I must admit I’m a little uncomfortable criticizing Relapse Prevention Therapy, and its father Alan Marlatt, if only because I want to be polite. I have the utmost respect for Mr Marlatt, as he was one of the most advanced and rational researchers/clinicians in the addictions field, and certainly, there are some very valuable ideas that he spearhead and upon which he built RPT. The idea of an Abstinence Violation Effect is indispensable, and testing that theory has yielded important insights, namely, that we shouldn’t be demanding abstinence of people/pushing an all or nothing view of substance use. Marlatt’s study on expectancy, where he disproved the “loss of control” theory is incredibly important work. Nevertheless, Relapse Prevention Therapy, on a whole, has some serious problems, and even contradicts some of the important lessons this distinguished researcher taught us.
My main problems with Relapse Prevention are as follows:
- The term “relapse” implies a disease, and a loss of control and/or domino effect.
- I believe that people will eventually do the things which they spend the most time focusing on – in this case: “relapse.”
Traditionally, treatment programs for addictive behaviors tended to ignore the relapse issue altogether. There seemed to be a general assumption in many programs that even to discuss the topic of relapse was equivalent to giving clients permission to use alcohol or drugs. The rationale that we present to our clients, administrators, and clinicians is that we already have numerous procedures in our society that require one to prepare for the possibility, no matter how remote, that various problematic and dangerous situations may arise. For example, we have fire drills to help us prepare for what to do if a fire breaks out in public buildings or schools. Certainly no one believes that by requiring people to participate in fire drills the probability of future fires increases; quite the contrary, in fact, the aim is to minimize the extent of personal loss and damage should a fire break out. The same logic applies in the case of relapse prevention. Why not include a relapse drill as a prevention strategy as routine part of substance abuse treatment programs? Learning precise relapse prevention skills and related cognitive strategies may offer clients the help they need to find their way on the highway of habit change. Most contemporary substance abuse treatment programs now incorporate relapse prevention in their protocols.
First off, I don’t doubt that at one time, “relapse” as a topic may have been ignored by treatment centers, however, by the time I first entered treatment (1997), it was a popular paradoxical mantra that “relapse is a part of recovery.” After all, it fits perfectly with the recovery culture’s insistence that one can’t quit forever and must take things “one day at a time.”
Second, and more importantly, I don’t buy their rationalization, or their analogy of fire safety. I have another analogy I’d like to counter with. Are you somehow missing the point when you teach fire safety to an arsonist? Please don’t get me wrong, I don’t mean to bring drinkers and drug users down to the level of such criminals, so perhaps my analogy is slightly flawed, but so is theirs. The fire safety they’re talking about is in response to an “act of God” or perhaps an accidentally started fire – so right there, they send the message that “relapse” is something that happens to people, rather than it being a behavioral choice that they make of their own free will.
Let me quote again:
the aim is to minimize the extent of personal loss and damage should a fire break out. The same logic applies in the case of relapse prevention.
“Should a fire break out” – well if the same logic applies, then you’ve now taught a concept which is completely at odds with other direct statements in Relapse Prevention literature which proposes to show people that they are in control of their substance using behavior. You don’t “break out” into a “relapse” – you choose to use substances – and should you escalate your choices to problematic levels approaching what we know as “relapse” then that’s just a heightening of those initial choices. Every choice along the way is still a choice, so why send the message that the initial choices are somehow different (or non-choices as it were).
I don’t know if the Relapse Prevention movement is truly responsible for the “relapse is a part of recovery” mantra (although I suspect they are), but by focusing their clients so heavily on Relapse Prevention and (as we will see in a later piece) Relapse Management, they are by default endorsing that mantra – that relapse is inevitable. If people have free will, and are in control of the choice to use substances, and if the disease model and loss of control theory is a crock (as Marlatt ever so subtly and diplomatically suggests throughout his work) then “relapse” is not inevitable at all. You can only do people a disservice by convincing them of this falsehood.
It does seem somewhat reasonable to have a “relapse drill” on the surface, but again, this is like teaching the arsonist how to escape the building once he’s set it on fire, or at the least, teaching him not to douse the place with even more gasoline once he’s set the fire. Perhaps we could teach the arsonist to find more joy in non-destructive activities – that, to me, seems like a far more valuable point of focus.
In Cognitive Behavioral Therapy (of which Relapse Prevention purports to be a form), thoughts and beliefs lie behind feelings and actions – RPT practitioners should challenge themselves and ask what kind of thoughts and beliefs they’re promoting/teaching, especially when RPT isn’t just a sidenote or one time relapse drill, but rather a lengthy process.
[1] G. Alan Marlatt, Ph.D., George A. Parks, Ph.D., and Katie Witkiewitz, Ph.C., Clinical Guidelines for Implementing Relapse Prevention Therapy A Guideline Developed for the Behavioral Health Recovery Management Project, December 2002 LINK TO PDF
You have obviously never struggled with chemical dependency. Alcoholism IS a disease, and it is uniformed and ignorant people like you who keep the stigma alive. We in the recovery world thank you for the additional damage you have just caused by writing this incorrect and very one sided article.
“You have obviously never struggled with chemical dependency.”
Presumably you have and that therefore makes you an expert? So cancer survivors know more about cancer than oncologists? Just because you are an addict does not make you an expert.
“Alcoholism IS a disease, and it is uniformed and ignorant people like you who keep the stigma alive. ”
Just saying alcoholism or other chemical dependencies are diseases does not make them so. Also social psychology research indicates that calling addiction a disease INCREASES stigma and discrimination.
“We in the recovery world thank you for the additional damage you have just caused by writing this incorrect and very one sided article.”
So are you saying you speak for everyone in recovery? Its people like you who are doing real damage by perpetuating incorrect, baseless and stigmatizing myths about addiction.
This is a great post. I understand the desire not to be rude. Hell, I feel that sensation often when I say anything critical of AA/Treatement/Recovery Community. But it’s too important to be timid about. The more I study this whole world of addiction, the more and more I think that it is a matter of psychology.
Kari Caldwell – What is the matter with you that you would suggest that someone like Mr. Slate who has declared many times that he, in fact, has struggled with chemical dependency, that you would come on here and write what you did. Were you not aware and just coming in guns a blazin’? You accuse him of a “one sided article,” but I’m willing to bet that you actually only like one-sided articles, don’t you? So long as it’s your side. Shame on you for trying to shame people into silence.
Hi Jonas,
“guns a blazin” is the perfect term to describe how most of the recovery-minions approach this site. I appreciate the passion, and it’d be great if it was accompanied by some honest debating techniques. Unfortunately, all they can seem to do is hurl names and ad hominems or other fallacious arguments. Can you believe that accusing someone of NOT being an addict, is actually an ad hominem? That’s how upside-down their world is – they actually think “oh this person must be stupid (or not credible, etc) because they’re not an addict!”
Don’t you love how Kari just attacks me, the messenger, instead of the argument, and accuses me of killing people with my ideas? I’ve only heard it about ten million times before, so I’m a little bit better at ignoring it by now, but it’s so ridiculous that it’s actually sad. Just picture her typing that out, hitting “post comment” and then actually thinking to herself “I got him good!” It’s so absurd. She thinks she got me, or made some kind of point, or proved me wrong, with name-calling!
As you read through the site more, you’ll see plenty of this nonsense. It never stops. Once in a while, I argue back, and they get so incredulous and act like they’re being attacked, when they were the ones who opened with name-calling – as if the record of the whole exchange isn’t right there in black and white for anyone to read. A good example of that is this commenter Colleen C on a recent post: http://www.thecleanslate.org/alcoholics-anonymous-allergy-model-madness-displayed-by-jane-velez-mitchell/#comment-113297
There’s been a bunch of others lately too, and I mostly try to let them peter out, but things they say are so absolutely misguided, irrational, and completely out of touch with reality that I feel I must respond – that I must show them the silly mistakes they’re making, and how they’re missing points that are so simple and right in front of their faces. IT’s really an odd experience running a site like this.
Anyways, thanks for the comments, and I’m glad you’re enjoying the site.
-Steven
Steven, you helped me immensely as I was making the transition out of what I saw as fear-based irrational 12-step program. My life has only continued to get better since I left that dogma. (One of my best friends still goes to 12 step meetings, but she does NOT believe in the disease theory; she goes for the emotional support to handle daily living situations.)
I consider people like you to be like Martin Luther King or Betty Dodson: despite emotional and societal opposition, you have the courage to speak out and thereby change the world.
Keep on keepin’ on…you know your purpose. It is good. 🙂
I’m glad to hear all is going well. Thanks for the compliments and generous comparison Kelly.
Hi Steve – I notice it on other sites too. It’s kind of jarring how rarely someone on the AA side of things is willing to engage in a more sober way.
“Can you believe that accusing someone of NOT being an addict, is actually an ad hominem?”
I thought of a little aphorism the other day that I think fits decently well alongside this. Maybe it could be refined, but it goes something like this:
Addiction: The only disease for which people get angry with you when you tell them that they don’t have it.
It’s kind of amazing. Letting someone know that they don’t have cancer is a joyous thing. Letting someone know that they don’t have a disease of addiction ought to be a joyous thing too, but it is often not received that way.