relevant
genetic variations can impact drug pharmacokinetics or
pharmacodynamics, thereby moderating treatment
response (pharmacogenetics). Second, the likelihood of
abstinence following a behavioral or pharmacological
intervention can be moderated by genetic influences on
metabolic processes, receptor activity/expression, and/or
incentive value specific to the addictive substance in
question. For instance, SNPs with functional implica-
tions for relevant neurotransmitter or metabolic path-
ways can influence the reward value of marijuana (e.g.,
FAAH; CNR1); nicotine (e.g., CYP2A6, CHRNB2,
CHRNA4); and alcohol (ALDH2, ADH1B), while others
show potential for influencing the incentive value of
multiple drugs (e.g., ANKK1; DRD4; OPRM1). Third,
variants implicated in broad traits relevant for addictive
behaviors–for instance, executive cognitive functioning
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(e.g., COMT) or externalizing traits (e.g., GABRA2,
DRD4)–could influence relapse proneness via general
neurobehavioral mechanisms, irrespective of drug class
or treatment modality. As summarized below, prelimin-
ary empirical support exists for each of these
possibilities.
Genetic influences on relapse have been studied most
extensively in the context of pharmacogenetics, with the

29. bulk of studies focusing on nicotine dependence (for
recent reviews see [83,84]). Several candidate poly-
morphisms have been examined in response to smoking
cessation treatments, especially nicotine replacement
therapy (NRT) and bupropion [84]. The catechol-O-
methyltransferase (COMT) Val158Met polymorphism,
established as predicting variability in prefrontal dopa-
mine levels, has been evaluated in relation to smoking
cessation in several studies. Independent trials of NRT
have found cessation rates to differ based on COMT
genotype [85-87]. A polymorphism in the nicotinic acet-
ylcholine ß2 receptor gene (CHRNB2) has been asso-
ciated with length of abstinence and withdrawal
symptoms during bupropion treatment [88] and with
relapse rates and ability to quit on the target day during
NRT [89]. One bupropion trial found that DRD2 varia-
tions predicted withdrawal symptoms, medication
response and time to relapse [90]. In a study of the mu-
opioid receptor (OPRM1) Asn40/Asp40 variant during
NRT, those with the Asp40 variant had higher rates of
abstinence and reduced negative affect compared to
Asn40 individuals [91]. Additionally, post-hoc analyses
indicated that Asp40 carriers were more likely to regain
abstinence following a lapse, suggesting a possible role
of the genotype in predicting prolapse.
The most promising pharmacogenetic evidence in
alcohol interventions concerns the OPRM1 A118G poly-
morphism as a moderator of clinical response to nal-
trexone (NTX). An initial retrospective analysis of NTX
trials found that OPRM1 influenced treatment response,
such that individuals with the Asp40 variant (G allele)
receiving NTX had a longer time until the first heavy
drinking day and were half as likely to relapse compared
to those homozygous for the Asn40 variant (A allele)
[92]. This finding was later extended in the COMBINE

30. study, such that G carriers showed a greater proportion
of days abstinent and a lower proportion of heavy drink-
ing days compared in response to NTX versus placebo,
whereas participants homozygous for the A allele did
not show a significant medication response [93]. More-
over, 87.1% of G allele carriers who received NTX were
classified as having a good clinical outcome at study
endpoint, versus 54.5% of Asn40 homozygotes who
received NTX. (Moderating effects of OPRM1 were spe-
cific to participants receiving medication management
without the cognitive-behavioral intervention [CBI] and
were not evident in participants receiving NTX and
CBI). A smaller placebo controlled study has also found
evidence for better responses to NTX among Asp40 car-
riers [94]. The Asp40 variant has further been linked to
intermediate phenotypes that could influence relapse
proneness, including hedonic responses to alcohol [95],
increased neural responses to alcohol primes [96],
greater craving in response to alcohol use [97] and
increased dopamine release in the ventral striatum dur-
ing alcohol challenge [98]. One study found that the
Asp40 allele predicted cue-elicited craving among indivi-
duals low in baseline craving but not those high in
initial craving, suggesting that tonic craving could inter-
act with genotype to predict phasic responses to drug
cues [97].
Findings concerning possible genetic moderators of
response to acamprosate have been reported [99], but
are preliminary. Additionally, other findings suggest the
influence of a DRD4 variable number of tandem repeats
(VNTR) polymorphism on response to olanzapine, a
dopamine antagonist that has been studied as an experi-
mental treatment for alcohol problems. Olanzapine was
found to reduce alcohol-related craving those with the

31. long-repeat VNTR (DRD4 L), but not individuals with
the short-repeat version (DRD4 S; [100,101]). Further, a
randomized trial of olanzapine led to significantly
improved drinking outcomes in DRD4 L but not DRD4
S individuals [100].
There is also preliminary evidence for the possibility
of genetic influences on response to psychosocial inter-
ventions, including those incorporating RP strategies. In
a secondary analysis of the Project MATCH data,
researchers evaluated posttreatment drinking outcomes
in relation to a GABRA2 variant previously implicated
in the risk for alcohol dependence [102]. Analyses
included MATCH participants of European descent who
provided a genetic sample (n = 812). Those carrying the
high-risk GABRA2 allele showed a significantly
increased likelihood of relapse following treatment,
including a twofold increase in the likelihood of heavy
drinking. Furthermore, GABRA2 interacted with treat-
ment condition to influence drinking outcomes. Among
those with the high-risk genotype, drinking behavior did
not appear to be modified by treatment, with outcomes
being similar regardless of treatment condition. How-
ever, treatment differences emerged in the low-risk gen-
otype group, such that TSF produced the best
outcomes, followed by MET [102]. In another psychoso-
cial treatment study, researchers in Poland examined
genetic moderators of relapse following inpatient alcohol
treatment [103]. Results showed that polymorphisms in
BDNF (Val66Met) and COMT (Val158Met) significantly
predicted relapse probability. Overall, evidence for
genetic moderation effects in psychosocial trials are
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32. Page 10 of 17
consistent with the notion that variants with broad
implications for neurotransmitter function, cognitive
function, and/or externalizing traits can potentially
influence relapse proneness. In the absence of a plausi-
ble biological mechanism for differential response to
specific psychosocial treatments (e.g., MET vs. CBT) as
a function of genotype, the most parsimonious interpre-
tation of these findings is that some variants will impose
greater risk for relapse following any quit attempt,
regardless of treatment availability or modality.
Findings from numerous non-treatment studies are
also relevant to the possibility of genetic influences on
relapse processes. For instance, genetic factors could
influence relapse in part via drug-specific cognitive pro-
cesses. Recent studies have reported genetic associations
with alcohol-related cognitions, including alcohol expec-
tancies, drinking refusal self-efficacy, drinking motives,
and implicit measures of alcohol-related motivation
[51,52,104-108]. Overall, the body of research on genetic
influences on relapse and related processes is nascent
and virtually all findings require replication. Consistent
with the broader literature, it can be anticipated that
most genetic associations with relapse outcomes will be
small in magnitude and potentially difficult to replicate.
Nonetheless, initial studies have yielded intriguing
results. It is inevitable that the next decade will see
exponential growth in this area, including greater use of
genome-wide analyses of treatment response [109] and
efforts to evaluate the clinical utility and cost effective-
ness of tailoring treatments based on pharmacogenetics.

33. Finally, an intriguing direction is to evaluate whether
providing clients with personalized genetic information
can facilitate reductions in substance use or improve
treatment adherence [110,111].
Mindfulness-based relapse prevention
In terms of clinical applications of RP, the most notable
development in the last decade has been the emergence
and increasing application of Mindfulness-Based Relapse
Prevention (MBRP) for addictive behaviors [112,113].
Given supportive data for the efficacy of mindfulness-
based interventions in other behavioral domains, espe-
cially in prevention of relapse of major depression [114],
there is increasing interest in MBRP for addictive beha-
viors. The merger of mindfulness and cognitive-beha-
vioral approaches is appealing from both theoretical and
practical standpoints [115] and MBRP is a potentially
effective and cost-efficient adjunct to CBT-based treat-
ments. In contrast to the cognitive restructuring strate-
gies typical of traditional CBT, MBRP stresses
nonjudgmental attention to thoughts or urges. From
this standpoint, urges/cravings are labeled as transient
events that need not be acted upon reflexively. This
approach is exemplified by the “urge surfing” technique
[115], whereby clients are taught to view urges as analo-
gous to an ocean wave that rises, crests, and diminishes.
Rather than being overwhelmed by the wave, the goal is
to “surf” its crest, attending to thoughts and sensations
as the urge peaks and subsides.
Results of a preliminary nonrandomized trial supported
the potential utility of MBRP for reducing substance use.
In this study incarcerated individuals were offered the
chance to participate in an intensive 10-day course in
Vipassana meditation (VM). Those participating in VM

34. were compared to a treatment as usual (TAU) group on
measures of post-incarceration substance use and psy-
chosocial functioning. Relative to the TAU group, the
VM group reported significantly lower levels of substance
use and alcohol-related consequences and improved psy-
chosocial functioning at follow-up [116].
More recently, a randomized controlled trial com-
pared an eight-week MBRP course to treatment as usual
(TAU), which consisted of 12-step-based process-
oriented discussion and psychoeducation groups [117].
The majority of MBRP participants (86%) engaged in
meditation practices immediately posttreatment and
54% continued practice for at least 4 months posttreat-
ment (M = 4.74 days/week, up to 30 min/day). Com-
pared to TAU, MBRP participants reported significantly
reduced craving, and increased acceptance and mindful
awareness over the 4-month follow-up period, consistent
with the core goals of MBRP. Over the course of treat-
ment, MBRP evinced fewer days of use compared to
TAU (MBRP: M = .06 days, TAU: M = 2.57 days).
These differences persisted at 2-month follow-up (2.08
days for MBRP vs. 5.43 days for TAU). Secondary ana-
lyses [118] showed that compared to TAU, MBRP parti-
cipants evinced a decreased relation between depressive
symptoms and craving following treatment. This
attenuation was related to subsequent decreases in alco-
hol and other drug use, suggesting MBRP led to
decreased craving in response to negative affect, thereby
lessening the need to alleviate affective discomfort with
alcohol and other drug use. Furthermore, individuals
with moderate depression in the MBRP group had a sig-
nificantly lower probability of substance use, fewer
drinks per drinking day, and fewer drinks per day than
individuals with moderate depression in TAU. A larger,
randomized trial comparing MBRP to TAU and RP is

35. currently underway at the University of Washington to
evaluate whether the addition of mindfulness to the
standard RP treatment leads to better substance use
outcomes following treatment. As is the case in other
clinical domains [114], interest in MBRP for substance
use disorders is increasing rapidly. Results of additional
randomized controlled trials will be important for
informing its broader application for various addictive
behaviors.
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Critiques of the RP Model
Following the initial introduction of the RP model in the
1980s, its widespread application largely outpaced efforts
to systematically validate the model and test its underly-
ing assumptions. Given this limitation, the National Insti-
tutes on Alcohol Abuse and Alcoholism (NIAAA)
sponsored the Relapse Replication and Extension Project
(RREP), a multi-site study aiming to test the reliability
and validity of Marlatt’s original relapse taxonomy.
Efforts to evaluate the validity [119] and predictive valid-
ity [120] of the taxonomy failed to generate supportive
data. It was noted that in focusing on Marlatt’s relapse
taxonomy the RREP did not comprehensive evaluation of
the full RP model [121]. Nevertheless, these studies were
useful in identifying limitations and qualifications of the
RP taxonomy and generated valuable suggestions [121].
The recently introduced dynamic model of relapse [8]

36. takes many of the RREP criticisms into account. Addi-
tionally, the revised model has generated enthusiasm
among researchers and clinicians who have observed
these processes in their data and their clients [122,123].
Still, some have criticized the model for not emphasiz-
ing interpersonal factors as proximal or phasic influ-
ences [122,123]. Other critiques include that nonlinear
dynamic systems approaches are not readily applicable
to clinical interventions [124], and that the theory and
statistical methods underlying these approaches are eso-
teric for many researchers and clinicians [14]. Rather
than signaling weaknesses of the model, these issues
could simply reflect methodological challenges that
researchers must overcome in order to better under-
stand dynamic aspects of behavior [45]. Ecological
momentary assessment [44], either via electronic device
or interactive voice response methodology, could pro-
vide the data necessary to fully test the dynamic model
of relapse. Ideally, assessments of coping, interpersonal
stress, self-efficacy, craving, mood, and other proximal
factors could be collected multiple times per day over
the course of several months, and combined with a
thorough pre-treatment assessment battery of distal risk
factors. Future research with a data set that includes
multiple measures of risk factors over multiple days
could also take advantage of innovative modeling tools
that were designed for estimating nonlinear time-varying
dynamics [125].
Directions for Future Research
Considering the numerous developments related to RP
over the last decade, empirical and clinical extensions of
the RP model will undoubtedly continue to evolve. In
addition to the recent advances outlined above, we high-
light selected areas that are especially likely to see
growth over the next several years.

37. Mechanisms of treatment effects
Elucidating the “active ingredients” of CBT treatments
remains an important and challenging goal. Consistent
with the RP model, changes in coping skills, self-efficacy
and/or outcome expectancies are the primary putative
mechanisms by which CBT-based interventions work
[126]. However, few studies support these presumptions.
One study, in which substance-abusing individuals were
randomly assigned to RP or twelve-step (TS) treatments,
found that RP participants showed increased self-effi-
cacy, which accounted for unique variance in outcomes
[69]. In a recent study, Witkiewitz and colleagues
(under review) found that individuals in the combined
behavioral intervention of the COMBINE study who
received drink-refusal skills training as part of the beha-
vioral intervention had significantly better outcomes
than those who did not receive the drink-refusal skills
training, particularly African American clients [127].
Further, there was strong support that increases in self-
efficacy following drink-refusal skills training was the
primary mechanism of change. In another study examin-
ing the behavioral intervention arm of the COMBINE
study [128], individuals who received a skills training
module focused on coping with craving and urges had
significantly better drinking outcomes via decreases in
negative mood and craving that occurred after receiving
the module.
Despite findings like these, many studies of treatment
mechanisms have failed to show that theoretical media-
tors account for salutary effects of CBT-based interven-
tions. Also, many studies that have examined potential
mediators of outcomes have not provided a rigorous
test [129] of mechanisms of change. These results sug-
gest that researchers should strive to consider alternative

38. mechanisms, improve assessment methods and/or revise
theories about how CBT-based interventions work
[77,130].
Continued empirical evaluation of the RP model
As the foregoing review suggests, validation of the refor-
mulated RP model will likely progress slowly at first
because researchers are only beginning to evaluate
dynamic relapse processes. Currently, the dynamic
model can be viewed as a hypothetical, theory-driven
framework that awaits empirical evaluation. Testing the
model’s components will require that researchers avail
themselves of innovative assessment techniques (such as
EMA) and pursue cross-disciplinary collaboration in
order to integrate appropriate statistical methods. Irre-
spective of study design, greater integration of distal and
proximal variables will aid in modeling the interplay of
tonic and phasic influences on relapse outcomes. As was
the case for Marlatt’s original RP model, efforts are
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needed to systematically evaluate specific theoretical
components of the reformulated model [1].
Integrating implicit cognition and neurocognition in
relapse models
Historically, cognitive processes have been central to the
RP model [8]. In the last several years increasing
emphasis has been placed on “dual process” models of

39. addiction, which hypothesize that distinct (but related)
cognitive networks, each reflective of specific neural
pathways, act to influence substance use behavior.
According to these models, the relative balance between
controlled (explicit) and automatic (implicit) cognitive
networks is influential in guiding drug-related decision
making [54,55]. Dual process accounts of addictive
behaviors [56,57] are likely to be useful for generating
hypotheses about dynamic relapse processes and
explaining variance in relapse, including episodes of sud-
den divergence from abstinence to relapse. Implicit cog-
nitive processes are also being examined as an
intervention target, with some potentially promising
results [62].
Related work has also stressed the importance of base-
line levels of neurocognitive functioning (for example as
measured by tasks assessing response inhibition and
working memory; [56]) as predicting the likelihood of
drug use in response to environmental cues. The study
of implicit cognition and neurocognition in models of
relapse would likely require integration of distal neuro-
cognitive factors (e.g., baseline performance in cognitive
tasks) in the context of treatment outcomes studies or
EMA paradigms. Additionally, lab-based studies will be
needed to capture dynamic processes involving cogni-
tive/neurocognitive influences on lapse-related
phenomena.
Evaluating neural markers of relapse liability
The use of functional magnetic resonance imaging
(fMRI) techniques in addictions research has increased
dramatically in the last decade [131] and many of these
studies have been instrumental in providing initial evi-
dence on neural correlates of substance use and relapse.
In one study of treatment-seeking methamphetamine

40. users [132], researchers examined fMRI activation dur-
ing a decision-making task and obtained information on
relapse over one year later. Based on activation patterns
in several cortical regions they were able to correctly
identify 17 of 18 participants who relapsed and 20 of 22
who did not. Functional imaging is increasingly being
incorporated in treatment outcome studies (e.g., [133])
and there are increasing efforts to use imaging
approaches to predict relapse [134]. While the overall
number of studies examining neural correlates of relapse
remains small at present, the coming years will
undoubtedly see a significant escalation in the number
of studies using fMRI to predict response to psychoso-
cial and pharmacological treatments. In this context, a
critical question will concern the predictive and clinical
utility of brain-based measures with respect to predict-
ing treatment outcome.
Conclusions and Policy Implications
Relapse prevention is a cognitive-behavioral approach
designed to help individuals anticipate and cope with
setbacks during the behavior change process. The broad
aim of RP, to reduce the incidence and severity of
relapse, subsumes two basic goals: to minimize the
impact of high-risk situations by increasing awareness
and building coping skills, and to limit relapse prone-
ness by promoting a healthy and balanced lifestyle. Over
the past decade RP principles have been incorporated
across an increasing array of behavior domains, with
addictive behaviors continuing to represent the primary
application.
As outlined in this review, the last decade has seen
notable developments in the RP literature, including sig-
nificant expansion of empirical work with relevance to

41. the RP model. Overall, many basic tenets of the RP
model have received support and findings regarding its
clinical effectiveness have generally been supportive. RP
modules are standard to virtually all psychosocial inter-
ventions for substance use [17] and an increasing num-
ber of self-help manuals are available to assist both
therapists and clients. RP strategies can now be dissemi-
nated using simple but effective methods; for instance,
mail-delivered RP booklets are shown to reduce smok-
ing relapse [135,136]. As noted earlier, the broad influ-
ence of RP is also evidenced by the current clinical
vernacular, as “relapse prevention” has evolved into an
umbrella term synonymous with most cognitive-beha-
vioral skills-based interventions addressing high-risk
situations and coping responses. While attesting to the
influence and durability of the RP model, the tendency
to subsume RP within various treatment modalities can
also complicate efforts to systematically evaluate inter-
vention effects across studies (e.g., [21]).
Although many developments over the last decade
encourage confidence in the RP model, additional
research is needed to test its predictions, limitations and
applicability. In particular, given recent theoretical revi-
sions to the RP model, as well as the tendency for dif-
fuse application of RP principles across different
treatment modalities, there is an ongoing need to evalu-
ate and characterize specific theoretical mechanisms of
treatment effects.
In the current review we have noted several areas for
future research, including examining dynamic models of
treatment outcomes, extensions of RP to include
Hendershot et al. Substance Abuse Treatment, Prevention, and
Policy 2011, 6:17

42. http://www.substanceabusepolicy.com/content/6/1/17
Page 13 of 17
mindfulness and/or self-control training, research on the
mechanisms of change following successful treatment
outcomes, the role of genetic influences as potential
moderators of treatment outcomes, and neurocognitive
and neurobiological examinations of the relapse process
using tests of implicit cognition and advanced neuroi-
maging techniques. In addition to these areas, which
already have initial empirical data, we predict that we
could learn significantly more about the relapse process
using experimental manipulation to test specific aspects
of the cognitive-behavioral model of relapse. For exam-
ple, it has been shown that self-efficacy for abstinence
can be manipulated [137]. Thus, one could test whether
increasing self-efficacy in an experimental design is
related to better treatment outcomes. Similarly, self-reg-
ulation ability, outcome expectancies, and the abstinence
violation effect could all be experimentally manipulated,
which could eventually lead to further refinements of
RP strategies.
Ultimately, individuals who are struggling with beha-
vior change often find that making the initial change is
not as difficult as maintaining behavior changes over
time. Many therapies (both behavioral and pharmacolo-
gical) have been developed to help individuals cease or
reduce addictive behaviors and it is critical to refine
strategies for helping individuals maintain treatment
goals. As noted by McLellan [138] and others [124], it is
imperative that policy makers support adoption of treat-
ments that incorporate a continuing care approach, such

43. that addictions treatment is considered from a chronic
(rather than acute) care perspective. Broad implementa-
tion of a continuing care approach will require policy
change at numerous levels, including the adoption of
long-term patient-based and provider-based strategies
and contingencies to optimize and sustain treatment
outcomes [139,140].
In support of continuing care approaches the United
States Office of National Drug Control Policy recently
published the 2010 National Drug Control Strategy in
the United States [141], which includes strategies to
integrate treatment for substance use disorders into the
mainstream health care system and to expand support
for continuing care efforts. One critical goal will be to
integrate empirically supported substance use interven-
tions in the context of continuing care models of treat-
ment delivery, which in many cases requires adapting
existing treatments to facilitate sustained delivery [140].
Given its focus on long-term maintenance of treatment
gains, RP is a behavioral intervention that is particularly
well suited for implementation in continuing care con-
texts. Many treatment centers already provide RP as a
routine component of aftercare programs. However, it is
imperative that insurance providers and funding entities
support these efforts by providing financial support for
aftercare services. It is also important that policy makers
and funding entities support initiatives to evaluate RP
and other established interventions in the context of
continuing care models. In general, more research on
the acquisition and long-term retention of specific RP
skills is necessary to better understand which RP skills
will be most useful in long-term and aftercare treat-
ments for addictions.

44. Author details
1Centre for Addiction and Mental Health, 33 Russell St.,
Toronto, ON, M5S
2S1, Canada. 2Department of Psychiatry, University of Toronto,
250 College
St., Toronto, ON M5T 1R8, Canada. 3Department of
Psychology, Washington
State University, 14204 NE Salmon Creek Ave, Vancouver,
WA, 98686, USA.
4Department of Psychology, University of Washington, Box
351525, Seattle,
WA 98195, USA.
Authors’ contributions
CH wrote the manuscript with contributions from KW. BG and
GAM assisted
in conceptualizing the paper and provided critical review. All
authors read
and approved the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 19 May 2011 Accepted: 19 July 2011 Published: 19
July 2011
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Cite this article as: Hendershot et al.: Relapse prevention for
addictive
behaviors. Substance Abuse Treatment, Prevention, and Policy
2011 6:17.
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http://www.ncbi.nlm.nih.gov/pubmed/8997787?dopt=Abstract
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http://www.ncbi.nlm.nih.gov/pubmed/15714046?dopt=Abstract
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http://www.ncbi.nlm.nih.gov/pubmed/21443311?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/21443311?dopt=Abstract
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http://www.ncbi.nlm.nih.gov/pubmed/21261434?dopt=Abstract
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http://www.ncbi.nlm.nih.gov/pubmed/21261434?dopt=Abstract
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77. http://www.ncbi.nlm.nih.gov/pubmed/14626454?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/14626454?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/11070524?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/11070524?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/11070524?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15464121?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15464121?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15997017?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15997017?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15997017?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19170666?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19170666?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19170666?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/20682188?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/20682188?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/20682188?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/10710845?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/10710845?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/10710845?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15482038?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15482038?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/15482038?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/16536671?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/16536671?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/16536671?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/11964098?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/11964098?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19161893?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19161893?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19161893?dopt=Abstract
http://www.ondcp.govAbstractIntroductionDefinitions of
relapse and relapse preventionMarlatt’s relapse prevention
model: Historical foundations and overviewDevelopments in
Relapse Prevention: 2000-2010The reformulated cognitive-
behavioral model of relapseEmpirical findings relevant to the
RP modelSystematic reviews and large-scale treatment outcome

78. studiesRecent findings in support of RP model componentsSelf-
efficacyOutcome expectanciesWithdrawalNegative affectSelf-
control and coping responsesEmerging topics in relapse and
relapse preventionUsing nonlinear methods to model
relapseGenetic influences on treatment response and
relapseMindfulness-based relapse preventionCritiques of the RP
ModelDirections for Future ResearchMechanisms of treatment
effectsContinued empirical evaluation of the RP
modelIntegrating implicit cognition and neurocognition in
relapse modelsEvaluating neural markers of relapse
liabilityConclusions and Policy ImplicationsAuthor
detailsAuthors' contributionsCompeting interestsReferences
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COLLEGE OF NURSING
EVIDENCE BASED PRACTICE ARTICLE REVIEW
SUMMARY
Utilizing evidence-based research in your practice ensures that
your patients receive the most effective care possible. It is
necessary for practitioners to review the research literature and
identify therapeutic modalities that have been tested empirically
and proven to more effective (as effective, or less effective)
than others. By providing the information below, you will begin
to build a library of EBP resources for your practice.
CriteriaValue
Introduction that includes the aspect of treatment the selected
article addresses:
Relapse prevention
1point

89. Summary of the article in your own words—500 words or less
(do not copy the abstract).
4points
Rate and grade the article using an evidence-based model.
1point
Use rating and grading to describe how the Psychiatric Nurse
Practitioner can
incorporate the findings in the article into practice.
2points
How has this article changed your perceptive/view of the
treatment discussed? 1point
APA formatting for sentence structure, grammar, and reference
citation. 1point
Total
10points