Psychological and environmental determinants of relapse in crack cocaine smokers

Journal

of Substance Abuse

Printed in the USA.

ORIGINAL

All

Treatment,

Vol. 6, pp.

95-106,

0740-5472/89

1989

$3.00 + .OO

Copyright 0 1989Pergamon Press plc

rights reserved.

CONTRIBUTION

Psychological and Environmental Determinants of Relapse in Crack Cocaine Smokers BARBARA African-American

C. WAU_.ACE,P~D

Studies Department, John Jay College Of Criminal Justice, City University of New York, New York, New York

Abstract - The paper reviews approaches to relapse in the treatment of cocaine abusers. Approaches reveal a common mechanism underlying relapse that involves drug craving, recall of euphoria, environmental cues, denial, myths of being able to sell or use drugs, and painful affect states necessitating use of a multifaceted clinical technique. Empirical validation of a common mechanism underlying relapse establishes a typology of psychological and environmental determinants of relapse for crack cocaine smokers (N = 35) who relapse after hospital detoxification and return a second time. Major findings are that relapse follows a painful emotional state (4OVo),failure to enter arranged aftercare treatment (370/o), or encounters with conditioned environmental stimuli (340/01, and involves narchistic psychopathology and denial (28.50/o) and interpersonal stress (24Yo); 85.7% involve multideterminants. Case examples illustrate the role of multideterminants in relapse. The paper educates clinicians to the integrated theory and multifaceted clinical technique necessary for efficacious treatment of cocaine patients, while the typology predicts probable relapse situations. Keywords-Crack,

cocaine,

relapse

prevention,

treatment,

minorities.

Characteristics of the growing population of compulsive crack cocaine smokers pose a new treatment challenge that necessitates changes in detoxification and therapeutic community programs (Wallace, 1987; Zweben, 1986; Rainone, Kott, & Maranda, 1988). Relapse also creates a challenge in outpatient treatment for cocaine abuse (Smith & Wesson, 1985; Spitz 8z Rosecran, 1987; Washton & Gold, 1987). Relapse for patients trying to maintain abstinence from various addictive substances has been a focus of previous research (Marlatt, 1980; Marlatt, 1982; Marlatt & Gordon, 1985; Hunt, Barnett, & Branch, 1971). Relapse phenomena common to compulsive crack cocaine smokers who meet criteria for cocaine dependence and inpatient hospitalization are investigated in this paper. The paper presents a review of contemporary approaches to relapse in the treatment of cocaine abuse. Analysis of approaches highlights existence of a common mechanism underlying relapse and commonalities in clinical technique. This investigation follows Marlatt (1985) in microanalysis of relapse episodes. Relapse episodes were content-analyzed for a sample of crack cocaine dependent patients who returned for a second inpatient hospital detoxification after ex-

INTRODUCTION Siegel (1985) describes compulsive patterns of cocaine usage, observing between 1978 and 1982 a dramatic change in compulsive users being predominantly smokers of cocaine freebase. Smith and Wesson (1985) discuss the west coast phenomenon of cocaine being sold in freebase form, under the name of “rock.” Rock is easily smoked without further preparation. On the east coast, a freebase form called “crack” is inexpensive and widely available. Freebase cocaine smokers are more likely to need hospitalization, as are intravenous cocaine users (Washton, 1987). Contemporary patterns of “rock” and “crack” smoking place users at risk for rapid escalation to addiction. Compulsive freebase cocaine smoking characterizes those individuals who meet hospitalization criteria for cocaine dependence.

Research in cooperation with Interfaith Medical Center, Department of Psychiatry, 555 Prospect Place, Brooklyn, New York 11238. Requests for reprints should be sent to Barbara C. Wallace, Ph.D., Assistant Professor, African-American Studies Department, John Jay College of Criminal Justice, City University of New York, 59th and 10th Avenue, New York, NY 10019. 95

B. C. Wallace

periencing a relapse. Results are presented, yielding a typology that classifies relapse episodes for psychological and environmental determinants. Illustrative case examples are described, showing that relapse in compulsive crack cocaine smokers is a multidetermined and complex phenomenon wherein psychological and environmental determinants subtly interact. By presenting empirical validation of mechanisms that determine relapse in the cocaine dependent, the paper aspires to aid clinicians striving to improve clinical efficacy. APPROACHES TO RELAPSE IN OUTPATIENT TREATMENT Numerous clinicians are recognizing the clinical challenge of managing relapse in the treatment of cocaine abuse. Regardless of the modality- whether individual, family, or group therapy, certain commonalities in treatment interventions emerge. This section summarizes these approaches and highlights commonalities in treatment interventions and the multifaceted nature of clinical technique utilized with cocaine abusers. Approaches to managing relapse include contingency contracting with well-motivated, well-educated outpatients for whom relapse results in severe consequences such as resignation of professional license or other notification of cocaine use sent to employers (Anker & Crowley, 1982). However, Crowley reported that over 50% of patients who are willing to engage in such treatment relapse after their contract ends (cited in “Reinforcing. . . ,” 1982). The complexity of relapse phenomena must be appreciated in order to understand how extremely motivated patients, who are clearly capable of abstinence in face of a contract, may still relapse in the postcontract period. Numerous clinicians validate the high likelihood that relapse will occur during recovery. Kertzner (1987) accepts episodic relapse as part of the illness. Kertzner states that individual psychotherapy must address the abstinence symptomatology cited by Gawin and Kleber (1986); increased drug craving is fueled by mounting dysphoria, selective recall of cocaine euphoria, and the likely presence of environmental cues. In a case example, Kertzner (1987) describes use of imipramine, tyrosine, and 1-tyryptophan, asserting the value of medication approaches (Rosecran & Nunes, 1987) to dysphoria-induced cravings. To address other aspects of the abstinence symptomatology, Kertzner’s (1987) technique includes challenging patient recall of euphoria with reminders of the crash. Crash reminders constitute a type of aversive stimuli. Environmental cues may trigger relapse. Thus, patients must avoid cocaine-associated environments, paraphernalia, and use of other disinhibiting drugs. Kertzner urges therapists to confront the myth that patients can sell cocaine without sampling cocaine.

Kertzner (1987) also recognizes the role of affective states and difficult situations in triggering relapse. An increased capacity to experience and tolerate affects occurs through treatment. Finally, random urine testing, a necessity in managing the denial and resistance characteristic of cocaine patients in the early stages of treatment, permits the therapist to be completely informed (pp. 145-146). By combining use of medication, behavioral techniques, psychodynamic interventions, confrontational education, and urine testing, Kertzner’s approach exemplifies progressive multifaceted approaches. The approach of Stone, Fromm, and Kagan (1984) is very similar, adding theoretical conceptualizations of the relapse process and treatment goals. The initial phase of recovery is usually seen as most wrought with peril. Stone, Fromme, and Kagan (1984) describe a “relapse binge trap” that usually occurs during the first three to six months of the attempted abstinence period. Stone and coworkers emphasize that chances are high that patients will relapse at least once during this period. Relapse is followed by a binge, which is a waiting trap, when feelings of defeat and inadequacy concerning a return to drug use lead to using cocaine again, resulting in the binge. In a successful treatment course, periods of abstinence grow longer, periods of cocaine usage are fewer, with management of feelings, drug cravings, and stressful situations improving over time in outpatient individual psychotherapy (pp. 235 8~ 258). Whether a patient is in or out of treatment, or beginning or ending treatment, relapse remains a highprobability event. This highlights the lifelong challenge of maintaining abstinence. Spitz (1987) addresses relapse in therapeutic groups. Spitz observes increased desire to use cocaine in group members not yet inducted into the group and in those about to graduate (p. 182). Relapse into episodic cocaine use is expected in rehabilitation. Results of mandatory urine testing are discussed in groups and counter denial. Peer confrontation can be intense, while group leadership prevents scapegoating of members who relapse. The group formulates strategies for those who have slipped. Severe drug use results in inpatient hospital treatment (pp. 189-190). Spitz and Spitz (1987) focus on relapse in family therapy. Enmeshed families represent a major group for whom family therapy is the treatment of choice; the tendency to relapse in such families is high (p. 215). Even after successful family treatment, relapses often occur. Contingency plans, on which families must agree, address management of relapse setbacks (p. 229). Thus, regardless of the treatment modality, all clinicians integrate an awareness of relapse phenomena into their treatment approach. Beyond awareness of relapse phenomena is the question of what is the proper response to relapse. Is hospitalization or another detoxification necessary?

97

Determinants of Relapse

Washton (1987) views a single slip as insufficient basis for hospitalization of an outpatient. Accordingly, patients must be prepared for relapse and taught management of their own behavior throughout outpatient treatment and the rest of their lives. Relapse prevention educates patients to avoid the most common and predictable factors leading to relapse. Washton (1987) states that therapists must (a) counter selective recall of drug induced euphoria by. keeping negative drug-related associations alive, (b) teach patients to attend to early warning signs of potential relapse and to avoid “set ups” or self-sabotaging acts that precede drug use, (c) discourage testing control by renewed drug experimentation, and (d) teach patients about the abstinence violation effect (Marlatt & Gordon, 1985) so they can avoid a defeatist reaction after a slip. Once prepared for the possibility of a slip, negative feelings of failure are less likely to fuel a full-blown relapse. According to Washton, this education avoids patients’ viewing treatment as a failure after a slip. Washton (1987) prepares patients to anticipate cravings triggered by environmental stimuli. Cravings may also follow internal states, such as boredom or depression, that were reliably followed by drug use in the past. Misconceptions are dispelled that once drug craving begins it builds in intensity and inevitably leads to drug use. Education emphasizes the temporary nature of cravings. They are short lived (usually reach a peak of intensity within l-2 hours) and can be managed by quick action that blocks access to drugs. Patients should change their environment and activities, and should seek out drug free friends or relatives. Planning ahead and rehearsing alternatives aids management of cravings (pp. 108-110). In order to be effective, clinicians must possess conceptualizations of relapse that are accurate, improve clinical efficacy in their treatment, and resonate with patient experience. These conceptualizations of relapse should be conveyable to patients in practical terms that patients can comprehend. Patients must understand that relapse is a process involving multiple factors and antecedents. Smith and Wesson (1985) conceptualize relapse in stages. A decision that one is “cured” leads to experimentation with alcohol or marijuana, followed by use of a small amount of cocaine. When loss of control is not immediate, patients are convinced of a cure and use cocaine episodically. Eventual loss of control makes relapse complete. They view loss of the ability to control the amount of cocaine used, with only lack of availability halting drug use, as indicating that complete abstinence from all drugs of abuse is necessary. In their view, attempts to return to controlled use of any drug should not be made. Wesson and Smith (1985) describe any attempt to return to controlled use as a “slip” or a relapse. Patients receive anticipatory guidance on the handling of

cocaine dreams, cocaine drug hunger, and addictive thinking (that is, notions of being “cured”). They stress that silence is the enemy of recovery. Open discussion of these issues in cocaine recovery groups and peer provision of positive alternatives is essential to disrupt the sequence of stages that lead to relapse. Gold (1984) discusses relapse via a case example. Relapse prevention involves patient resolutions: avoiding drug-using associates, drug-user environments, and use of non-program-approved prescriptions. Cocaine can be thought about and craved, but not used. Outpatient treatment must be followed despite pressure to terminate (p. 49). Once clinicians appreciate the likelihood of relapse and possess conceptualizations of how relapse occurs, they must be able to inform patients of what to expect and how to behave. Ultimately, remaining in outpatient treatment with clinicians who support tenuous psychological functioning and address patients’ vulnerability to environmental stimuli is central to prolonging abstinence. Patients need help managing tendencies toward addictive thinking, defensive functioning, and difficulty managing affect states. Analysis of Clinical Treatment Approaches Gold, Washton, and Da&is (1985) explicitly recognize that some of their relapse prevention strategies are adopted from Marlatt’s (1980, 1982) work with alcoholism. “These strategies incorporate a variety of behavioral, cognitive, educational, and self-control techniques aimed at reducing the potential for relapse . . .” (p. 140). Stone and coworkers (1984) and Kertzner (1987) directly address management of painful affect states from a psychodynamic perspective, while all the clinical approaches combine behavioral, cognitive, educational, and self-control techniques. These multifaceted clinical approaches implicitly suggest that multideterminants of relapse are being responded to as evidenced by the technical interventions chosen. These clinicians validate the existence of a common mechanism underlying relapse, since so many commonalities in technique emerge. Each clinician perceives and responds to the same part of a metaphoric “elephant,” so to speak. Marlatt (1985) contends that “there is a common mechanism underlying the relapse process across different addictive behaviors” (p. 40). A more modest aim, to validate common mechanisms underlying cocaine abusers’ tendency to relapse, is realized by this literature review of approaches to relapse. The common mechanism underlying relapse is reducible to several closely related factors which determine a relapse episode. The clinicians’ approaches point toward the following factors: (a) drug craving; (b) recurrent selective recall of cocaine euphoria; (c) the provocative power of drug associated environmental cues; (d) processes of denial and addictive think-

98

B. C. Wallace

ing that permit patients to set themselves up; (e) myths or delusions of being able to sell, use, or be around cocaine or other drugs; and (f) recurrent painful affective states previously self-medicated with cocaine. Research approaches also clarify a common mechanism underlying relapse for various addictions (Marlatt & Gordon, 1985). The present empirical approach to relapse may further validate the existence of a common mechanism underlying relapse for a cocaine dependent population. MARLATT’S RELAPSE PREVENTION MODEL

Marlatt (1985) criticizes the standard practice in the addiction field which views relapse as an end state. He warns that these pessimistic approaches, if assimilated by patients while in treatment, set up a self-fulfilling prophecy where “any violation of abstinence will send the pendulum to the extreme of relapse” (p. 31). In addition, Marlatt (1985) criticizes the disease model’s emphasis on internal causation. Here, the cause of relapse is usually attributed to internal factors associated with the disease condition, and behaviors associated with relapse are equated with the emergence of symptoms signalling reactivation of the underlying disease. Ignored are the influence of situational and psychological factors as potential determinants in the relapse process (p. 31). Shaffer (1987) argues that just because “social scientists and drug treatment specialists are encouraging the application of the disease label to various forms of substance abuse and dependence, that does not make it so” (p. 103). In contrast to this disease model perspective, microanalysis of relapse reveals various determinants of relapse. Marlatt (1985) reports data on drinking, heroin, gambling, and overeating addictions. The most frequent determinants of relapse are (a) negative emotional states (35%), (b) direct or indirect social pressure (20%), and (c) interpersonal conflict (16%). These three primary high-risk situations are associated with almost three-quarters of all the relapses reported (pp. 37-38). Beyond the Disease Model: The Need for New Metaphors. The creative development of relapse prevention models that utilize metaphors other than the disease model must be encouraged (Miller 8z Pechacek, 1987; Wallace, 1989). For Marlatt (1985), a lapse or single slip represents a metaphoric fork in the road that can lead to total collapse or a path toward positive change. Growth and positive change follow when a slip is used to provide important information about the causes of the slip and how to correct for its possible occurrence in the future (p. 35). Thus, Marlatt leads the way in inviting social scientists and drug

treatment specialists to utilize metaphor and create relapse prevention models that go beyond disease conceptualizations. PSYCHOLOGICAL VULNERABILITY AND ENVIRONMENTAL STIMULI

The relapse prevention model presented in this paper is based on a rationale that appreciates the psychological vulnerability of patients who face conditioned environmental stimuli associated with prior cocaine usage. Psychological vulnerability in interaction with environmental stimuli represents a dynamic explanation of the high potential for relapse which cocaine dependent patients possess post detox. An additional central concept that explains the psychological vulnerability of patients is narcissism. The section below focuses on the role of narcissistic traits in cocaine patients’ personality functioning as it determines management of internal and external stimuli. The Predominance

of Narcissism

A predominance of narcissistic personality disturbance is attributed to drug users. Kleber and Gawin (1984) emphasize that cocaine serves narcissistic needs and helps patients cope with boredom, inner emptiness, and management of psychiatric disturbance. Pathological narcissism characterizes early stages of sobriety in the alcoholic and involves feelings of loneliness, boredom, and emptiness (Levin, 1987). Levin (1987) states that his views on the pathological narcissism of the newly sober alcoholic extend to other addictions. The patient is vulnerable, depressed, insecure, fragile, and perhaps exhilarated. Exhilaration represents euphoria and hope, but also the ego’s response to escape from a life-threatening situation. Euphoria is a manic defense against underlying depression and fear. While this defense may be adaptive, it increases vulnerability to internal and external dangers (pp. 219-220). Levin (1987) synthesizes the theories of Kohut (197 1, 1977) and Kemberg (1975, 1976) in describing the selfpsychology and functioning of the newly sober alcoholic. Characteristic pathological narcissism in early sobriety involves a cohesive but insecure self. Therapists may observe grandiosity of less than psychotic proportions, arrogance, isolation, and unrealistic goals. Levin also observes feelings of entitlement, need for omnipotent control, poor differentiation of self and object, and deficits in the self-regulating capacities of the ego. In addition, the ability to tolerate affective states is poor while massive anxiety easily emerges. These manifestations of the grandiose self may be deeply repressed or denied; a resultant facade of pseudo self-sufficiency, never smoothly integrated into a mature self, predominates (pp. 222-232).

Determinants

99

of Relapse

Levin (1987) also discusses borderline phenomena related to failure to securely integrate good and bad self and object representations into stable internal objects. This may also characterize psychological functioning during early stages of sobriety. The associated defenses of splitting, denial, primitive idealization, and projective identification are observed. However, narcissistic pathology predominants (pp. 233-234). Ritual, rigidity, and the need for omnipotent control are also observed by Levin (1987). They are characteristic of the grandiose self and are seen in a compulsivity. Compulsivity is a defense, a reaction formation, against the underlying impulsivity. Thus, obsessivecompulsive personality traits can characterize early sobriety (p. 240). Wallace (1987) discusses overreliance on splitting, self-inflation, and grandiosity as defenses against inner pain. This suggests the presence in a crack population of the kind of psychopathology Levin (1987) describes in alcoholics. The predominance of narcissism in patients attempting abstinence reveals a not-at-all surprising difficulty negotiating internal and external dangers. Massive anxiety and affective states represent internal dangers that are poorly managed. Thus, recurrent painful affective states are poorly regulated, contributing to self-medication strategies. A resultant vulnerability to external dangers also results when facades of pseudo self-sufficiency and unrealistic goal setting prevail. The investigation’s content analysis of actual patient relapse episodes attempts documentation of these processes. The way in which vulnerability to internal and external dangers plays a role in relapse may receive empirical verification. METHODS: MICROANALYSIS OF RELAPSE EPISODES Relapse episodes were content analyzed for a sample of crack-cocaine-dependent patients. A detailed description of methods follows. The Population For a two-year period (1986-1988) characterized by increasing admissions for cocaine dependence, 288 patients were treated for cocaine dependence on a specialized crack unit. Diagnosis of cocaine dependence followed DSM III-R criteria, justifying inpatient hospitalization. Most patients reported usage of the cocaine derivative “crack,” some “cooked up” their own freebase cocaine, while all were compulsive smokers. The total two-year population of 288 crack cocaine patients was 95% black, 7% hispanic, and less than 1% white. From the total population of cocaine-dependent patients, 12% (N = 35) returned for a second detox, comprising the population of the present study.

Table 1 summarizes demographic data on the sample under study. The sample is 94% black. Data on educational background indicated that 26% had some college education, 31% were high school graduates, and 43% were high school dropouts. Employment data revealed that 59% were unemployed while 40% had been employed within the past year. Welfare recipients constitute 14% of the sample. In the three-month period before their first detox, 23% had lost jobs, suggesting a pattern of crackcocaine-related decline in personal functioning. Many had had jobs paying between $25,000 and $30,000 annual salary; a full 20% had working-class or lowermiddle-income jobs. Consistent with crack related patterns of decline is the finding that 28.5% were homeless, entering the shelter system at some point within the previous year. Procedure: The Relapse Interview Marlatt’s (1985) discussion of results of microanalysis of relapse episodes refers to data obtained from

TABLE 1 Demographics (N = 35) Mean Background

Data

Patient Race and Sex Black Males Black Females White Males Other

n

%

Age

26 7

74.3 20 2.85 2.65

29.8 28.4 25 42

1

Level of Education College graduates 2 years college 1 year college High school/GED 12th-grade dropout 11 th-grade dropout 1 Oth-grade dropout Sth-grade dropout l

3 3 3 11 2 6 5 2 Black Males

Employment History Unemployed Worked past year Past low/mid work Currently employed Current mid inc work Lost job past 3 mos SSI disability Welfare Homeless Past Year l

3 learning disabled.

16 9 7 3

45.7 25.7 20 8.6

2

5.7

3 4 3

8.6 11.4 8.6

10

28.52

8.6 8.6 8.8 31.4 5.7 17.1 14.3 5.7 Black Females 4 3 2 -

1 2

11.4 8.6 5.7 -

2.85 5.7

Other

100

questionnaires that patients had completed. In this investigation, data arose from (a) observation of patients during clinical interviews and treatment for narcissistic psychopathology and (b) patient responses to a relapse interview. Patients entering detox a second time were treated by the same primary therapist from the first detox, unless extenuating circumstances prevailed, such as departure of the original therapist. All 35 patients in this sample saw the author in treatment during the first and second detox. A psychosocial update or clinical relapse interview occurred with returning patients. The interview focused on several key issues reducible to the following questions: 1. What happened post-detox? 2. What were your aftercare treatment plans? 3. Did you enter aftercare treatment? 4. What was aftercare treatment like for you? 5. When was the first time that you used drugs post detox? 6. What were the circumstances surrounding relapse? 7. What happened after you used drugs? 8. Why do you think you began using drugs again? 9. What has been your pattern of drug use? 10. What made you decide to seek a second detox? 11. What kind of drug-related problems have you had? 12. What are your current aftercare treatment plans? The clinical relapse interview helps the patient to analyze the relapse event and to grow by understanding the determinants of relapse. Frequently patients are able to utilize relapse education gained during the first detox to analyze what happened themselves. Guidelines are established for handling difficult circumstances in the future. Usually the best management plan for potential relapse situations involves therapeutic support in negotiating internal and external dangers. Thus, the importance of utilizing aftercare treatment is stressed and referrals are made for patients in light of their responses to question 12. Occasionally confrontation, education, or interpretation of patient denial is necessary in directing patients into appropriate treatment. Responses to question 9 indicate severity of drug use, extent of loss of control, and nature of a patient’s self-destructiveness; in combination with the mental status examination, these factors determine final treatment recommendations. The clinical relapse interview also focuses on responses to questions 10 and 11 for feelings of guilt, shame, and depression attending the experience of relapse and further personal decline. Interventions stress the adaptive strengths of patients who seek help through a second detox and the fact that patients can learn new knowledge about personal ,challenges to abstinence. Supportive psychotherapy throughout detox addresses painful issues such as loss of family sup-

B. C. Wallace port, employment, child custody, and housing. In addition, patients often discuss embarrassment on the unit, perceiving that staff may be negatively evaluating them for having relapsed. Patient responses in the clinical relapse interview to question 5 are analyzed for the period of time it took to relapse. Responses to questions 1 through 8 (excluding 5) are content analyzed for determinants of relapse. In addition, clinical observations of patients’ use of the defense of denial and for narcissistic psychopathology are coded. RESULTS The time from discharge to relapse and results of content analysis of relapse episodes follow in this section. Findings establish a typology of psychological and environmental determinants of relapse. Time to Relapse Results for time to relapse indicate 31.4% relapse within a week, 24.3% relapse between 2 weeks to a month, 20% relapse between 60 to 90 days, 8.6% relapse between 3.5 to 4.5 months, and 5.7% relapse between 6 to 7 months, totalling 94.3% before 6 months expire. Within the first 90 days post detox, 76% relapse. TYPOLOGY OF PSYCHOLOGICAL AND ENVIRONMENTAL DETERMINANTS OF RELAPSE Content analysis of patient responses and clinical observations reveals that the primary determinants of relapse fall into a psychological/personality domain and an environmental/interpersonal domain. Several categories within the psychological and environmental domains emerge. The relapse categories and results are in Table 2. The Psychological/Personality

Domain

The categories of the psychological/personality domain classify into five types the internal factors that relate to relapse. These internal factors may involve recurrent, painful affective states (Khantzian, 1985), use of psychological defenses, and personality characteristics of individuals. 1. Painful Emotional State. A painful emotional state can be, for example, a recurrent, painful affective state, feelings of emptiness, boredom, loneliness, depression, frustration, or anger. In the sample, the majority (40%) of relapses within the psychological domain involve a painful emotional state.

101

Determinants of ReIapse TABLE 2 Psychologlcal and Environmental Determinants

of Relapse

n

%

14 10

40 28.5

13 3 10 4 2

37.14 8.57 28.57 11.42 5.7

Environmental/Interpersonal Domain Environmental Stimuli Interpersonal Stress Escalated to drug of choice Hard Test Handling Money Homeless Factor/No Family Support Therapeutic Community Shortcoming

12 12 5 4 5 7

34.28 24.38 14.28 11.42 14.28 20

Multideterminants of Relapse 1 Factor only Psychological only Environmental only Combination of 2 Combination of 3 Combination of 4 Total Involving Multideterminants

5 3 6 13 14 3 30

14.28 8.57 17.14 37.13 40 8.57 85.7

Typology

and Multideterminants

Psychological/Personality Domain Painful Emotional State Narcissistic Denial/Denial Fails to Enter Arranged Aftercare Treatment = Therapeutic Community = Outpatient Treatment Clinic Refused Aftercare Treatment Drug Craving

Most Common Combinations Painful Emotional State & Interpersonal Stress Narciss. Denial & Fails Enter/Refuses Aftc. TX

7

20

8

22.8

Denial leads to the belief that they do not need to go, even though they agreed during detox. Overconfidence, manic defenses, and grandiosity fuel this and other unrealistic beliefs, impacting formulation of poorly constructed goals. Patients frequently state, “I figured I could do it on my own” or “I decided I didn’t need it.” This is the second most common determinant of relapse (37.14%). 4. Refused Aftercare Treatment. Refusal of aftercare treatment occurs during detox when a patient outrightly refuses aftercare treatment plans. Grandiosity prevents assimilation of education. “It doesn’t apply to me, my problem isn’t that bad” is frequently heard along with “I can do it on my own.” Feelings of superiority over other patients and staff offering professional recommendations justifies refusing aftercare treatment for some patients. This refusal is a factor in 11.42% of relapses. 5. Drug Craving. Drug craving often follows vivid dreams or olfactory stimulation from cigarette smoke, or is recurrent as an internal event. As an internal experience often impulsively followed by a drive to seek drugs, it is a category within the psychological domain. Drug craving operates in 5.7% of relapses. The Environmental/Interpersonal

Narcissistic Denial/Denial. This category reflects use of a psychoanalytic approach (Wallace, 1987; Levin, 1987) in the microanalysis of relapse episodes. Narcissim exacerbates denial, as denial is more commonly understood. Accordingly, a “narcissistic denial” permits overconfidence, unrealistic goal setting, and naive courting of external danger. Primitive distortion of reality, where patients’ behavior reflects assuming that impulses do not exist, is all the more dangerous where narcissism is also a factor. Reality testing is impaired and patients feel they can accomplish anything. Attitudes reflect a manic defense and exuberance (Levin, 1987). More typically understood denial is also observed in patients. The category does not distinguish between narcissistic denial and commonly understood denial. However, 22% of relapses involve narcissistic denial and 5.7% involve denial, totalling 28.5%.

2.

3. Failure to Enter Arranged Aftercare Treatment. Closely related to narcissistic denial/denial is a failure to enter arranged aftercare treatment. Usually a therapeutic community (TC) appointment or an outpatient treatment (OPT) appointment is made for patients.

Domain

The environmental/interpersonal domain includes six categories classifying external determinants of relapse. External dangers are environmental and interpersonal stimuli that are poorly managed by psychologically vulnerable patients. The categories are below. 1. Environmental Stimuli of People, Places, Drugs. Patients encounter old conditioned stimuli in the environment and then relapse. Stimuli repeatedly associated with drug use include people, places, and drugs. Compulsive cocaine using is easily triggered by reinforcing cues that become associated with the drugs’ rewarding effects (Stone et al., 1984, p. 36). These cues are external factors that constitute external dangers, given their power to evoke conditioned responses. Relapse episodes involved this factor 34.38% of the time. This was the most frequently cited category of the environmental/interpersonal domain. 2. Interpersonal Stress. Interpersonal stress usually occurs with family or loved ones. It frequently involves the ambivalence others feel toward patients. These individuals, from whom patients have stolen, are disappointed in patients and have lost trust in patients. Patients are usually proud of completing detox and do not expect expressions of hostility, persisting suspiciousness, and lack of trust. Interpersonal

102

stress is often followed by a painful emotional state. Interpersonal stress operated in 34.28% of relapses. 3. Escalaiion to Drug of Choice. Use of alcohol, marijuana, and intranasal cocaine led to compulsive use of crack cocaine in 14.28% of relapse episodes. This escalation to drug of choice occurred after celebrations (Christmas, New Years, and family religious ceremony) for three cases in the sample. Holidays are challenging external events that vulnerable patients may handle poorly, feeling pressure to sample alcohol. Escalation from just one sampling of alcohol or cocaine to compulsive crack cocaine smoking occurs. One patient escalated from intranasal cocaine to compulsive freebase smoking. 4. Hard Test Handling Money. Hard tests are situations vulnerable patients have difficulty managing. The most common difficult situation involves handling sums of money. Because of the repeated association between having money and spending most, if not all, of it on drugs, possession of money is a hard test that vulnerable patients frequently fail; 11.42% of relapses involved this factor. 5. Homeless Factor/No Family Support. Being homeless usually follows loss of family support. Relatives and lovers eventually respond to theft and loss of trust in patients with dismissal of patients from their homes. Homelessness and lack of family support were determinants of relapse in 14.28% of the relapse episodes. Homelessness usually means involvement with the shelter system. Patients describe shelters as places where drugs are sold and rampantly used by residents and by some staff. Also, returning to a shelter while waiting for a therapeutic community bed may mean automatic exposure to old conditioned stimuli in the environment or painful feelings such as depression. Homelessness and lack of family support dictate a therapeutic community as the only logical aftercare treatment, but a waiting list of a few days to a few weeks for the homeless can be too much of a challenge for vulnerable patients to manage. Thus, homelessness/no family support is frequently a determinant of relapse. 6. Therapeutic Community Shortcoming. A long waiting list or delay in entering a therapeutic community is one shortcoming that therapeutic communities possess. Domiciled patients experience waiting lists of 4 to 8 weeks. Policies of refusing admittance to patients on psychiatric medication and with medical problems also represent shortcomings of therapeutic communities. Therapeutic communities generally lack adequate psychiatric and medical staffing. However, without such staff, many clients are turned away. In the sample, three patients on antipsychotic medication,

B. C. Wallace three with medical problems, and one on a waiting list experienced relapse where therapeutic community shortcomings are a determining factor, totaling 20% of relapses. Multideterminants of Relapse Only 14.28% of relapses involved only one factor. Usually, both psychological/personality and environmental/interpersonal domains are involved. However, for 8.57(r/oof patients only psychological determinants of relapse prevailed, and for 17.14% only environmental determinants operated. A combination of three determinants of relapse is most common (40%), while 85.7% of relapses involved multideterminants. The most common combination of determinants involves painful emotional states from the psychological domain and interpersonal stress from the environmental domain (20%). However, examining both failure to enter arranged aftercare treatment and refusal of aftercare treatment together, these occurred in combination with narcissistic denial 22.8% of the time. Thus, microanalysis of relapse episodes reveals the multideterminants of relapse. The psychological and environmental determinants of relapse highlight the complexity of relapse as an event involving the subtle interaction of a number of factors. ILLUSTRATIVE CASE EXAMPLES Case examples illuminate typical patient experience of relapse post detox. The typology of psychological and environmental determinants arose from microanalysis of the kind of data presented in the case examples. Case of US US (not the patient’s real initials) is a 35year-old black female. She is a graduate of an elitist northeastern university with a work history in a municipal service industry, which paid $25,000 annually. During her first detox, she uses primarily defenses of intellectualization in interpersonal interactions with staff and competes with the psychology rehab therapist who directs writing and drama workshops. During the first detox, she feels superior to the staff and to the lower income patients. In the clinical relapse interview, US devalues this first detox as a “joke.” She relapses one week post detox. US has two daughters, ages 8 and 10, moved out to distant relatives by a concerned family member three months prior to the second detox because of US’s deterioration in functioning. At the same time, she is also asked to take a leave of absence from work after sleeping on the job from crack-related exhaustion after all night binges. She enters the second detox one year after the first. During the second detox, themes in therapy deal with separation from her children. US engages in splitting between narcissistic rage at staff and relatives who pushed for

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of Relapse

her hospitalization, and painful affects of depression and abandonment related to her children. Both states have longstanding roots in a history of less than ideal object relations. Separation from her children intensifies feelings of abandonment felt after her mother’s death many years before. US was very dependent upon her mother, but split-off all painful affect at the time of her death, describing a mask of control worn throughout her mother’s funeral rites and never betrayed thereafter. Intranasal cocaine use characterizes this former period of denial of grief. On the other hand, denial and narcissism have roots in a dysfunctional family where father’s alcoholism is a hushed family affair that occurs behind closed doors out of the sight of the children, while a close dependency on mother is fostered. Separation from her husband several years ago buoyed self-esteem and a sense of pseudo self-sufficiency. US didn’t need him because she “did everything” herself anyway, reflecting her grandiosity. The relapse interview indicates that US failed to enter her arranged outpatient appointment. Grandiosity and feelings of superiority prevent entrance into treatment. Narcissistic denial is evidenced by failure to acknowledge severity of her problem while dangers likely to lead to relapse are confidently courted. Relapse occurs upon resuming a relationship with a drug-using boyfriend, despite articulated plans to discontinue this relationship in response to education she receives on this topic during the first detox. A visit to his apartment one week post detox leads to resumption of regular crack usage.

Analysis of Case Example The case illustrates the role of narcissistic traits in relapse and how narcissism exacerbates denial. Her denial of the severity of her addiction and a strong motive to continue self-medicating levels of pain and depression that keep rising-especially after her children are moved away from her -result in an entire year elapsing between first and second detoxes. US also utilizes borderline phenomena of splitting between an enraged, independent, aloof, and grandiose state and a tearful, dependent, abandoned, anxious, and depressed state. The underlying painful affects and use of manic defenses contributes to resuming drug use. The case illustrates the interactive nature of the multiple determinants of relapse. Narcissistic denial, failure to attend arranged aftercare treatment, and return to environmental stimuli of people, places, and drugs serve as multideterminants of relapse. US’s psychological vulnerability contributes to poor management of the challenge of encountering environmental stimuli of a drug-using boyfriend and his apartment where they previously used drugs. Psychological vulnerability also contributes to poor regulation of internal recurrent painful affective states of depression and loneliness. Seeking out her boyfriend’s company may have been a response to feelings of loneliness, although US does not express this possibility. After her second detox, US enters a residential

therapeutic community. period of approximately

She experiences 8 weeks.

a waiting

Case of EJ EJ (not the patient’s real initials) is a 30-year-old black male who dropped out of 1lth grade but holds a $29,000-a-year job in a federal service industry. EJ enters his first detox depressed and dismayed over loss of his wife (also a crack user), his job, his furnished apartment, and the dissolution of his family of five children. The bureau of child welfare placed 2 children in a foster home, 2 children with a relative (also a crack user), and 1 child with another relative. EJ lives alone in an apartment in a crack-infested tenement where EJ occasionally deals drugs. Numerous females narcissistically mirror EJ. They frequently visit him, get high, and use freely offered advice to manage their affairs. EJ recreates his large family with these women, acting as a central authority figure in these women’s lives. During both detoxes, EJ is polite but similary organizes the patient community, recreating a family setting desperately missed. His efforts at community organization on the detox unit subtly imply grandiose superiority to the treatment structure offered on the unit. EJ does not directly refuse aftercare treatment during his first detox, stating he has his own (superior) plans to return to an outpatient clinic where an intake interview has already occurred. He is confident that he will stay drug free, having recently promised one of his children they will live with him soon. This pseudo self-sufficiency contributes to failure to enter aftercare treatment. EJ stays drug free for one month by staying in isolation in his apartment and working for himself in construction. Feelings of loneliness and social isolation are difficult to manage. Shame over his personal deterioration prevents contact with his mother and family of origin who have not been seen in over a year. EJ begins to smell crack rising from a downstairs apartment in his crack infested tenement. In response to this stimuli, he soon resumes compulsive smoking. Shocked and dismayed by a relapse he felt sure would not occur, EJ seeks immediate treatment through a second detox six weeks after his first detox after a long binge in which he loses all control.

Analysis of Case Example EJ exemplifies manifestation of a facade of pseudo self-sufficiency when the grandiose self is denied. EJ’s need for omnipotent control and setting of unrealistic goals betrays narcissistic personality disturbance. His overconfidence does not eliminate underlying depression and loneliness. He states, “Things have snowballed, and everything is heading downhill.” A compulsivity in recreating the structure and organization of his old family, where he is in charge is seen in the tenement and in detox. Failure to attend aftercare treatment, painful emotional states (loneliness, depression), and environmental stimuli (crack smoke/ fumes) combine as determinants of relapse.

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B. C. Wallace DISCUSSION

Content analysis of relapse episodes establishes categories of the typology with psychological/personality and environmental/interpersonal domains. The research findings empirically validate the existence of a common mechanism underlying relapse for cocaine patients. Of the six factors that arise from analysis of clinicians’ approaches to outpatient treatment of cocaine abuse (Rosecran & Spitz; 1987; Smith & Wesson, 1985; Stone et al., 1984; Washton & Gold, 1987), all but one were empirically validated. The role of drug craving, environmental cues, denial, being around/ using drugs, and painful affective states in determining relapse correspond to categories of the typology. Selective recall of cocaine euphoria was not a research finding in this sample. However, it may be an intervening variable following the dysphoria of a painful affective state or drug craving and actual use of drugs, remaining undetectable in patient responses to the relapse interview questions. Future research should refine questioning to detect action of the variable of recall of cocaine euphoria. Beyond the research sample, recall of cocaine euphoria does correspond to the author’s clinical observation of patient experience. By examining cocaine dependence in an inpatient hospital population, this paper extends the body of literature on relapse phenomena. In addition, this empirical approach extends the data compiled by Marlatt on addiction to alcohol, heroin, gambling, and overeating (1985) by examining addiction to cocaine. Time-to-relapse findings validate earlier research that two-thirds of those who relapse do so within the first 90 days of attempted abstinence (Marlatt, 1985). In this study, time to relapse results show that 76% relapse within the first 90 days post detox. In fact, these compulsive crack cocaine smokers relapse at a higher rate than those alcoholics, heroin addicts, gamblers, and overeaters in Marlatt’s (1985) sample. These findings validate clinical wisdom that the initial threeto six-month period of attempted abstinence is the time in which relapse is most likely to occur for cocaine abusers (Stone, et al., 1984), since 94.3% of the relapses in the study occur before a six-month period expires. These results reveal the early stages of attempted abstinence to be a precarious period of vulnerability that must be carefully navigated by patients. Microanalysis of relapse episodes supports the observations of Levin (1987). Narcissism, associated defensive functioning, and poor management of internal affective states is a predominant factor in relapse in early stages of attempted abstinence. The psychological/personality domain covers these factors and responses that are internal. Manic defenses and denial are, for example, internal defensive processes. On the other hand, the typology’s environmental/interper-

sonal domain covers patient responses to external events. The two domains are intimately interrelated. For example, the use of defenses such as mania or denial impact reality testing and determine one’s approach to environmental and interpersonal stimuli. Thus, the typology and findings are compelling in their support of the relapse prevention model based on the dynamic interaction of psychological vulnerability with environmental stimuli. Major findings are that relapse follows a painful emotional state (40%), failure to enter arranged aftercare treatment (37Vo), and encounters with conditioned environmental stimuli (34Oro); 85% involve multideterminants. The category and finding of the prevalence of painful emotional states as determinants in relapse supports Marlatt’s (1985) finding that 35% of relapses involve a negative emotion. Together, these findings empirically justify Khantzian’s (1985) assertions that patients self-medicate recurrent painful affective states. The finding that 37% of relapses involve failure to enter arranged aftercare treatment reflects the importance of patients receiving therapeutic support to address their psychological vulnerability. In treatment, patients can receive assistance in managing recurrent painful affective states, interpersonal stress, and challenging environmental stimuli. Results showing 34.28% of relapses involve encounters with environmental stimuli of people, places, and drugs are reminiscent of Marlatt’s (1985) category of direct or indirect social pressures (20%). Encounters with these external influences and factors are often too challenging for psychologically vulnerable patients to manage successfully. Another significant finding involves the fact that 24.38% of relapses involve interpersonal stress as a determinant. This is similar to Marlatt’s (1985) interpersonal conflict that was a determinant in 16% of relapses. Also of note is the finding that 14.28% of relapses involve escalation to drug of choice (crack) after use of alcohol or intranasal cocaine. This finding supports clinical wisdom, warning against use of alcohol and marijuana and testing of control with cocaine (Smith & Wesson, 1985; Washton, 1987). Another important finding is that 20% of relapses involve therapeutic community shortcomings. These involve long waiting lists, rejection of patients on psychiatric medication and of those with medical problems. This finding directly relates to the research of Rainone and coworkers (1988). They report on the psychiatric and medical problems that characterize crack patients in drug free residential programs who were able to meet these stringent admission criteria. They recommend addition of medical and psychiatric staff to manage these patient problems. The presence of sufficient staff and modifications in therapeutic

Determinants of Relapse

communities may permit admitting patients on antipsychotic medication. Waiting lists can be remedied by creation of new specialized crack residences. The problem of long waiting lists highlights the special problems that patients who have lost jobs, insurance benefits, and financial resources face when seeking treatment post detox. Compulsive crack cocaine smokers readily deteriorate to such levels (including homelessness). Patients must enter therapeutic communities instead of private rehabilitation centers. Long waiting lists necessitate recommending that patients attend narcotics or cocaine anonymous meetings daily until entrance into a residential program. The role of psychological and environmental determinants, their interaction, and the complexity of relapse is illustrated through case examples. The finding that 85.7% of relapses involve multideterminants is dramatically illustrated in the case examples as is the predominance of narcissistic psychopathology in early stages of attempted abstinence in cocaine users. Relapse in compulsive freebase cocaine smokers is empirically shown to be a complex process. The complexity of relapse and evidence of its multideterminants suggests the need for approaches to relapse that go beyond disease model conceptualizations of internal causation and reactivation of an underlying disease state.

CONCLUSION

The paper presents a review of contemporary approaches to relapse phenomena in the treatment of cocaine abuse. An analysis of these approaches identifies common mechanisms underlying relapse in outpatient treatment of cocaine abuse. What emerges is a striking similarity in observations and technical interventions among the clinicians’ approaches reviewed. By following Marlatt (1985) in a microanalysis of relapse episodes for 35 patients who return a second time to detox after relapsing, the research empirically validates existence of a common mechanism underlying relapse in crack cocaine patients. Results establish a typology of psychological/personality and environmental/interpersonal determinants of relapse. Case examples illustrate the kind of data content analyzed, the role of multideterminants, and the predominance of narcissistic psychopathology. Research findings highlight the fact that the initial period of attempted abstinence is wrought with peril for psychologically vulnerable patients who face challenging environmental stimuli. Clinicians must recognize the nature of challenging internal and external dangers patients will encounter as they attempt abstinence from a seductive drug such as crack cocaine that has been smoked compulsively. Perhaps of most import is the finding that relapse

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is quite likely when patients fail to enter treatment after initial detoxification. This highlights the crucial role of being engaged in treatment as a strategy for maintaining abstinence from cocaine. Relapse prevention models (Marlatt & Gordon, 1985; Miller 8~ Pechacek, 1987; Wallace, 1989) that appreciate and address the role of multideterminants of relapseperhaps going beyond the disease model-may improve clinical efficacy and treatment outcomes. The limitations of the research are that the sample was small (N = 35) and no interrater reliability in content analysis of relapse episodes is available. Future research could benefit by using a second rater for content analysis to provide interrater reliability for the categories which arose from microanalysis. Future research must empirically assess relapse rates for all patients -not only those patients who return for a second detox. Efforts to document treatment outcomes (Washton, 1987) must expand. An advantage over utilizing questionnaires for microanalysis of relapse episodes (Marlatt, 1985) exists in the present approach, which uses clinical interview data and incorporates clinical observation. Categories of narcissistic denial/denial arise from use of clinical observation, permitting documentation of the predominance of narcissistic psychopathology during early stages of attempted abstinence in the cocaine dependent. In order to be able to work effectively with patients, the self-psychology of patients and the role of narcissistic psychopathology must be appreciated by clinicians. Management of painful affective states, denial, and narcissistic psychopathology require psychodynamic technique. The logic of utilizing multifaceted clinical approaches with cocaine patients is supported by the major findings of the study. Encounters with conditioned environmental stimuli and interpersonal stress require behavioral, cognitive, educational, and self-control techniques. Education must prepare patients “to anticipate the likelihood of relapse, so that they may engage in preventive alternative behavior” (Marlatt, 1985, p. 33). The value of the paper is the creation of the typology of psychological and environmental determinants of relapse which validates a common mechanism underlying relapse and directs treatment interventions by predicting probable relapse situations. The typology is a key tool in the clinical work of preparing patients for successful management of various internal and external challenges that could lead to relapse. Beyond clinicians’ preferences for particular treatment orientations and philosophies on disease models is a vital need for effective clinical interventions for a growing population of compulsive cocaine users (Siegel, 1985). Clinical appreciation of the subtle interaction of the multideterminants of relapse may prove an important element of successful treatment strategies. It is hoped

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that this paper represents an important step in developing a body of properly trained professionals who possess the integrated theory and multifaceted clinical technique necessary for efficacious treatment of cocaine patients.

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