Intervention Summary

Relapse Prevention Therapy (RPT)

Relapse Prevention Therapy (RPT) is a behavioral self-control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. RPT can be used as a stand-alone substance use treatment program or as an aftercare program to sustain gains achieved during initial substance use treatment. Coping skills training is the cornerstone of RPT, teaching clients strategies to:

Understand relapse as a process
Identify and cope effectively with high-risk situations such as negative emotional states, interpersonal conflict, and social pressure
Cope with urges and craving
Implement damage control procedures during a lapse to minimize negative consequences
Stay engaged in treatment even after a relapse
Learn how to create a more balanced lifestyle

Coping skills training strategies include both cognitive and bevarioral techniques. Cognitive techniques provide clients with ways to reframe the habit change process as a learning experience with errors and setbacks expected as mastery develops. Behavioral techniques include the use of lifestyle modifications such as meditation, exercise, and spiritual practices to strengthen a client's overall coping capacity.

Descriptive Information

Areas of Interest	Substance use disorder treatment Co-occurring disorders
Outcomes	1: Drinking behavior 2: Smoking abstinence 3: Cocaine use 4: Marital adjustment 5: Confidence in smoking cessation
Outcome Categories	Alcohol Drugs Family/relationships Tobacco
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	Urban Suburban
Implementation History	RPT was first implemented. Although the exact number of sites implementing RPT is unknown, a meta-analysis of the research literature reported 26 studies that evaluated the effectiveness of this therapeutic approach for substance abuse with more than 9,000 participants. Outside the United States, evaluations of RPT have been conducted in Canada and Scotland.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	RPT has been adapted for a prison-based population by the Federal Correctional Service of Canada in Ottawa, Ontario.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Outcomes

Outcome 1: Drinking behavior
Description of Measures	Drinking behavior was measured using the Timeline Followback (TLFB) method. The TLFB method asks clients to retrospectively estimate their daily alcohol consumption over a period ranging from 7 days to 24 months prior to the interview. In this study, clients retrospectively estimated their daily alcohol consumption as none, less than 3 ounces, or more than 3 ounces and reported any days spent in jail, or in the hospital for alcohol-related reasons. To establish confidence in the accuracy of the self-reports, spouses were interviewed separately about their husband's drinking using the same method, and client and spouse reports were combined after reconciliation of discrepancies. Percent days abstinent--defined as not drinking at all, not in jail, and not hospitalized for alcohol-related reasons--was calculated for the 12 months prior to study entry, the 4-6 months during which clients received the initial treatment, each 90-day period during the 12-month relapse prevention phase, and each 90-day period in the subsequent follow-up phase, up to 30 months following the end of initial treatment.
Key Findings	In a randomized clinical trial (RCT), couples with an alcoholic husband participated in 4-6 months of behavioral marital therapy (BMT) and then were randomly assigned to 1 of 2 conditions: up to 18 sessions of conjoint Relapse Prevention (RP) over the next 12 months or no further treatment (BMT only). BMT consisted of 6-8 sessions with individual couples followed by 10 group sessions with multiple couples. Follow-up RP sessions took place with individual couples for 50-75 minutes and were scheduled biweekly for the first 3 months, monthly for the next 3 months, and every 1.5 months for the final 3 months. Additionally, RP therapists could schedule up to 3 additional crisis sessions at any time during the 12-month period. Data were analyzed at 8 points: pre-BMT (baseline), post-BMT, and at 3, 6, 12, 18, 24, and 30 months post-BMT. Among the findings from this trial: The BMT plus RP participants reported significantly more days abstinent than BMT-only participants at the 6-month (p = .027), 12-month (p = .028), and 18-month (p = .05) follow-ups. These differences were associated with medium effect sizes (eta-squared = 0.0625 to 0.0841). Study participants in both conditions (BMT plus RP and BMT only) reported significantly more abstinent days at follow-up assessments compared with the year prior to study entry (p < .001).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 2: Smoking abstinence
Description of Measures	Smoking abstinence was measured using monthly, mail-in postcards that asked clients to report their "current number of cigarettes per day" and "total number of cigarettes for the month." Clients who did not return postcards were contacted by telephone by staff blinded to group assignment. Abstinence was defined as smoking five cigarettes or less in any given month. Clients lost to follow-up were assumed to have relapsed and were considered smokers. Additionally, at a face-to-face, 12-month postintervention assessment, clients were asked about their tobacco use in the previous 6 months and provided a saliva sample that was tested for thiocyanate concentrations at or above 80 ug/ml, a biochemical marker of smoking exposure in the past 10 to 14 days. Since thiocyanate may also reflect dietary and other nontobacco sources of cyanates, saliva samples testing positive were then tested for cotinine. Clients with cotinine levels at or above 5 ng/ml were considered smokers, regardless of self-report. Clients who did not attend the 12-month follow-up were contacted by mail or telephone by staff blinded to group assignment. If abstinence was reported, the client was asked to provide a saliva sample, collected at either the home or workplace. Clients reporting abstinence but refusing to provide a saliva sample and clients lost to follow-up were considered smokers.
Key Findings	In an RCT, smokers participated in a 4-day series of 2-hour group sessions for smoking cessation that provided training on the use of more than 40 behavioral and cognitive smoking cessation techniques such as changing daily routines, deep breathing, and relaxation exercises. Clients abstinent from smoking (i.e., with no carbon monoxide in breath samples) at the 1-week follow-up session were randomly assigned to 1 of 3 conditions: a RP skills-training program in which clients actively developed and rehearsed specific coping strategies, a discussion control condition that basically offered social support, or a no-treatment control condition with no additional client meetings. Both the RP skills-training and discussion group conditions met weekly for 3 more weeks in a small group format. Among the findings from this trial: At the 1-month postintervention follow-up, self-reported continuous smoking abstinence rates were 83.6% for the RP skills-training participants, 77.4% for discussion group participants, and 65.4% for the no-treatment participants (p < .001). Significantly more participants in the RP skills-training condition reported sustained smoking abstinence over the 12 months of follow-up, with a lower rate of relapse relative to participants in both the discussion group and the no-treatment condition (p = .04). Participants assigned to either the discussion group or no-treatment condition were 23% more likely than participants assigned to the RP skills-training condition to report smoking relapse during the 12 months of follow-up (RR = 1.23), a difference that was associated with a small effect size. Significantly more participants in the RP skills-training condition (41.3%) reported sustained smoking abstinence (biochemically verified) at the 12-month follow-up compared with either the discussion group (34.1%) or no-treatment (33.3%) conditions (RP skills-training vs. discussion and no-treatment conditions combined, p < .05).
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.8 (0.0-4.0 scale)

Outcome 3: Cocaine use
Description of Measures	Cocaine use was assessed by (1) a composite cocaine subscale derived from a modified version of the Addiction Severity Index (ASI) and (2) self-reported days of cocaine use in the prior month, verified at each follow-up assessment by urinalysis. The standard ASI provides composite scores for seven domains: medical, legal, employment, drug, alcohol, family, and psychological functioning. Composite scores on the subscales vary from 0 to 1, with higher scores indicating greater severity and need for treatment. For this study, the ASI's drug composite subscale was broken into two subscales, "cocaine use only" and "other drugs," by adding items on the quantity and frequency of use, the duration of consecutive periods of abstinence, and the level and type of treatment involvement in the month prior to the assessment.
Key Findings	In a double-blind RCT, cocaine-dependent clients (DSM-III-R criteria) seeking outpatient treatment were randomly assigned to one of four treatment conditions: RP plus desipramine, clinical management plus desipramine, RP plus placebo, and clinical management plus placebo. The RP condition emphasized skills training to help clients identify high-risk situations for relapse and use more effective coping strategies. The clinical management condition provided a supportive doctor-patient relationship, education, empathy, and medication management that included monitoring the client's clinical status and treatment response. Clinical evaluators carried out assessments before treatment, weekly during the 3 months of treatment, at treatment termination, and at 1, 3, 6, and 12 months after treatment termination. Findings from this study included: At the end of treatment, clients reported less weekly cocaine use (confirmed by urinalysis, p < .001) and less cocaine and alcohol use and fewer family/social and psychological problems on the ASI (p < .01) relative to baseline, regardless of condition assignment. Client ASI cocaine and alcohol composite scores continued to decrease across follow-up assessments up to 12 months after treatment termination (p = .01). Among clients assigned to the RP conditions, those with high levels of cocaine use at baseline (> 4.50 grams weekly) reported longer periods of sustained cocaine abstinence during treatment than those with low levels of cocaine use at baseline (1.00-2.50 grams weekly; p = .05) and remained in treatment longer (attended 8.6 vs. 6.0 sessions, respectively; p < .03). Clients reporting 4 or more weeks of sustained cocaine abstinence during treatment (as opposed to less than 4 weeks) continued to report periods of sustained cocaine abstinence during follow-up (p < .001). This finding was independent of condition assignment, despite a nonsignificant trend favoring clients assigned to the RP conditions. Exposure to treatment programs or services outside the study during follow-up was associated with lower self-reported cocaine use (p < .001). Even after controlling for this exposure, however, clients assigned to the RP conditions reported less frequent cocaine use in the prior month (p = .03) and fewer problems associated with cocaine use (ASI cocaine composite subscale score, p = .01) at the 6- and 12-month follow-ups compared with clients in the clinical management conditions. In general, clients who received nonstudy treatment during the 12-month follow-up period were more likely to have completed treatment (p = .01) and to have lower ASI cocaine composite subscale scores at the end of treatment (p = .02), regardless of condition assignment.
Studies Measuring Outcome	Study 3
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 4: Marital adjustment
Description of Measures	Marital adjustment was measured using the Marital Adjustment Test (MAT), a 15-item self-report instrument administered to both the husband and wife. Eight of the items are rated on a 6-point scale ranging from 0 (always disagree) to 5 (always agree). Six of the items are presented with 2-4 response options. The 15th item is a line with 7 points ranging from "very unhappy" to "perfectly happy" on which respondents indicate their overall contentment with their marriage. Items on the MAT address issues such as family finances, recreation, affection, friends, sexual relations, philosophy of life, and dealing with in-laws. Scores range from 2 to 158; scores of 100 or higher for both partners indicate a well-adjusted marriage.
Key Findings	In a RCT, couples with an alcoholic husband participated in 4-6 months of behavioral marital therapy (BMT) and then were randomly assigned to one of two conditions: up to 18 sessions of conjoint RP over the next 12 months or no further treatment (BMT only). BMT consisted of 6-8 sessions with individual couples followed by 10 group sessions with multiple couples. Follow-up RP sessions took place with an individual couple for 50-75 minutes and were scheduled biweekly for the first 3 months, monthly for the next 3 months, and every 1.5 months for the final 3 months. Additionally, RP therapists could schedule up to 3 additional crisis sessions at any time during the 12-month period. Data were analyzed at 8 points: pre-BMT (baseline), post-BMT, and at 3, 6, 12, 18, 24, and 30 months post-BMT. Among the findings from this trial: Wives assigned to BMT plus RP reported significantly higher marital adjustment than BMT-only wives at all follow-up points except the 6-month assessment (p values ranging from less than .001 to .041). These differences were associated with medium to large effect sizes (eta-squared = 0.0784 to 0.1681). Wives assigned to BMT plus RP who reported low marital adjustment before study entry reported higher marital adjustment at all follow-up points (p = .012), a difference that reflects a medium effect size (eta-squared = 0.1156). Among wives who reported low marital adjustment before study entry, those assigned to BMT plus RP reported higher marital adjustment in months 18-30 following BMT than those assigned to BMT only (p = .032). BMT-only wives with low marital adjustment prior to study entry reported a steep decrease in marital adjustment in months 18-30 following BMT (p = .040). These differences were associated with medium effect sizes (eta-squared = 0.0784 to 0.090). Couples (both husband and wife) assigned to BMT plus RP reported higher marital adjustment at the end of treatment and throughout the 24-month follow-up assessment than before study entry (p < .001). In general, regardless of condition assignment, husbands' reports of marital adjustment at follow-up were directly related to their reported marital adjustment before study entry (p < .001); that is, if reported marital adjustment was low before the study, it remained low at each follow-up assessment, and conversely, if it was high before the study, it remained high through each follow-up. The change in husbands' reported marital adjustment from pre- to posttreatment was associated with a large effect size (eta-squared = 0.5329).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 5: Confidence in smoking cessation
Description of Measures	Confidence or self-efficacy in smoking cessation was measured by client responses to the following item: "What is the likelihood that you will resume smoking again?" Responses were on a 5-point scale ranging from 1 (very unlikely to resume smoking) to 5 (very likely to resume smoking). This item was asked before study entry and at the end of treatment.
Key Findings	In an RCT, smokers participated in a 4-day series of 2-hour group sessions for smoking cessation that provided training on the use of more than 40 behavioral and cognitive smoking cessation techniques such as changing daily routines, deep breathing, and relaxation exercises. Clients abstinent from smoking (i.e., no carbon monoxide in breath samples) at the 1-week follow-up session were randomly assigned to 1 of 3 conditions: an RP skills-training program in which clients actively developed and rehearsed specific coping strategies, a discussion control condition that basically offered social support, or a no-treatment control condition with no additional client meetings. Both the RP skills-training and discussion group conditions met weekly for 3 more weeks in a small group format. Findings from this trial included: At the end of treatment, clients in both the RP skills-training and discussion group conditions reported higher confidence in being able to abstain from smoking than those in the no-treatment condition (p < .005). When clients who had relapsed in the treatment month were excluded, however, there were no significant differences between groups in this outcome; there was only a generalized increase in confidence ratings among all abstinent clients regardless of condition assignment (p < .0001).
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	Data not reported/available
Study 2	26-55 (Adult)	60% Female 40% Male	94% White 6% Race/ethnicity unspecified
Study 3	18-25 (Young adult) 26-55 (Adult)	73% Male 27% Female	54% Race/ethnicity unspecified 46% White

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Drinking behavior	4.0	4.0	1.8	4.0	3.0	4.0	3.5
2: Smoking abstinence	2.5	2.8	1.8	3.0	3.0	3.5	2.8
3: Cocaine use	3.5	3.5	3.5	3.5	3.0	4.0	3.5
4: Marital adjustment	4.0	4.0	1.8	4.0	3.0	4.0	3.5
5: Confidence in smoking cessation	1.5	2.5	1.8	2.0	3.0	3.5	2.4

Study Strengths

The Timeline Followback Method and the Marital Adjustment Test are widely used measurement instruments with strong psychometric support. The validity of the drinking behavior and marital adjustment outcomes was strengthened by convergence with other data sources (breath alcohol and spousal reports/ratings). The validity of smoking abstinence was strengthened by biochemical confirmation, and the validity of reported cocaine use was bolstered by urine toxicology at the follow-up assessments. The Addiction Severity Index is a well-known assessment instrument with strong psychometric properties. Two of the three studies had minimal attrition/missing data, and the third study addressed missing data using a strong random-effects regression approach. All three studies had strong, thorough, and detailed analyses appropriate to their study designs.

Study Weaknesses

The reliability and validity of the monthly postcard reports of smoking through the 12-month follow-up period are unknown. Self-reported confidence in smoking cessation was based on only one item, presumably derived from a larger scale with documented evidence of validity, but the psychometric properties underlying this single item in the present study are unclear. Two of the three studies had no measurement of treatment fidelity to evaluate the dose or content of the actual RP elements getting through to each client.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.3	3.5	2.5	3.1

Dissemination Strengths

A large number of materials are available to support implementation, many of which are easily accessible through the Web. Clinical guidelines provide a clear rationale and sequence for implementing this intervention. A comprehensive training workshop program offers a wide array of information on substance abuse treatment for diverse populations coupled with clear guidance for the use of this intervention. Outcome measures and general evaluation guidance are available to support quality assurance.

Dissemination Weaknesses

The burden of identifying and selecting the essential materials from among the many available is placed on the implementer. Very little guidance is provided on the organizational, staffing, or supervision requirements for implementation. Beyond the training workshops, no ongoing coaching, booster training, or supervision training is available. Little guidance is provided on how to identify, use, and interpret the available outcome measures. No standard measures for assessing fidelity are provided. The fidelity checklists provided for review were designed for specific studies and may not be appropriate for general implementation.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
RPT manuals	Contact developer for license	No
Therapist guidebooks	$20-$55 each	No
Client workbooks	$20-$40 each	No
Client videos	$100-$750 each	No
2- to 5-day training and consultation workshops	$4,000 per day	No
Program development	$4,000 per day	No