Page 1 of 12http://spider.apa.org/ftdocs/ccp/1999/august/ccp674563.html 8/30/2000Efficacy of Relapse Prevention A Meta-Analytic Review Jennifer E. IrvinDepartment of Psychology University of Central Florida Clint A. BowersDepartment of Psychology University of Central Florida Michael E. DunnDepartment of Psychology University of Central Florida Morgan C. WangDepartment of Statistics University of Central Florida ABSTRACTAlthough relapse prevention (RP) has become a widely adopted cognitive—behavioral treatment intervention for alcohol, smoking, and other substance use, outcome studies have yielded an inconsistent picture of the efficacy of this approach or conditions for maximal effectiveness. A meta-analysis was performed to evaluate the overall effectiveness of RP and the extent to which certain variables may relate to treatment outcome. Twenty-six published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants were included in the analysis. Results indicated that RP was generally effective, particularly for alcohol problems. Additionally, outcome was moderated by several variables. Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment using uncontrolled pre—post tests. Jennifer E. Irvin is now at the Department of Psychology, University of South Florida. Portions of this article were presented at the 105th Annual Convention of the American Psychological Association, Chicago, Illinois, August 1997. Correspondence may be addressed to Clint A. Bowers, Department of Psychology, University of Central Florida, Orlando, Florida, 32816-1390. Electronic mail may be sent to [email protected] Received: May 1, 1997 Revised: December 15, 1998 Accepted: January 6, 1999 Despite the increasing appeal of relapse-prevention (RP) interventions based on the work of Marlatt andGordon (1985) , studies have failed to yield a consistent picture of the effectiveness of this cognitive—behavioral approach ( Rawson, Obert, McCann, & Marinelli-Casey, 1993 ). In a recent narrative review of 24 studies, Carroll (1996 ) concluded (a) that RP appeared to be effective relative to no-treatment control groups, (b) that RP appeared to be equally effective as other active treatments, and (c) that comparison of Journal of Consulting and Clinical Psychology © 1999 by the American Psychological Association August 1999 Vol. 67, No. 4, 563-570 For personal use only--not for distribution.Page 2 of 12http://spider.apa.org/ftdocs/ccp/1999/august/ccp674563.html 8/30/2000RP with attention and discussion control groups yielded inconclusive results. Carroll also concluded that the effectiveness of RP did not vary with class of substance use disorder. Given the broad-based use of RP and the uncertainty regarding its overall effectiveness, there is a need to empirically evaluate RP interventions and the extent to which moderator variables relate to treatment outcomes. Toward that end, we conducted a meta-analysis to quantify the effect of RP on substance use behavior and overall psychosocial adjustment and to identify moderator variables that may relate to heightened or attenuated effectiveness of RP. The RP model hypothesizes that there are common cognitive, behavioral, and affective mechanisms that underlie the process of relapse, regardless of the particular problem behavior considered ( Marlatt &Gordon, 1985 ). Thus, it seems that RP should be efficacious in preventing relapse across various classes of addictive behaviors. In addition, the modality in which RP is delivered should be associated with relative costs and benefits. For example, individual treatment may provide the best format for targeting clients' individual needs, whereas group treatment may provide increased social support and create important opportunities for practicing new skills ( Schmitz et al., 1997 ). Furthermore, working with others in a collective attempt to maintain behavior changes may foster support and encouragement ( Marlatt & Gordon,1985 ). Although there has been considerable controversy regarding the relative effectiveness of inpatient versus outpatient treatment for substance use, evaluations of this issue have indicated that treatment setting may have little to do with outcome (e.g., Miller & Hester, 1986 ). The theoretical rationale on which RP is based, however, suggests that treatment delivery in an inpatient setting may not provide patients with real-life opportunities to practice newly acquired skills or give them the opportunity to encounter problems while they still have the close support of treatment professionals. Therefore, in investigating moderators, it was important to examine the extent to which the effectiveness of RP was impacted by treatment setting. The RP model conceptualizes addiction as stemming from a collection of maladaptive habit patterns rather than from purely physiological responses to substance use ( Marlatt & Gordon, 1985 ). Therefore, specific predictions regarding the potential efficacy of the adjunctive use of medication with RP are not addressed theoretically. Similarly, type of substance use outcome measure used to evaluate RP is not theoretically addressed by the model but is of considerable importance because of the controversy surrounding this issue (see L. C. Sobell & Sobell, 1990 ). Studies included in the present analysis typically used verified self-report, unverified self-report, or biochemical measures of substance use, creating an opportunity to compare these methods. One goal of the present analysis was to evaluate the overall efficacy of RP. Therefore, it was important to examine the effects of RP when compared with other active interventions, no-additional-treatment controls, discussion controls, physician advice, and psychoeducation. Finally, the theoretical rationale underlying RP suggests that a critical stage of the habit—change process begins after initial cessation of substance use ( Marlatt & Gordon, 1985 ) and relapse is conceptualized as a transitional process in which individuals may or may not return to habitual substance use following a lapse. In support of this concept, Moos and Finney(1983) reported that a considerable portion of the variability associated with the long-term effectiveness of alcohol treatment is related to environmental factors that emerge after completion of formal
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