Relapse prevention

1. Introduction

Version followed: Marlatt & Gordon's (1985) cognitive-behavioural relapse prevention (RP) model as laid out for clinicians by Larimer, Palmer & Marlatt (1999), with Witkiewitz & Marlatt's (2004) reformulated dynamic model used for case formulation. Mindfulness-Based Relapse Prevention (MBRP; Bowen, Chawla & Marlatt) is a separate, manualised derivative; it appears here only where it adds a named technique. Gorski's CENAPS relapse-prevention model is a different approach and is not covered. [source: Larimer et al. 1999; Wikipedia: Relapse prevention]

RP is a cognitive-behavioural maintenance model, not a fixed-session therapy. It can be delivered on its own, as aftercare, or as the maintenance phase of any addiction treatment, individually or in groups. Developed for alcohol and drug problems, it has been adapted to smoking, gambling, eating problems, sexual offending and sexual risk behaviour. [source: Guilford contents, Marlatt & Donovan 2005; Wikipedia]

Core idea of change: relapse is a process, not an endpoint. It begins before the first use and continues after it. Whether someone uses in a high-risk situation depends less on the situation itself than on their coping response. Coping well builds situation-specific self-efficacy. Failing to cope, together with positive outcome expectancies about the substance, makes a first use (a lapse) likely. Whether a lapse turns into a full relapse or a return to the goal ("prolapse") depends largely on how the person explains it. Blaming a stable, global personal failing (the abstinence violation effect, AVE) drives further use. Seeing it as a specific coping error that can be learned from does not. Behind these immediate triggers sit covert antecedents: lifestyle imbalance, rationalisation and denial, apparently irrelevant decisions, and urges or cravings. These steer the person into risky situations. Treatment teaches the person to anticipate and cope at every point in this chain. [source: Larimer et al. 1999; Witkiewitz, Marlatt & Walker 2005]

2. Framework

Status of the structure. The primary sources do not prescribe numbered phases or a fixed session count for classic RP. They describe an assessment logic and two families of intervention: specific strategies for immediate determinants and global lifestyle self-control strategies. The phase sequence below arranges that material for clinical use. [synthesis] Session counts are not fixed in the sources [uncertain]. RP is commonly delivered as a block of weekly sessions or embedded in a broader programme. MBRP, by contrast, is 8 weekly 2-hour group sessions with daily home practice. [source: Marlatt, Addiction and the Mind slides]

Assessment logic (primary). Assess in two directions: forward from the high-risk situation to the person's response, and backward to the lifestyle factors that put them in those situations. [source: Larimer et al. 1999]

Formulation layer: dynamic model (Witkiewitz & Marlatt 2004). Relapse is multidetermined and nonlinear. Small changes in risk can produce sudden, large shifts in behaviour, and factors interact through feedback loops. [source: Wikipedia] Tonic processes are chronic vulnerability. They include distal risks such as family history and years of dependence, along with cognitive processes and physical withdrawal states, and they can accumulate. Phasic responses are the moment-to-moment factors, such as affect and coping behaviour, that tip a high-risk situation into use or not. [source: Snelleman 2018 thesis, summarising Witkiewitz & Marlatt 2004; the original paper is not drawn on. [uncertain] on finer details]

[source for phase content: Larimer et al. 1999; booster sessions: Wikipedia; phase ordering and move-on criteria: synthesis]

Format notes. RP can run with clients who are not yet abstinent (self-monitoring of use situations) or already abstinent (monitoring urges). [source: Larimer et al. 1999] The goal can be abstinence or reduced use. The Larimer overview includes a lapse contract that limits how much is drunk, which implies the model is compatible with harm-reduction goals. [inferred, uncertain] RP is often combined with medication, such as naltrexone or disulfiram for alcohol. [source: Larimer et al. 1999]

3. Guiding principles

[source: Larimer et al. 1999 unless tagged otherwise]

• Relapse is a process, not an event. Intervene anywhere along the chain (lifestyle, decisions, situation, response, the lapse, its aftermath), not just at the moment of use.
• A lapse is not a relapse. A lapse is a fork in the road. Treat every slip as a point where the client can choose prolapse.
• Compensatory stance. Marlatt contrasted moral, disease and spiritual models of addiction. In the compensatory model the client is not blamed for developing the problem but is responsible for changing it, and relapse is a mistake or temporary setback. Never treat a lapse as a moral failing. [source: Marlatt slides, after Brickman]
• Change is skill acquisition, not willpower. Frame every task as learning and practice. Do not treat it as a test of character.
• Collaboration: the client as colleague. Invite the client to observe their own behaviour objectively, as a co-investigator.
• The response matters more than the situation. Exposure to risk is unavoidable. Put most of the work into coping responses, not only into avoiding situations.
• Self-efficacy is situation-specific. Rate confidence per situation and work on the weakest. Outcome may hinge on the lowest rating (Haaga's "Achilles' heel" idea). [source: Witkiewitz, Marlatt & Walker 2005]
• Small, achievable steps. Break goals into subtasks, such as getting through today or handling the next party, and give feedback on every success, including unrelated ones.
• Make the hidden steps visible. Covert antecedents (shoulds/wants imbalance, "I deserve it" rationalisations, apparently irrelevant decisions) need to be named before they can be managed.
• Urges are conditioned responses, not true desires. Teach that urges are normal, cue-driven and time-limited, so the client can observe them rather than obey or fight them.
• Weigh delayed as well as immediate consequences. Expectancies favour short-term relief, so always bring the delayed costs into view.
• Prepare for a lapse without permitting one. Lapse planning works like an emergency kit: most clients will not need it, but it limits damage if they do.
• Balance, not just abstinence. A lifestyle dominated by obligations generates the desire for indulgence. Build in wants.
• Expect nonlinearity. Risk accumulates quietly, through tonic factors, and can tip suddenly. Watch trends across sessions and do not rely on a single craving rating. [source: Wikipedia; Snelleman 2018 on Witkiewitz & Marlatt 2004]
• Warm, accepting, motivational style. Praise effort, validate how hard the work is, and recognise small steps. MBRP facilitation draws explicitly on person-centred and motivational interviewing style. [source: Witkiewitz, Marlatt & Walker 2005; Marlatt slides]

4. Intervention inventory

Larimer et al. (1999) sort RP interventions into specific strategies, which target the immediate determinants (A), and global lifestyle self-control strategies, which target covert antecedents (B). Group C collects techniques from MBRP and related sources. Unless tagged otherwise, the purpose and core procedure of each item come from Larimer et al. 1999. Step-by-step detail beyond that source is marked [synthesis]. All example language is illustrative wording, not quotation.

A. Specific intervention strategies

A1. Teaching the RP model (relapse as a journey)

• Purpose / when: First sessions, and again after any lapse. Gives the client a shared map for treatment and removes the "one slip = total failure" belief before it is tested.
• Steps: (1) Present relapse as a journey with easy and hard stretches and road signs that warn of danger. (2) Draw the chain: high-risk situation → coping or no coping → self-efficacy up or down → expectancies → lapse → attribution → prolapse or relapse. [chain: Witkiewitz, Marlatt & Walker 2005, Fig. 1] (3) Explain that planning is like carrying a map, a toolbox and a spare tyre. (4) Ask the client to place one of their own past episodes on the chain. [synthesis] (5) Distinguish lapse from relapse explicitly.
• Example language (illustrative): "Think of recovery as a long drive. Some stretches are easy, some are icy. We're going to work out where your icy stretches are, and pack a spare tyre in case you skid."
• Watch for: Clients who hear "lapses are normal" as permission. Pair the message with the lapse plan (A12) and the client's own goal. Working when: the client spontaneously uses "lapse" and "high-risk situation" in later sessions.

A2. Interview about past lapses, relapses, relapse dreams and fantasies

• Purpose / when: Assessment phase. Identifies the client's personal high-risk situations (HRS) from their own history.
• Steps: (1) Pick the most recent lapse or relapse. (2) Reconstruct it slowly: where, who, time, mood, physical state, thoughts, what happened just before and the hours before that. [synthesis] (3) Repeat for 2–3 episodes and look for common patterns. (4) Ask about relapse dreams and daydreams: what situation the client imagines using in. (5) Classify each episode using Marlatt's categories. Intrapersonal: negative emotions, negative physical states, positive emotions, testing personal control, urges and temptations. Interpersonal: conflict, social pressure, positive social emotions. [taxonomy: Larimer et al. 1999; Marlatt slides] (6) Write a ranked HRS list.
• Example language (illustrative): "Let's slow down the last time you used, almost frame by frame. Where were you an hour before? What was going through your mind?"
• Watch for: Shame shutting down detail; keep a curious, non-judgemental tone. In Marlatt & Gordon's (1985) data, negative emotional states were the largest category, so probe mood even when the client says they "just felt like it". [source: Marlatt slides]

A3. Standardised assessment of situations and self-efficacy

• Purpose / when: Assessment and progress review. Quantifies which situations are risky and how confident the client feels in each.
• Steps: (1) Administer a situation inventory and a situational confidence measure. Larimer et al. name the Inventory of Drinking Situations and the Situational Confidence Questionnaire; both are licensed instruments, and items are not reproduced here. (2) Plot risk against confidence and target high-risk, low-confidence situations first. [synthesis] (3) Repeat at intervals to track change.
• Example language (illustrative): "This questionnaire helps us see which situations are hardest for you and how sure you feel about handling each one."
• Watch for: Questionnaires show confidence, not actual willingness or skill. Follow up with rehearsal (A7). Treat the lowest-confidence situation as the priority. [source: Witkiewitz, Marlatt & Walker 2005]

A4. Self-monitoring

• Purpose / when: From assessment onward. Shows triggers in real time. Clients still using record use situations; abstinent clients record urges.
• Steps: (1) Agree a simple daily log covering time, situation, people, emotion, thoughts, urge strength, what the client did, and whether they used and how much. Keep the format the client's own. [synthesis] (2) Ask them to record as soon after the event as possible. (3) Review the log at the start of every session and look for where urges peak. (4) Feed patterns into the HRS list.
• Example language (illustrative): "This week, every time you notice an urge, jot down where you were, who you were with and what you were feeling. Don't change anything yet, just notice."
• Watch for: Monitoring alone may not trigger self-regulation (Hufford et al. 2002, cited in Witkiewitz, Marlatt & Walker 2005), so always use the data in session. On non-completion, see section 5.

A5. Recognising warning signals and apparently irrelevant decisions (AIDs)

• Purpose / when: Once HRS are known. Trains early detection, so the client can leave or avoid a situation before it peaks.
• Steps: (1) Teach the three warning signals: AIDs, rising stress or lifestyle imbalance, and strong positive expectancies. (2) Explain AIDs: small, harmless-looking choices that edge toward risk, such as buying alcohol "in case guests drop by", which later let the person disclaim responsibility. (3) Take a past episode and trace backward through the decisions that led there. (4) At each choice point, name the safer alternative. [synthesis] (5) Agree on 2–3 of the client's typical AIDs to watch for.
• Example language (illustrative): "When you decided to take the route past the pub, did that feel like a decision at the time? Let's see how many small choices came before the drink."
• Watch for: Defensiveness if AIDs are presented as accusations. Frame them as how everyone's mind works. Working when: the client reports catching an AID in the moment ("I noticed I was about to…").

A6. Coping skills training: situation-specific and general

• Purpose / when: The core of the skills phase, for each top-ranked HRS.
• Steps: (1) Check the client's motivation and existing ability in that situation. (2) Choose the skills. Situation-specific: refusing drinks or drugs, assertive communication. General: meditation, anger management, positive self-talk. (3) Teach the skill briefly by describing it, modelling it, and naming its key components (for refusal, e.g. clear "no", eye contact, alternative offered, change of subject). [refusal components: synthesis] (4) Move on to rehearsal (A7).
• Example language (illustrative): "Let's build a script for when your brother offers you a beer. What would a short, firm no sound like in your words?"
• Watch for: Skills taught in the abstract without links to the client's actual situations. Coping gains do not fully explain CBT effects (Witkiewitz, Marlatt & Walker 2005), so keep self-efficacy and expectancies in view too.

A7. Behavioural rehearsal and written coping plans

• Purpose / when: After teaching each skill. Rehearsal tests willingness and actual execution, which questionnaires cannot.
• Steps: (1) Set up a role play of a specific anticipated HRS, with the therapist (or group members) playing the other person. (2) Client practises the response. (3) Give specific feedback on what worked and one thing to adjust, then rerun. [synthesis] (4) Increase difficulty, for example with a more insistent offerer. (5) Write a coping plan for the situation: the trigger, warning signs, two or three responses, and who to call. (6) Agree a real-life try-out as homework where safe.
• Example language (illustrative): "I'll be your friend at the barbecue and I'm going to push a bit. Try your line, and we'll stop and tweak it."
• Watch for: Role-play avoidance or joking. Start with low-stakes scenes. Working when: the client reports using the planned response in real life.

A8. Enhancing self-efficacy

• Purpose / when: Throughout treatment, especially when confidence is low or after a lapse.
• Steps: (1) Keep a collaborative stance in which the client is a colleague and observer. (2) Frame change as learning skills, not proving willpower. (3) Break the goal into small, achievable subtasks, such as today, this weekend, or the next HRS. (4) Notice and feed back every success, including unrelated ones like arriving on time. (5) Re-rate situational confidence after each success. [synthesis]
• Example language (illustrative): "You handled Friday's argument without drinking. That's exactly the situation you rated as hardest. What did you do that worked?"
• Watch for: Overconfidence, such as a client who wants to "test" themselves. Testing personal control is itself an HRS category. [source: Larimer et al. 1999]

A9. Challenging outcome expectancies ("eliminating myths and placebo effects")

• Purpose / when: When the client expects strong positive effects, such as relaxation, confidence or sociability, from using.
• Steps: (1) Elicit expectancies by interview or questionnaire. (2) Teach that much of alcohol's perceived social benefit comes from expectation (set) and setting, citing research findings. (3) Use the client's own experiences to test each belief. (4) Bring the delayed consequences into view next to the immediate effects. (5) Revisit when expectancies resurface. [source: Larimer et al. 1999]
• Example language (illustrative): "You said a drink makes you more relaxed at parties. Talk me through the last party: the first hour, the third hour, and the next morning."
• Watch for: Lecturing. Let the client's own evidence do the work. In MBRP, expectancy work also covers future-oriented thinking about anticipated euphoria. [source: Witkiewitz, Marlatt & Walker 2005]

A10. Decision matrix

• Purpose / when: Ambivalence, or before a known HRS. Weighs options concretely.
• Steps: (1) Draw a grid. Rows: stay with the goal vs resume use. Columns: immediate positive, immediate negative, delayed positive, delayed negative consequences. (2) Client fills in each cell. (3) Discuss which cells carry most weight and which are being discounted, usually the delayed negatives of using. (4) The client keeps the matrix and rereads it when tempted. [step 4: synthesis]
• Example language (illustrative): "Let's be honest about both sides, including what's good about using. Then look at what each choice gives you tomorrow and next month."
• Watch for: Empty "positives of using" cells. If the client denies any benefit, the matrix won't hold up in a real urge. Validate the real pull.

A11. Cognitive restructuring of lapses (countering the AVE)

• Purpose / when: Taught before any lapse and used throughout. It is essential after a lapse.
• Steps: (1) Explain the AVE: guilt and "I've blown it" thinking after a slip drive further use. (2) Identify the client's likely attribution, for example "no willpower" or "I'm an addict, it's hopeless". (3) Reframe the lapse as a mistake that shows where planning needs work, not a personal failing. Shift the attribution from stable, global and internal to specific, situational and changeable. (4) Conduct a lapse analysis: what was the HRS, what coping was missing, what is the plan next time. [synthesis] (5) Return to the goal.
• Example language (illustrative): "One drink on Saturday doesn't erase eight weeks. It tells us something about Saturday nights we didn't know. What can we learn from it?"
• Watch for: Restructuring that slides into minimising. Keep accountability ("this matters") while removing catastrophe ("this is the end"). Working when: lapses get shorter and smaller over time. [lapse duration and intensity as RP's main effect: Marlatt slides, citing Carroll 1996]

A12. Lapse management plan: contract, contact, review

• Purpose / when: The final phase of treatment (it can come earlier). Limits the damage if a lapse happens.
• Steps: (1) Agree a contract limiting how much the client will use if a lapse occurs. (2) Agree that the client contacts the therapist as soon as possible after a lapse. (3) After any lapse, the client reviews the situation for triggers. (4) Present all of this as emergency preparedness: probably never needed, sensible to have. [source: Larimer et al. 1999]
• Example language (illustrative): "This is like a fire drill. If you do slip, here's what you've agreed to do: stop, get out, call me, and we'll look at it together."
• Watch for: Make sure the plan does not read as permission. Make contact easy and non-punitive, so clients actually call.

A13. Reminder card

• Purpose / when: Paired with A12. Written instructions for the moment of a lapse, when thinking is impaired.
• Steps: (1) Write a wallet-sized card with the client, in their words. Content: stop using; safely leave the situation; reminders that a lapse is a mistake, not failure; the phone numbers of the therapist and support people. [content per Larimer et al. 1999; exact wording is the client's own] (2) Client carries it at all times and reads it aloud in session once. [synthesis]
• Example language (illustrative): "What would you need to read in that moment? Let's write it so it sounds like you talking to yourself."
• Watch for: Cards left at home. A phone note or lock-screen version works too. [synthesis]

B. Global lifestyle self-control strategies

B1. Lifestyle balance assessment (shoulds vs wants)

• Purpose / when: Assessment and global phase. Lifestyle imbalance is the strongest covert antecedent. Chronic obligations raise stress and the desire for indulgence ("I owe myself a drink").
• Steps: (1) Client logs daily activities for a week. (2) They label each as a want, a should, or both. (3) Optionally use a standardised hassles/uplifts measure; Larimer et al. name the Daily Hassles and Uplifts Scale, a licensed instrument not reproduced here. (4) Review the balance together and spot the days or times when shoulds pile up. (5) Link high-should days to past urges or lapses from the self-monitoring. [step 5: synthesis]
• Example language (illustrative): "Looking at your week, Tuesday to Thursday is almost all 'shoulds'. Is that also when the urges were strongest?"
• Watch for: Clients with genuinely heavy obligations, such as caring roles or shift work. Work on small wants and on what can be changed, not on blaming the client's choices.

B2. Restoring pleasurable activities and substitute indulgences

• Purpose / when: After B1, when wants are scarce. Use meets a need for pleasure or relief, and that need must be met another way.
• Steps: (1) List hobbies, people and activities that use displaced. (2) Add substitute indulgences that give immediate gratification, such as recreation or a massage. (3) Schedule specific ones into the coming week, particularly on high-risk days or times. [scheduling: synthesis] (4) Review what was done and how it felt.
• Example language (illustrative): "What did you used to enjoy before drinking took up your evenings? Which one could you do this Thursday?"
• Watch for: Anhedonia early in abstinence. Activities may feel flat at first, so present them as practice rather than instant reward. [synthesis]

B3. Positive addictions

• Purpose / when: Medium to long term. Builds regular, healthy, absorbing habits, such as meditation, exercise, yoga or reading, that become intrinsically rewarding and raise self-efficacy through mastery. The term comes from Glasser (1976). [source: Larimer et al. 1999; Witkiewitz, Marlatt & Walker 2005]
• Steps: (1) Help the client choose one activity they can do regularly. (2) Start small and consistent. (3) Track it alongside urges. (4) Highlight mastery as it grows. [steps 2–4: synthesis]
• Example language (illustrative): "We're looking for something you'd miss if you skipped it, but that leaves you better off, not worse."
• Watch for: The activity turning compulsive or punitive. Keep it about wellbeing rather than performance targets. [synthesis]

B4. Relaxation, stress management and time management training

• Purpose / when: When stress or lifestyle imbalance drives risk.
• Steps: Teach relaxation (e.g. progressive muscle relaxation or breathing), stress-management and time-management skills, and practise them in session. Assign daily practice and link it to the client's high-stress periods. [skills named by Larimer et al. 1999; specific methods: synthesis]
• Example language (illustrative): "Let's practise this now for ten minutes, so you know what it feels like before you need it."
• Watch for: Relaxation-induced anxiety in some clients. Offer an eyes-open or active alternative. [synthesis]

B5. Stimulus control

• Purpose / when: Early in change. Reduces exposure to conditioned cues.
• Steps: (1) Remove alcohol or drugs and paraphernalia from home, office and car, at least temporarily, including "guest" supplies, glasses, corkscrews and pipes. (2) Search for hidden or forgotten supplies, which can be powerful temptations. (3) Temporarily change conditioned cues, such as the favourite chair or the music played while using. (4) Agree when and whether any of this will be reviewed. [step 4: synthesis]
• Example language (illustrative): "Where in the house might there still be a bottle you've forgotten about? Let's make a list before you go home."
• Watch for: Housemates who use. Negotiate shared-space arrangements or involve them. [synthesis]

B6. Avoidance strategies

• Purpose / when: For situations the client cannot yet cope with: declining invitations, leaving risky settings, and steering clear of problem places and people.
• Steps: (1) Identify which HRS should be avoided for now and which must be coped with. (2) Plan exits and polite refusals. (3) Revisit as skills grow, moving from avoidance to coping. [steps 1 and 3: synthesis; avoidance of cues linked to lower relapse: Gossop et al. 2002, cited in Witkiewitz, Marlatt & Walker 2005]
• Example language (illustrative): "For the next month, the Friday work drinks are a 'no'. Let's plan how you'll say that."
• Watch for: Avoidance spreading into isolation, which itself becomes a negative-emotion HRS.

B7. Labelling and detaching from urges

• Purpose / when: When urges feel like commands or proof of failure.
• Steps: (1) Teach that urges are normal conditioned responses to external cues, like Pavlov's dog salivating at the bell. They are not expressions of the client's true desire. (2) Practise labelling them in the moment ("this is an urge triggered by…"). (3) Explain that urges peak and subside fairly quickly if not acted on. [source: Larimer et al. 1999; labelling phrasing: synthesis]
• Example language (illustrative): "That pull when you drove past the bar is your brain doing what it was trained to do. It's a signal, not an order."
• Watch for: Clients reading urges as evidence that treatment isn't working. Normalise them repeatedly.

B8. Urge surfing

• Purpose / when: To ride out urges without fighting them or giving in. Teach it after B7, then practise it during cue-triggered urges.
• Steps: (1) Introduce the image of the urge as a wave that rises, peaks and falls. (2) In session, guide the client to notice where the urge sits in the body, its intensity and how it shifts, while breathing steadily. [body focus: synthesis consistent with MBRP] (3) Have them observe the urge rise and fall without acting on it and without trying to suppress it. (4) Debrief on how the urge changed. (5) Assign practice whenever urges occur, logging their peak and duration. Not acting on an urge at its peak weakens the conditioned link. [source: Larimer et al. 1999; Witkiewitz, Marlatt & Walker 2005, citing Marlatt 2002; Marlatt slides]
• Example language (illustrative): "Imagine the craving as a wave. You're on a board. You don't have to fight the wave or let it knock you off. Just stay on and notice it rise, crest and roll in."
• Watch for: Practising with real cue exposure in session needs consent and a plan for leaving safely. Start with recalled urges. [synthesis] Working when: logged urge peaks get lower and shorter.

B9. Relapse road maps

• Purpose / when: For complex, recurring HRS. It maps branching choices and exposes AIDs.
• Steps: (1) Pick a recurring HRS, for example contact with an ex-partner that often becomes an argument. (2) Draw the scenario as a branching diagram: each choice point and its likely outcomes, including the chance of conflict. (3) At each branch, list the coping responses available. (4) Mark the safest route and the early exits. (5) The client keeps the map. [source: Larimer et al. 1999; steps 4–5: synthesis]
• Example language (illustrative): "When she calls about the kids, what are the ways the conversation can go? Let's draw each branch and where you can step off."
• Watch for: Maps that are too abstract. Use real names, times and places.

C. Related techniques from MBRP and other sources

C1. SOBER breathing space (MBRP)

• Purpose / when: A brief practice for moments of craving or stress in daily life and in HRS.
• Steps: Stop wherever you are; Observe what is happening in body and mind; bring focus to the Breath as an anchor; Expand awareness to the whole body and surroundings; Respond mindfully rather than automatically. Practise in session, then use it during the week, especially when triggered. [source: Marlatt slides]
• Example language (illustrative): "When you notice the urge, try SOBER: stop, notice what's here, a few breaths, widen out, then choose what to do."
• Watch for: Use as avoidance ("breathing it away"). The aim is awareness, then a chosen response.

C2. Formal mindfulness practices (MBRP)

• Purpose / when: When the client is in the MBRP programme or adding mindfulness to RP. Aims: notice triggers, move off automatic pilot, tolerate discomfort without self-medicating, and accept present experience.
• Steps: Practices named are the body scan, sitting meditation (breath, then body, emotions and thoughts), walking meditation and mountain meditation, with daily home practice. Session themes run from automatic pilot and relapse, through triggers and craving, high-risk situations, thoughts as just thoughts, and self-care and lifestyle balance, to support networks. [source: Marlatt slides] Full scripts are in Bowen, Chawla, Grow & Marlatt (2021, 2nd ed.) and are not reproduced here. See the MBRP guide for full delivery.
• Example language (illustrative): "We're not trying to get rid of the craving. We're getting to know it."
• Watch for: Facilitators are expected to keep their own practice. [source: Marlatt slides]

C3. Relapse warning-signs worksheet (Daley & Marlatt)

• Purpose / when: The Daley & Marlatt therapist guide (Overcoming Your Alcohol or Drug Problem, Treatments That Work series) has a chapter on reducing the risk of relapse, which introduces lapse and relapse and uses a Relapse Warning Signs Worksheet. [source: OUP chapter page]
• Steps: Only the title and purpose were visible [uncertain]. In general terms, the client lists their personal early warning signs (changes in mood, thinking, behaviour and routines) and a response to each. [synthesis]
• Watch for: Use the published worksheet if you have the guide. Do not reconstruct it from memory.

C4. Programmed (planned) relapse [uncertain]

• Marlatt & Gordon (1985) are widely reported to describe a therapist-supervised "programmed relapse" for selected clients. The primary text is not drawn on, and Larimer et al. (1999) do not include it. [uncertain] Do not use it without the original text, specialist supervision and a clear ethical and medical rationale. Never use it where withdrawal or overdose risk exists. [synthesis]

C5. Monitoring tonic and phasic risk (dynamic-model formulation) [synthesis]

• Purpose / when: Ongoing case formulation, derived from Witkiewitz & Marlatt (2004).
• Steps: (1) Record the client's tonic risks: family history, years of use, chronic stressors, withdrawal state, entrenched expectancies. (2) Each session, rate phasic factors: current mood, coping use, craving, motivation, recent HRS. (3) Watch for several factors worsening together rather than any single one. Craving alone was rarely the sole determinant of relapse in the Snelleman data. [source: Snelleman 2018] (4) Increase contact or booster sessions when risks cluster.
• Watch for: Over-reliance on craving ratings as a relapse predictor.

5. Handling problems

The primary sources give guidance mainly on lapses, the AVE, low self-efficacy and covert relapse planning. Most other responses below are [synthesis] built on RP principles.

• A lapse occurs mid-treatment. Treat it as the most useful data of the course. Activate the lapse plan (A12) and do a lapse analysis (A2 format). Restructure the attribution (A11), update the HRS list and coping plan, and re-rate confidence. Look out for AVE signs in yourself as well: therapist disappointment can mirror the client's guilt. [Larimer et al. 1999; last point: synthesis]
• Lapse becomes full relapse. Without judgement, reassess the goal, the level of care and any need for medical withdrawal management. Return to phase 2 with the new episode. Make clear that re-engaging is itself prolapse. [synthesis]
• "I don't have high-risk situations" / minimal disclosure. Use self-monitoring before interviewing. Ask about relapse dreams and fantasies, which can reveal situations clients don't volunteer, and use standardised situation inventories. [A2–A4 sources; ordering: synthesis]
• Covert relapse planning: AIDs, rationalisation, "I deserve it". Name the pattern openly and without blame, using the client's own examples. Trace the decision chain (A5) and check lifestyle balance (B1), since "deserving" often signals too many shoulds. [Larimer et al. 1999]
• Testing personal control. Clients who want to prove they can handle one drink or the old crowd. Name testing as a recognised HRS category. Explore what they want to prove. Use the decision matrix (A10). [category: Larimer et al. 1999; response: synthesis]
• Overconfidence after early success. High confidence may hide an untested Achilles' heel. Re-rate situational confidence and identify the lowest-rated situation. Keep booster sessions. [Witkiewitz, Marlatt & Walker 2005; synthesis]
• Low self-efficacy and hopelessness. Break goals into tiny subtasks and log every success, including unrelated ones. Reframe the work as learning a skill, not using willpower. [Larimer et al. 1999]
• Non-adherence to monitoring or homework. Simplify the format (phone note, one line, tick boxes). Review whatever was done, without criticism. Ask what got in the way and treat that obstacle as an HRS. Link each task to the client's own goal. If monitoring itself triggers craving or shame, monitor fewer details. [synthesis]
• Resistance or ambivalence about the goal. Use the decision matrix and a motivational interviewing style rather than argument. Clarify whether the agreed goal is abstinence or reduced use, and work toward the goal the client will actually pursue, noting safety limits. [MI style: Marlatt slides; goal flexibility: inferred, uncertain]
• Overwhelm from negative emotion. Negative emotional states are the most common relapse precipitant. Prioritise affect-regulation skills (B4, C1, B8) and screen for depression, anxiety, trauma and suicidality. Refer or treat in parallel. [category: Larimer et al. 1999; Marlatt slides; screening: synthesis] For suicide risk, follow standard structured risk assessment and safety planning. Lethal-means counselling covers safe storage or removal, including stockpiles of the client's substances or medications. [synthesis]
• Urges escalate during urge surfing or cue work. Stop exposure. Ground the client (breath, feet, room). Leave the cue and debrief. Rebuild with recalled rather than live cues, and agree consent and exit steps in advance. [synthesis]
• Interpersonal conflict and social pressure. Rehearse refusal and assertive communication (A6–A7). Map recurring conflicts with road maps (B9). Consider involving family or partners where the client agrees. [Larimer et al. 1999; family involvement: synthesis]
• Therapeutic rupture after a lapse (client hides the lapse, misses sessions, expects judgement). Reach out promptly. Acknowledge the difficulty of returning and restate the compensatory stance: setback, not crime. Repair before analysing. [stance: Marlatt slides; rupture repair: synthesis]
• Lifestyle imbalance that can't easily change (caring, poverty, shift work). Focus on micro-wants and substitute indulgences that fit the client's real constraints. Connect them with practical and social support. [synthesis]
• Group delivery issues (one member's lapse destabilises others; war stories glamorise use). Set norms that lapses are discussed as learning. Steer stories toward the chain and the coping alternatives. Debrief members who were triggered. [synthesis] Effect sizes appeared larger in group than individual formats in one meta-analysis (Irvin et al. 1999). [Marlatt slides]
• Physiological risk. After a period of abstinence, tolerance falls. For opioids and other depressants, a lapse carries higher overdose risk. Include overdose-risk education and naloxone access in lapse planning where relevant. Coordinate with medical care for withdrawal and medication. [synthesis; not in RP sources]
• When RP alone isn't enough. Persistent heavy use, severe comorbidity or unsafe environments call for a higher level of care, medication or a combined programme. RP effects show mostly in reducing the frequency and intensity of relapse, not in preventing every lapse. [Larimer et al. 1999; Marlatt slides citing Carroll 1996]

Sources

Sources

• Relapse Prevention: An Overview of Marlatt's Cognitive-Behavioral Model — Larimer, Palmer & Marlatt (1999), Alcohol Research & Health 23(2) (govdocs copy)
• Addiction and the Mind — G. Alan Marlatt, presentation slides (RP and MBRP)
• Mindfulness-Based Relapse Prevention for Alcohol and Substance Use Disorders — Witkiewitz, Marlatt & Walker (2005), J. Cognitive Psychotherapy 19(3)
• Relapse Prevention, 2nd ed. — Guilford table of contents
• Overcoming Your Alcohol or Drug Problem, Therapist Guide — chapter page, OUP
• Snelleman, M. (2018). PhD thesis, Erasmus University (summary of Witkiewitz & Marlatt 2004 dynamic model)
• Relapse prevention — Wikipedia

Further reading (not drawn on)

• Marlatt, G. A., & Gordon, J. R. (Eds.) (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Guilford Press.
• Marlatt, G. A., & Donovan, D. M. (Eds.) (2005). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors (2nd ed.). Guilford Press.
• Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug problems: That was Zen, this is Tao. American Psychologist, 59(4), 224–235.
• Hendershot, C. S., Witkiewitz, K., George, W. H., & Marlatt, G. A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6, 17. [full text not reachable; uncertain]
• Bowen, S., Chawla, N., Grow, J., & Marlatt, G. A. (2021). Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician's Guide (2nd ed.). Guilford Press.
• Daley, D. C., & Marlatt, G. A. (2006). Overcoming Your Alcohol or Drug Problem: Effective Recovery Strategies, Therapist Guide (2nd ed.). Oxford University Press.
• Witkiewitz, K., & Marlatt, G. A. (Eds.) (2007). Therapist's Guide to Evidence-Based Relapse Prevention. Academic Press. [uncertain]