Relapse prevention and safety planning: A viable short term intervention
Kirsty Bell Hunter
Consultant Clinical Psychologist
Kirsty Bell Hunter is a consultant clinical psychologist currently in private practice. Previously she worked with the Department of Corrections Psychological Services for eight and a half years, with proficiency in assessing and treating sexual offenders. Kirsty has a particular interest in journeys of recovery. She conducted a Level Seven Research Project in 2016, which formed the basis of this article.
The author acknowledges Nikki Reynolds, previous Chief Psychologist, and Dr Nick Wilson, Principal Advisor, Psychological Research, Department of Corrections for supporting the safety planning research project. She would also like to acknowledge the value that researchers offer to cutting edge psychology for the overarching goal of social well-being. Research is precious and valuable in a fast-paced world. Current theories and practices need investigation, new conclusions need to be drawn, and truths need to be validated. Were it not for the researchers, the world as it is would not exist.
This article provides a brief summary of the findings of the research. For a copy of the full research paper with a comprehensive literature review, diagrammatic representations, analysis of the data, a best practice booklet, a safety plan template, a full bibliography and suggestions for further research, please contact Dr Nick Wilson: email@example.com
Relapse prevention has been defined as a method of self-management based on the implementation of adaptive responding in situations of high risk (Dowden & Andrews, 2007). It serves as a framework to prevent the reoccurrence of unwanted behaviours (Hanson, 2000). Safety plans are living documents amenable to change over time and with circumstances, and are critical to the prevention of relapse into unwanted and unhelpful behaviours (National Domestic Violence Hotline (2016). Relapse prevention and the development of safety plans feature within rehabilitation and reintegration interventions to assist individuals who have been in prison to transition back into society (Department of Corrections New Zealand, 2017).
This research project investigated what contributes to best practice safety planning and how safety plans were being implemented within individual interventions by Departmental psychologists. The project aimed to identify key factors to relapse prevention and safety planning, assist with the implementation of better safety planning practices, improve the quality of current safety plans, and to contribute to brief stand-alone interventions for individuals serving short sentences.
It was expected that the results would inform psychologists about what constitutes best practice for safety planning and guide effective psychological practice. As a result of this research, regular training for staff on improving safety plans has been introduced. In addition to drawing attention to offence mapping, skills rehearsal, and training significant others, example plans and structured approaches have also been developed for staff use.
For around three decades relapse prevention in general has chiefly been implemented through manualised treatment packages (as a component of treatment), or as general treatment (Donovan & Witkiewitz, 2012; Keeling & Rose, 2005; Mann, Webster, Schofield & Marshall, 2004). At the outset, relapse prevention was developed as a psycho-educational cognitive-behavioural programme based on social learning theories (Hanson, 2000; Prisgrove, 1993; Polascheck, 2003; Witkiewitz & Marlatt, 2007). Relapse prevention was used as an overarching term to describe a series of cognitive and behavioural strategies that would assist individuals to anticipate and manage possible relapses (originally into alcohol use) (Witkiewitz & Marlatt, 2007). One would potentially view incidents as critical indicators that may lead to lapses and relapses or towards continued change maintenance (Marlatt & George, 1984). Relapse prevention aimed to facilitate a balanced lifestyle and to moderate the likelihood of excessively unhealthy behaviours being engaged in (Marlatt & George, 1984).
Marlatt and colleagues originally identified a number of core components to relapse prevention, the basis of which was the identification of high-risk situations (Witkiewitz & Marlatt, 2006). A high-risk situation constitutes any situation that increases the likelihood and the risk of an individual engaging in a transgressive behaviour (Witkiewitz & Marlatt, 2006). Such situations may involve contextual, emotional, cognitive, or experiential factors. Marlatt and Gordon,1985 and Marlatt and Nathan, 1978 (cited in Witkiewitz and Marlatt, 2007), developed a taxonomy (a categorical hierarchy of triggers) that they suggested contributed to individuals relapsing, which was to be used within relapse prevention work. The early model has been critiqued, expanded, and developed over time (Bickley & Beech, 2002 [in Keeling & Rose, 2005]; Kadden, 1996; Keeling & Rose, 2005; Laws, 1999; Pithers, 1990; Ward, 2000; Ward & Hudson, 2000; Witkiewitz & Marlatt, 2007). However, there remains a dearth of current literature in this area.
Relapse prevention with individuals in prisons typically includes the development of personalised applicable safety plans that assist them to recognise, avoid and mitigate situations of danger or risk, and adaptively respond to such situations. During the time that the author worked as a Departmental psychologist in prisons and probation settings, it became evident that a large number of individuals in prison and on probation had developed safety plans as either a component to their treatment, or as a stand-alone intervention. Safety plans were often reviewed with psychologists at significant assessment interviews, during ongoing treatment, within relapse prevention support groups, with probation officers and with families/whānau and significant others.
At the outset of the project in 2016, it appeared that within Psychological Services there was no standardised practice for safety planning in individual treatment contexts. It seemed that safety plans ranged in design and content from basic to comprehensive and detailed.
Literature review overview
The author's research included a comprehensive literature review, which examined the history and development of relapse prevention planning over 30 years and its application to various populations of Corrections’ clients (e.g. sex offenders, violent offenders, intellectually impaired, youth, all genders and ethnic groups).
Meta-analyses, reviews and studies into interventions utilising components of traditional relapse prevention are limited but have discussed the efficacy of this intervention (Dowden & Andrews, 2007; Donovan & Witkiewitz 2012; King & Polaschek, 2003; Laws 1999). Relapse prevention has been defined as a method of self-management based on the implementation of adaptive responding in situations of high risk (Dowden & Andrews, 2007) and serves to prevent the reoccurrence of unwanted behaviours (Hanson, 2000). Moreover, the literature indicated effect sizes for prosocial change when safety plans were developed with individuals in correctional contexts, irrespective of risk bands (Dowden, Antonowicz & Andrews, 2003).
Useful frameworks for relapse prevention interventions have evolved over time into core components for individual relapse prevention interventions and safety plans. Core components involve offence chaining, the learning and development of management skills, rehearsal of skills across multiple domains, the inclusion and teaching of significant others in individual's lives, and cultural applicability. Meta-analyses demonstrated that relapse prevention intervention needs to be implemented with the principles of risk, need, and responsivity, to bring about successful therapeutic outcomes (Dowden & Andrews, 2007). However, relapse prevention and safety planning also needs to be specific to an individual’s requirements rather than global, and the training of significant others is critical to positive outcomes (Dowden & Andrews, 2007). While core components were established for better safety planning, areas that provide little utility were also identified (Dowden, Antonowicz & Andrews, 2003; Dowden & Andrews, 2007).
The most promising core component established for relapse prevention planning was training significant others (Dowden, Antonowicz & Andrews, 2003; Dowden & Andrews, 2007). Other components identified as being effective included offence chaining and identifying relapse precipitants, release planning rehearsal, and the identification of high-risk situations. Components seen to be less effective included developing skills to cope with failures, and booster sessions (Dowden and Andrews, 2007).
Elements that contributed to higher rates of re-offending reduction were:
- Relapse rehearsal: The rehearsal of newly learnt skills is frequently engaged in by the participant and evaluated by the therapist and the participant. Rehearsal should include graduated exposure to more difficult scenarios and social learning scenarios.
- Training significant others: Family, wider family and significant community members are trained in an individual’s offence pathways and their newly learned skills. Significant others require training to learn how to look for prosocial target behaviours and how to positively reinforce these with the participant. Offence chaining should be conducted on not just one offence but on multiple offence pathways.
- High-risk situations: High-risk situations are well planned for and skills for managing potential risk scenarios are practised.
- Cognitive behavioural learning strategies should be engaged in to manage negative cognitive and affective states.
- Risk, Needs, Responsivity: Better relapse prevention outcomes are achieved when criminogenic needs are targeted.
- Programme manuals yielded higher mean effect sizes: Manualised programmes are efficacious and provide utility, yet at the same time individualised and detailed relapse prevention plans need to be created.
Factors that were not found to reduce re-offending were identified as:
- how to deal with failures, coping with failure
- participation in booster sessions
- enhancing self-efficacy.
Blume and Garcia De La Cruz (2005)noted that individuals from a bi-cultural society require competency in skills to serve them well in both cultures. Lifestyle balance (including the importance of family, communities, roles and environmental determinants) as with Marlatt and Gordon's (1985) early relapse prevention model, was supported as being pertinent to ethnic groups. For culturally relevant prevention intervention a number of factors need to be considered and likely included.
Noted factors were:
- A strong focus on developing a therapeutic alliance.
- The inclusion of first languages and meanings inherent to first languages.
- The use of relational narratives and stories to demonstrate cognitive-
behavioural examples of risk.
- The development of culturally relevant skills.
- The inclusion of family and extended family members (in the learning of relevant skills and activities).
- The inclusion of elders and relevant community members (in the learning of relevant skills and activities).
- Acknowledgment of traditional healing practices that may be helpful with preventing relapse.
The research questions
The research indicated effect sizes for prosocial change when safety plans have been implemented with individuals within correctional contexts, irrespective of risk bands (Dowden, Antonowicz & Andrews, 2003). Within treatment programmes in New Zealand (NZ) Department of Corrections settings modularised safety planning is undertaken. The questions remained as to the implementation of safety plans by NZ Corrections psychologists undertaking safety plans within individualised treatments. It was hypothesised that psychologists’ safety plans would differ across clients but that for the most part key components of safety planning would primarily be met.
The project explored and evaluated safety plans developed in treatment (prison and probation-based) by correctional psychologists with participants between 2013 and 2014. A total of N=50 reviews were undertaken by the writer and categorised into a) demographics, and b) a safety plan review. To obtain a randomised sample, COBRA downloads of treatment reports were accessed from the 2013 and 2014 period from the Central, Northern/Waiariki, and Lower North regions. Every third participant’s treatment report was scanned by the writer for indications of safety planning. Participants that had been treated by the writer were screened out to eliminate potential biases.
Demographics were recorded for the sample and included:
- RoC*RoI score (checked in IOMS, COBRA and reports)
- ASRS score (checked in COBRA)
- Index offence (violence; sexual; general, sexual and violence; sexual and general; violence and general, sexual violence)
- Referral (treatment and safety planning, safety plan only)
- Relapse Prevention intervention (manualised, non-manualised, or combined).
Safety Plan Criteria:
Variables were extracted from criteria in the literature and from safety planning modules used within prison-based treatment programmes, for evaluation of the safety plans within the data set.
- Offence mapping
- Unbalanced lifestyle factors (e.g., antisocial associates)
- Negative cognitions (e.g., “I want to hit him”, “I’ll show her”)
- Negative emotions (e.g., anger, inappropriate sexual arousal)
- Reward/positive cognitions (e.g., “I will feel high”)
- Early warning signs
- Seemingly innocent choices
- High-risk situations
- Skills developed in treatment (e.g., mindfulness techniques, communication skills, and time out)
- Rehearsal across contexts – generalisation of skills
- Positive lifestyle balance
- Strategies (e.g., telephone my probation officer, talk to my support people)
- Protective factors clearly included in safety plan
- Support people and contact details included in plan
- Training significant others.
The safety plans were thoroughly reviewed by the author and scores were attributed as to whether the components of the safety plans were present. For example:
- None completed = 0
- One completed = 1
- Two completed = 2
- Three or more = 3.
Six files from the data set were initially reviewed and scored by the writer. The review included treatment reports, safety plans and session notes (psychological file and Integrated Offender Management System – IOMS notes). The files were then reviewed and scored by a second Corrections psychologist and discussion was held as to the clarity of the items. Inter-rater reliability was established at 50%. Adjustments were made to the phrasing of items for clarity and consistency across assessing the safety plans. The second psychologist rescored the safety plans (where they had not previously fully understood what the item had intended to capture). The data set was handed to a third Departmental psychologist who reviewed the files and scored the data accordingly. Percentage agreement resulted in 75% convergence of scoring.
Further data collection
The writer collected further data by way of file review including treatment reports, safety plans and session notes (psychological file and IOMS notes) to optimise data collection. A basic analysis was undertaken by way of calculating means for the variables that had been evaluated, with respect to the data gathered for safety plans. This enabled the writer to access some descriptive statistical information. Descriptive statistics were evaluated to compare and contrast safety planning practices from the sample against the best practice established through the literature. It was assumed that the sample would represent the likely safety planning practices with Departmental psychologists engaging in individualised safety planning within prison contexts.
The safety plans varied in quality and the inclusion of core components. Lifestyle balance, the management of negative emotions, the development of psychological skills, and early warning signs featured reasonably well within the sample and were considered to be well addressed. Moderately addressed areas included negative cognitions, protective factors, reward cognitions and the inclusion of significant others’ details. Least addressed core components were offence pathways, rehearsal of learned psychological skills, and training significant others. These important components were not frequently included during intervention. However, the reviewed safety plans demonstrated that high-risk situations and risk management strategies were rigorously addressed.
Multiple high-risk situations and risk management strategies (such as exit strategies and calling support people) were also evidenced in the reviewed plans. The small number of structured safety planning interventions that were undertaken made for ease of reviews and succinct yet comprehensive safety plans. Clear data was present when formal safety planning had taken place. With less structured treatment, in many cases the clarity of the safety plans was lacking. Offence maps had been conducted in under half the sample; when they had been, clear phases of the relapse model were evident within the safety plans.
In summary, the review of the safety plans found that most were fit for purpose and importantly, addressed relevant areas. While there were some differences in plans, they all rigorously addressed high-risk situations and risk management strategies. The review did identify that some plans could be further improved by including multiple offence pathways, rehearsal of learned psychological skills, and training significant others.
Andrews and Bonta (2010) identified a Risk, Needs, Responsivity approach to addressing relapse prevention and that the following areas should be included: positive therapeutic alliance, skills development, cognitive-behavioural therapies, training of significant others, family support, structured formats, and matching of risk for relapse to the intensity of the intervention. For the most part, Risk, Needs, Responsivity principles were adhered to in the reviewed plans. Responsivity issues were well met with language interpreters, and cultural considerations were made in many cases. However, while around a third of safety plans had recommended a support meeting/whānau hui, more work is needed to ensure that this important aspect takes place as only a small number of the proposed meetings had occurred. The reasons for the proposed meetings not occurring appeared varied and further research is recommended to establish patterns and strategies to address these barriers where possible.
Results demonstrated a stronger positive trend towards engaging in both treatment and safety planning, with a considerable range in the number of treatment sessions provided. Non-manualised approaches were favoured and were primarily seen to incorporate various components of the standard relapse prevention model.
Demographics of Sample Group (N = 50)
Range in years.
Low (with ASRS score).
Low/Moderate to Moderate.
Sexual & Violence
Sexual & General
Violence & General.
Sexual, Violence & General
Treatment and Safety Planning
Safety plan only
Treatment and Safety Planning
Relapse prevention intervention provided with manualised plans, or independently developed.
Manualised with non-manualised
Number of sessions
Mean calculations for Core Components of Reviewed Safety Plans.
Components Included in Safety Plans
Frequency of components
High Risk Situations
Positive Lifestyle Factors
Unbalanced Lifestyle factors
Early Warning Signs
Significant Others details included
Rehearsal of Skills
Training Significant Others – Recommended support meeting/whanau hui
Training Significant Others - Actioned support meeting/whanau hui
This research project aimed to review and explore best practice relapse prevention and safety planning practices by NZ psychologists working in individual Corrections-based therapy, and to assess how practice was being conducted. Results demonstrated that NZ Corrections psychologists were addressing a number of key areas well (such as high-risk situations, and risk management), although some other important areas such as offence mapping, skills rehearsal, and training significant others could be improved. However, overall, risk, needs, responsivity factors identified as being critical areas for relapse preventions as identified by Andrews and Bonta (2010), were being met.
It was apparent that consideration of a balanced lifestyle was valued and included within safety plans, and would likely contribute to the mitigation of unhealthy behaviours that could lead back to further offending. Marlatt & Gordon (1985) and Lowman, Allen & Stout (1996) indicated that the management of intrapersonal and interpersonal conflicts, negative and positive emotional states, and social pressures are key to effective relapse prevention. The research demonstrated that practices by NZ Corrections psychologists have been meeting such targets.
Offence chaining, the rehearsal of psychological strategies, and training significant others were the least well-addressed areas within the reviewed safety plans. Rehearsal of relapse prevention strategies and training of significant others were strongly supported by Dowden & Andrews (2007) meta-analysis. That these areas were found to be least well-addressed suggested that they may be difficult for an individual to work on while in prison or that psychologists were not fully aware of the impacts generated from behavioural rehearsal of relapse prevention skills.
Similarly, an inclusive approach was identified as best practice with cultural minority groups. The research suggested that inclusive approaches (such as whānau hui) for significant others provide forums for appropriate training of support people and are likely be influential to the efficacy of relapse prevention. Given that Māori and Pasifika predominated the ethnic demographics, and that the Polynesian culture is an inherently collective rather than an independent culture, suggests that psychologists could apply a more rigorous approach to meet this key component of safety planning. While support meetings/whānau hui were often recommended, it seemed that more attention needed to be paid to follow up and facilitation of such meetings.
Implications and future directions
The research project established where core components of relapse prevention were a part of regular practice, and identified where psychologists may meet the gaps to ensure better practice. The results of this research and the review of safety plans have been used to train Department psychologists in improving their safety plans, with particular attention to multiple offence pathways, rehearsal of strategies, and, where possible, significant others training. It is expected as a result of this research that the plans developed by Department psychologists will be even more effective. The project also provided foundations for further research into the area of safety planning in New Zealand.
The research project established core components of safety plans and what constitutes best practice for safety planning. The project revealed that safety plans are dynamic documents that can significantly impact an individual’s life. If well-constructed and developed to target core components and tailored to a person's needs, a safety plan can provide both individuals and their significant others with valid ongoing strategies for transitioning into and maintaining prosocial living. When reflecting upon the literature, the research project found reasonably positive results (albeit with room for improvements which have now been implemented). Relapse prevention is a viable short term intervention and when best practices are implemented with safety planning, will likely make substantial ongoing contributions to reducing re-offending in New Zealand/Aotearoa over the long term.
Andrews, D. & Bonta, J. (2010). Relapse Prevention. The Psychology Of Criminal Conduct (5th ed). New Jersey: Lexis Nexis. 287-289.
Blume, A. & Garcia De La Cruz. (2005). Relapse Prevention Among Diverse Populations. Relapse Prevention: Maintainence Strategies In The Treatment Of Addictive Behaviors. New York: The Guildford Press. 45-65.
Department of Corrections New Zealand. (2017). Working With Offenders. Retrieved from: https://www.corrections.govt.nz/working_with_offenders/prison_sentences/employment_and_support_programmes/rehabilitation_programmes.html
Dowden C. & Andrews, D. (2007). Utilising Relapse Prevention with Offender Populations: What Works. Therapist's Guide to Evidence-Based Relapse Prevention. Oxford: Elsevier. 339-350.
Dowden, Antonowicz & Andrews. (2003). The Effectiveness of Relapse Prevention With Offenders: A Meta-Analysis . International Journal of Offender Therapy and Comparative Criminology , Vol 47 (5). 516-528.
Donovan, D., & Witkiewitz, K. (2012). Relapse Prevention: From Radical Idea To Common Practice. Addiction , Research and Theory, 20 (3). 204-217.
Hanson, R. K. (2000). What Is So Special About Relapse Prevention. In Laws, D.R. Remaking Relapse Prevention With Sexual Offenders. California: Thousand Oaks. pp. 27-38.
Kadden, R. (1996). Is Marlatt's Taxonomy Reliable Or Valid? Addiction, (91) S 139-145.
Keeling, J. R. & Rose. J. L. (2005). Relapse Prevention With Intellectually Disabled Sexual Offenders. Sexual Abuse: A Journal of Research and Treatment, Vol 17, (4). 407-420.
King. L., & Polaschek. D. L.L. (2003). The Absitinence Violation Effect: Investigating Lapse and Relapse Phenomena Using The Relapse Prevention Model With Domestically Violent Men. New Zealand Journal Of Psychology, Vol 32, (2). 67-75.
Laws, D.R. (1999). Relapse Prevention: The State Of The Art. Journal Of Interpersonal Violence. Vol 14 (3). 285-302.
Lowman, C., Allen. J., & Stout. R.L. 1996. Replication and extension of Marlatt's taxonomy of relapse precipitants: overview of procedures and results. The Relapse Research Group. Addiction. Vol 91 Suppl (Suppl):S51-71.
Mann, R. W., Webster. S., Schofield. S., and Marshall. W (2004). Approach Versus Avoidance Goals in Relapse Prevention With Sexual Offenders. Sexual Abuse: A Journal of Research and Treatment, Vol 16, (1). 65-75.
Marlatt. G.A., & Gordon, J.R. (1985). Relapse Prevention: Theoretical Rationale And Overview Of The Model. In G.A.Marlatt & J.R. Gordon (Eds), Relapse Prevention. New York: Guildford Press. 250-280.
Marlatt, G. A., & George, W. H. (1984). Relapse Prevention: Introduction And Overview Of The Model. British Journal Of Addiction. Vol 79. 261-273.
National Domestic Violence Hotline. 2016. Safety Planning. http://www.loveis respect.org/for-yourself/safety-planning.
Prisgrove, P. (1993). A Relapse Prevention Approach To Reducing Aggressive Behaviour. Serious Violent Offenders: Sentencing, Psychiatry And Law Reform. Proceedings of a conference held 29-31 October 1991. Canberra: Australian Institute of Criminology. 180-191.
Pithers, W. (1990). Relapse Prevention For Sexual Aggressors: A Method for Maintaining Therapeutic Gain and Enhancing External Supervision. Handbook Of Sexual Assault: Issues, Theories, and Treatment of the Offender. New York: Springer. 343-361.
Polaschek, D. L.L.(2003). Relapse Prevention, Offense Process Models, and the Treatment of Sexual Offenders. Professional Psychology: Research and Practice, Vol 34 (4). 361- 367.
Ward, T. (2000). Relapse prevention: Critique and Reformulation. The Journal of Sexual Aggression. Vol 5 (2), 118-133.
Ward, T., & Hudson, S.M. (2000). A Self-Regulation Model of Relapse Prevention. In Laws, D.R., Hudson, S. M., & Ward. T. Remaking Relapse Prevention With Sex Offenders. Thousand Oaks, California: Sage. 79-101.
Witkiewitz, K. & Marlatt, G. A. (2006). Overview Of Harm Reduction Treatments For Alcohol Problems. International Journal Of Drug Policy Vol 17. 285-294.
Witkiewitz, K. & Marlat, G. A. (2007). Overview Of Relapse Prevention. Therapists' Guide to Evidenced-Based Relapse Prevention. London: Elsevier Inc. 3-17