A Google search on "relapse prevention" (RP) returns over 3.5 million "hits." Over a half a million of these web pages are in a language other than English, including 24,000 in French, almost 20,000 in Spanish, over 17,000 in German, and even 100 in Icelandic. There are also over 27,000 web pages that reference books on relapse prevention. In a Medline search, the keyword phrase, "relapse prevention," identified over 1,000 articles. Fully 977 of these articles appeared following the publication of the first edition of Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors in 1985. On the jacket of this volume, Peter Nathan predicted that the "book will stand as a landmark in the history of therapeutic ideas..." Certainly, when one considers the influence of this book on the field of addictions treatment, Dr. Nathan cannot be accused of overstatement.

The second edition of this now classic text, published last year by Guilford Press, provides a thorough-going review of the relapse prevention literature that has grown exponentially over the past 20 years. In the first chapter of this new volume, Alan Marlatt and Katie Witkiewitz offer a selected but balanced review of research on self-efficacy, outcome expectancies, coping and other factors associated with lapse and relapse which are the cornerstone concepts of relapse prevention theory and treatment. For example, they highlight the contributions Saul Shiffman and colleagues have made through their EMA studies to our understanding of the dynamic interplay of these factors in the lapse and relapse processes; and they take note of recent research that indicates that improvements in coping skills are not a mediating mechanism of improved outcomes of cognitive-behavioral interventions for addictive disorders. In the closing pages of the chapter, Marlatt and Witkiewitz suggest directions for future research, conceptual and methodological as well as empirical, that take into consideration recent thinking in chaos theory, self-regulation theory, and mindfulness. I found it particularly interesting to learn that recent studies of alcohol treatment, using nonlinear statistical models that are sensitive to discontinuous change, have been far more successful in predicting outcome (e.g., relapse) than traditional linear approaches.

The following chapter discusses the application of relapse prevention to minority populations, while each of the remaining 12 chapters of the book focuses on a particular addictive behavior (including four chapters on nonsubstance addictive disorders — gambling, eating disorders, sex offending, and sexually risky behaviors) with discussions often echoing and elaborating on themes presented in Chapter 1. The chapter on relapse prevention for smoking, written by Saul Shiffman, Jon Kassel, Chad Gwaltney and Dennis McChargue, begins with a discussion of the issues related to the application of harm reduction to smokers and highlights some advances in knowledge and the controversies that surround harm reduction approaches to treating tobacco dependence. Most of the chapter, however, focuses on a discussion of abstinence-based approaches to intervention (e.g., identification of high-risk situations, coping skills training) that form, together with lifestyle modification, the core of relapse prevention strategies across addictive behaviors that are very familiar to readers of this newsletter. The chapter also includes an interesting discussion of the authors' own findings pertaining to the abstinence violation effect and their implications for treatment. The chapter then closes with a brief discussion of new modes of delivering treatment, including telephone counseling and internet-based approaches. Overall, while the chapter does not break any new ground, it serves well as an introduction to many of the issues clinicians and researchers grapple with and the tools they use in their efforts to make smoking history.

In addition to their focus on RP and its application to the particular addictive behavior under consideration, each chapter also serves as a more general introduction to issues pertaining to that addictive behavior. Most chapters provide an overview of the epidemiology of use, discuss harm reduction and drug withdrawal effects, briefly consider psychiatric comorbidities, discuss alternative and often complementary treatments (e.g., cue exposure treatment, contingency management, medications), and, very importantly, review the literature on the efficacy of RP interventions. Some chapters also give special emphasis to these issues in adolescent populations (see the chapters on marijuana, gambling, and club drugs), and the chapter on club drugs provides extensive information on what they are, what effects they produce, both desirable and undesirable, and their potential for long-term damage to health. At the same time, there is considerable redundancy between the chapters, and unfortunately, the redundancy is most pronounced in the discussions most relevant to RP treatment. Whether it's the Matrix Model for the treatment of stimulant dependence that is being described, or the Model of Relapse Prevention Therapy for opioid dependence, or cognitive-behavioral treatments for eating disorders, the differences between the treatment approaches were not so easy to discern. In this sense, the book perhaps unwittingly makes the case that the strategies used in RP treatment are not substantially different from what they were when the first edition appeared. Progress has been slow.

One of the strengths of the second edition, however, and one of the important ways in which it differs from its predecessor, is in the emphasis it places on how RP and other treatment strategies can work together to increase treatment effectiveness. Indeed, to stimulate the reader to consider these possibilities was one of their intended goals, as Marlatt and Donovan tell us in the book's preface. Thus, as Kathleen Carroll and Richard Rawson discuss in their chapter on stimulant abuse, two recent studies have demonstrated the incremental efficacy of adding contingency management to RP treatment. As evidence of their complementarity, these studies found that contingency management had short-term effects, while RP had long-term "sleeper" effects. Examples are also sprinkled throughout the book of RP studies which have added motivational enhancement therapy, cue exposure, and dialectical behavior therapy. Interestingly, findings have not been consistent across addictive behaviors. For example, alcohol treatment studies have found incremental efficacy when cue exposure treatment has been added to RP, while the results of smoking cessation studies have been disappointing. But one also comes away from this book with the realization that surprisingly few "additive" and "dismantling" studies have been conducted with RP in combination with other behavioral treatments, and that much more work still needs to be done.

The book suffers somewhat from the lack of a final integrating chapter. Each of the previous chapters contains a wealth of information and it would have been very useful to provide a closing synthesis. This synthesis could have helped the reader to understand how the RP literature for each of the addictive disorders compares to one another. It would also have helped the reader to assess the state of the field as a whole. My own sense from these chapters is that the efficacy of RP treatment varies widely across addictive behaviors; that, for example, the literature strongly supports the use of RP interventions in alcohol and tobacco treatment as well as for eating disorders; that the literature for stimulant users is thin but also supports the use of these interventions; that the literature for marijuana users is not supportive; and that little if anything can be said about the efficacy of RP interventions for gamblers and users of club drugs because research in these areas is still very much in its infancy. To the extent that there is greater variation in the efficacy of RP interventions across addictive disorders than across clinical trials within each of the disorders, some discussion by the editors about the possible reasons for this variation would also have been useful. Finally, I would be remiss not to add that the book under review is meant to be used in conjunction with a companion volume, Assessment of Addictive Behaviors (Guilford Press, 2005; http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/donovan.htm&dir=pp /addictions&cart_id=992637.27959 ) by these same editors. Together, these two volumes provide a comprehensive review and update of the RP literature which make them worthy heirs to the first edition of this book.

About the author: David Kalman, Ph.D., is an Assistant Professor in the Department of Psychiatry in the Boston University School of Medicine. His interests include clinical trials, smoking cessation in psychiatric populations, and interactions between smoking and other drug dependencies