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Relapse precipitants and behavioral marital therapy
Addlctive
Pergamon
Behaviors, Vol. 20, No. 3. pp. 383-393. 1995 Copyright C 1995 Elsevier Science Ltd PrInted in the USA. All rights reserved
0306-4603195 59.50 + .OO
0306-4603(94)00079-4
RELAPSE PRECIPITANTS AND BEHAVIORAL MARITAL THERAPY STEPHEN
A. MAISTO
VA Medical Center, Pittsburgh, and University of Pittsburgh Medical School
JAMES R. MCKAY University of Pennsylvania
TIMOTHY
J. O’FARRELL
VA Medical Center, Brockton. and Harvard Medical School Abstract - The major purpose of this study was to provide descriptive data on the first relapse episodes and reasons for terminating relapses of subjects who completed a course of behavioral marital therapy (BMT) for alcoholism. Another aim of the study was to compare the relapse episodes and relapse terminations of subjects who received BMT with or without additional relapse prevention (RP) treatment for one year. The subjects were selected from a sample of 74 men who began an outpatient Department of Veterans Affairs BMT program. These men were evaluated pre- and post-BMT, and at 3, 6. 9. and I2 months after completing BMT. A total of 31 subjects relapsed at least once after they began BMT. The data showed that these men tended to report more than one situational or personal precipitant of their first relapses. Similarly, they tended to report more than one reason for ending their relapse episodes. Comparison of the subjects assigned to the two RP conditions revealed an equal number (12) of relapse episodes, but RP subjects’ relapse\ tended to last fewer days than did no-RP subjects’. The consistency of these findings with previous research on cognitive-behavioral models of relapse and the implicationa of these findings for the concept of high-risk situation, are discussed.
Clinicians have known for many years that relapse is a serious and persistent problem in the treatment of alcohol and other drug use disorders. Systematic research on the problem of relapse received a great stimulus by Marlatt and colleagues’ (Marlatt & Gordon, 1985) cognitive behavioral model of the relapse process. A central construct in Marlatt’s and other cognitive-behavioral models is the “high-risk situation.” This concerns factors internal (e.g., mood) or external (e.g., taverns) to the person that are associated with the past consumption of alcohol or other drugs at undesired levels. Accordingly, high-risk situations occasion a higher likelihood of undesired substance use. People who are trying to maintain changes in their substance use require behavioral skills or other resources to cope with high risk situations without abusing alcohol or other drugs. Our initial research on relapse following behavioral marital therapy (BMT) for alcoholism was heavily influenced by Marlatt’s model (Connors. O’Farrell. & Pelcovits, 1988; Maisto, O’Farrell, Connors, McKay, & Pelcovits, 1988; Maisto, O’Farrell, McKay, Connors, & Pelcovits, 1988; McKay, O’Farrell, Maisto, Connors, & Funder, 1989). These studies were based on reports by male patients and their spouses about the patient’s two most recent relapse episodes. The questions This research was supported by the Department of Veterans Affair\ and by grant R01 AA08637 from the National Institute on Alcohol Abuse and Alcoholism to the third author. Requestsfor reprints should be sent to Stephen A. Maisto. Ph.D.. Department of Psychology. Syrdcuse University, 430 Huntington Hall. Syracuse. NY 13244. 383
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about relapse precipitants were open-ended and replicated the questions that Marlatt and colleagues reported that they used in their early studies of relapse (Marlatt & Gordon, 1980). In our first studies of relapse, subjects were interviewed two years following their participation in a clinical trial of group BMT for alcoholism (O’Farrell, Cutter, Choquette, Floyd, & Bayog, 1992; O’Farrell, Cutter, & Floyd, 1985). The results of this research were the bases of the current series of studies of relapse and BMT. Data were collected from male patients and their spouses or partners who participated in an outpatient BMT program for alcoholism. In a randomized controlled clinical trial of relapse prevention (RP) following BMT (see O’Farrell, Choquette, Cutter, Brown, & McCourt, 1993) half of these couples then received aftercare in the form of individual BMT sessions over the course of one year, and half did not. This new series of studies on relapse feature several major improvements over our first efforts. First, subjects were assessed on a number of variables before beginning and after completing the BMT program and then multiple times over the subsequent 30 months. The RP treatment occurred in the first 12 of these 30 months post-BMT. Therefore, the findings reported in this paper are part of a prospective follow-up data base, compared to the long-term retrospective data from our first studies. Another major improvement is use of the Relapse Questionnaire (Maisto, McKay, & O’Farrell, 1985). This questionnaire represents an advance over previous relapse assessment techniques in several ways. Subjects indicate which of a list of possible relapse precipitants had any influence at all on their taking the first drink and they rate the degree of that influence. This information is provided in addition to openended questions about relapse precipitants, probably the most common method in this area of research. Therefore, the Relapse Questionnaire provides more quantitative as well as qualitative data on relapse precipitants. In the Relapse Questionnaire the same format and procedures are followed in obtaining information on reasons for terminating relapse episodes. Furthermore, subjects are free to report more than one precipitant or termination factor for a given relapse episode. The present study had two major purposes. The first was to present descriptive analyses of the quantitative data on the degree of influence of relapse precipitants and on reasons for terminating relapse episodes occurring in the first 12 months of follow-up. Part of this aim was to provide an initial evaluation of a more complex concept of high-risk situation, made possible by the fact that subjects were not restricted in the number of relapse precipitants they reported. In their early studies of relapse that were the bases of their cognitive-behavioral model, Marlatt and colleagues used a “hierarchical” method of coding in which only one main precipitant was coded for each relapse (Marlatt & Gordon, 1985). Such measurement procedures may have oversimplified the concept of high-risk situation, however, as some research suggests that high-risk situations may often involve more than one factor (Heather & Stallard, 1989; Zywiak, Westerberg, Connors, Maisto, & Waldron, 1994). The data on patients’ reasons for ending relapse episodes will provide information on a clinically important topic to which researchers have given little attention (Amodeo, Kurtz, & Cutter, 1992). The second objective of this paper was to compare subjects who received BMT with or without additional RP on the number of relapse episodes that occurred, duration of relapse events, reported relapse precipitants, and reported reasons for terminating relapse episodes. It was expected that RP subjects would report fewer and briefer relapse episodes than no-RP subjects. The analyses presented in this
Relapse precipitants
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paper concern data collected at the post-BMT assessment months, which spanned the time of the RP treatment.
and for the subsequent
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12
METHOD
Subjects
The subjects were selected from a sample of 74 men who were in an outpatient Department of Veterans Affairs behavioral marital therapy alcohol treatment program. They met the following criteria for inclusion in the study: (a) aged 25 to 60; (b) married at least one year or living together in a stable common-law relationship for at least 3 years; (c) met DSM-III-R criteria for alcohol abuse or dependence; (d) scored 2 7 on the Michigan Alcoholism Screening Test (MAST; Selzer, 1971); (e) consumed alcohol in the 120 days prior to initial assessment; and (f) accepted the goal of abstinence from alcohol or nonprescribed drugs at least for the duration of the treatment. Criteria for exclusion were: (a) wife or partner also abused alcohol and had been abstinent for less than six months; (b) either spouse met DSM-III-R criteria for psychoactive substance use disorder (other than alcohol) in the past 6 months; (c) either spouse met DSM-III-R criteria for schizophrenia, delusional (paranoid) disorder, bipolar disorder, major depression, other psychotic disorder, or borderline personality disorder; and (d) couple were separated and unwilling to reconcile for the project. Subjects who provided data on their relapse episodes (n = 3 1) ranged in age from 26 to 56 (m = 41.30, SD = 8.04), all were White, and 76% were employed full-time. The sample averaged 12.86 (SD = 2.23) years of education, 13.9 (SD = 10.4) years of problem drinking, MAST scores of 34.90 (range 11-51, SD = 11.45), and Alcohol Dependence Scale (Skinner & Allen, 1982) scores of 18.06 (range 2-44, SD = 10.64). Procedure Primary treatment.
The BMT program consisted of 6 to 8 weekly pregroup sessions conducted conjointly with each couple and 10 weekly BMT couples group sessions. The BMT treatment package, which was designed to promote sobriety, positive activities, and better communication, is described in detail elsewhere (O’Farrell, 1993a). One week after the last BMT session, couples were randomly assigned either to receive or not to receive further treatment in the form of relapse prevention sessions. The one-year follow-up began at this point. Of the 74 couples who began the BMT groups, 64 attended at least five BMT sessions and completed the post-BMT assessments. Seven couples assigned to the RP condition either refused the additional treatment (n = 1) or discontinued the sessions very quickly (n = 6). Efforts were made to replace these dropouts with subsequent random assignments, with the result that 30 subjects were randomly assigned to the RP condition and 29 subjects to the no-RP group. There were no significant differences between subjects in the two groups on demographic and alcohol-related variables (see O’Farrell et al., 1993). RP intervention. Couples in the RP condition were scheduled to receive fifteen 50to 75minute conjoint sessions over a course of 12 months. The RP sessions had three major purposes: (a) to maintain marital and drinking improvements achieved in BMT, (b) to work on unresolved or newly emerged marital and drinking issues, and (c) to develop and rehearse a cognitive/behavioral relapse prevention plan that was
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focused on identifying high-risk situations and early warning signs for relapse, as described by Marlatt and Gordon (1985). A full description of the RP intervention is found in O’Farrell (1993b). Assessment of relapse episodes. At the end of the BMT program and at the 3-, 6-, 9-, and 12-month follow-ups, patients and partners provided information on the patients’ drinking behavior over the preceding 90 days. Time-line follow-back techniques were used to gather data on drinking behavior. These techniques have been shown to be highly effective in obtaining self-reports of daily drinking behavior with a high degree of reliability and accuracy (Sobell & Sobell, 1992). If, based on the time-line data, the patient experienced any relapse episodes during the preceding follow-up period, the Relapse Questionnaire was administered to both the patient and his partner. Consistent with our previous research, relapse was defined as a period of one day or more in which any drinking occurred, surrounded by 2 weeks or more of abstinence. When reviewing the relapse data it is important to keep in mind one consequence of this definition. It is possible that a relapse would not be recorded for a follow-up interval even if a subject were drinking during the entire time that it covers. For example, a subject could begin a relapse during the first follow-up interval and then continue drinking throughout the second interval. Nevertheless, because of this definition, a relapse would be recorded for the first interval but not for the second. Of the 74 subjects in the study, 31 had relapsed at some point during the BMT program or during the first 12 months of the follow-up and completed the Relapse Questionnaire. Some of these subjects had relapses in more than one period; in these cases, the first relapse to occur was retained for analysis.’ Relapse
Questionnaire
The Relapse Questionnaire (Maisto et al., 1985) is a IS-minute structured interview that is divided into three sections. In the first section, subjects provide information about the period of time in which the relapse occurred and the number of light and heavy drinking days during the relapse. In the second section, subjects indicate which of 6 situational factors and 8 personal factors were involved in the onset of their relapse episodes. This distinction between situational and personal factors was originally based in Marlatt and colleagues’ (Marlatt & Gordon, 1985) typology of relapse precipitants. Factors implicated in the relapse are then rated on a scale of 1 (small degree) to 5 (great degree), according to the degree of influence subjects perceive the factor had in initiating the relapse. If a subject reports that a factor was not involved in a relapse, he is assigned a score of zero for that factor. Conceptually, it was expected that there would be low to moderate correlations within and between situational and personal factor items in the Relapse Questionnaire. This hypothesis stemmed from the idea of the specificity of high-risk situations. In fact, based on the degree of influence data, Cronbach’s alpha for the situational factors (excluding the “other” item was .50, and for the personal factors (also excluding the “other” item) it was .47. Cronbach’s alpha for the 12 precipitant items (excluding the two “other” items) was .66. These findings were based on the first relapses of 31 subjects in the sample, as reported below. ‘In seven cases in which a subject relapse was retained for analysis.
had a relapse
during
BMT and another
during
the follow-up,
the latter
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In the third section of the Relapse Questionnaire, subjects indicate which of 11 factors led them to terminate their relapse episode. The factors that led to the end of the episode are then rated on a scale of 1 to 5, again according to the degree of influence subjects perceive the factor had in ending the drinking episode. RESULTS
Occurrence
of relapse
As noted, 31 of the 74 patients relapsed at least once following their beginning the primary BMT program and completed the Relapse Questionnaire. A total of 51 relapse episodes were reported by these 31 subjects to have occurred either during primary BMT or over the 12 months of follow-up. The relapse episodes lasted from 1 to 92 days. First relapses (N = 31), which were the bases of statistical analyses reported in this paper, averaged 14.3 days. A total of four of these episodes were reported to occur during the primary BMT treatment, ten during the first 3 months of the follow-up, seven during the next 3 months of the follow-up, and ten during months 7-12 of the follow-up. Relapse precipitants
Table 1 presents a list of the situational and personal relapse precipitants included in the Relapse Questionnaire, the number of subjects who indicated that a precipitant had any influence at all for their first relapse, and the mean influence rating for a respective precipitant reported by those latter subjects. As Table 1 suggests, subjects tended to perceive that more than one precipitant contributed to their relapse episodes. The mean number of situational influences reported was 1.97 (n = 31; range O-6), and the mean number of personal influences reported was 3.79 (n = 29, range l-8). The mean total number of precipitants reported was 5.45 (n = 29). Table 1 also shows that when subjects perceived that a factor did contribute to a relapse they tended to rate its degree of influence as at least moderate. Table I, Number of subjects indicating a precipitant contributed to beginning drinking. and mean degree of influence of each precipitant they reported Relapse precipitant Situational Wife Other family Other people Someone offered a drink Alcohol available Other situational Personal Feeling good Feeling angry Feeling down Feeling uptight Desire to drink or get high Let down guard about alcohol Feel could control drinking Other personal/psychological
n
No. of subjects
Mean influence
31 31 31 31 31 31
13 7 II 9 15 6
4.1 4.0 3.4 2.6 3.8 4.3
30 30 30 30 29 29 29 30
12 13 10 16 17 22 16 4
3.8 4.2 4.2 4.1 4.3 4.4 4.3 2.8
Note. Thirty-one relapse episodes were included in the analyses. Influence was rated on a 1 (small influence) to 5 (great influence) Likert-type scale. The number of subjects reporting about relapse precipitants and their influences vary because of missing data. Mean values are based on the numbers of subjects who reported tha a precipitant had any influence at all.
S. A. MAISTO et al.
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100 r 90 80 70 60 50 40 30 20 -
L
10
0’ GE’
OTHER
ALCOtA
PEOPLE
AVAlLABLE
FEELING
OMER
OFFEREO
FAMILY
DRINK
GO00
OTHER
‘I
OOWN
ANGRY
/+a
SlTVATlONAL
I,
1
FEELING
UPTIGHT
GET HIGH
CONTROL DRINKING
LET DOWN
OTHER
PERSONAliSYCHOLOGlCAL
RELAPSE PRECIPITANT
Fig. 1. Percenage relapse episode. each precipitant 30 for personal,
of subjects reporting that a relapse precipitant influenced their beginning a Thirty-one relapse episodes were included in the analyses, but the ns for vary due to missing data. The n for all interpersonal precipitants = 31, n = n = 29 for desire to get high, let down guard, and control drinking.
Figure 1 shows the percentage of subjects who reported that a precipitant contributed to their relapse. The figure shows clearly that only for the unspecified “other” precipitants did fewer than 20% of the subjects report that a precipitant had at least a small influence on their relapses. Some clusters of precipitants are noteworthy. Wife was reported by over 40% of the subjects, which is highly relevant in a trial of BMT. The presence of alcohol (48.4%) and the desire to drink or get high (58.6%) were reported by a high proportion of subjects. Negative affect stood out as well. In this regard, 43.3% reported the precipitant feeling angry, 33.3% feeling down, and 53.3% feeling uptight. The precipitants able to control drinking (55.2%) and letting down one’s guard (75.9%) also were reported by high proportions of the subjects. Reasons for terminating
relapse episodes
Table 2 presents the 11 reasons for terminating relapses that are included on the Relapse Questionnaire, the frequency with which a reason was indicated as making any contribution to terminating relapses, and the mean degree of influence of those reasons that were reported. Table 2 suggests that subjects frequently reported more than one reason, as the mean number of reasons reported for the full sample was 4.21. Similar to reports of relapse precipitants, the reports represented in Table 2 reveal that if a reason for stopping drinking was reported at all it tended to be perceived as having at least a moderate influence.
Relapse precipitants
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and behavioral marital therapy
Table 2. Number of subjects indicating a reason for stopping drinking was influential, and mean degree of influence of each reason they reported Reason for stopping
n
Feeling bad emotionally Feeling bad physically Admisison to formal treatment program Work problems Legal problems Marital or family problems Others’ intervention Knew problem would happen Just decided to stop Nonavailability of alcohol Other reasons
30 30 30 30 30 30 30 30 29 29 30
No. of subjects
Mean influence 4.3 4.3 4.3 2.5 3.0 4.6 3.x 4.8 4.5
20 15 9 4 4 17 13 21 17
I
1.0
1
1.0
Note. Thirty-one relapse episodes were included in the analyses. Influence was rated on a I (small influence) to 5 (great influence) Likert-type scale. The number of subjects reporting about reasons for terminating relapses and their degree of influence varies because of missing data. Mean values are based on the numbers of subjects who reported that a reason had any influence at all.
Figure 2 shows the proportion of subjects who reported each of 11 reasons for terminating their relapse episodes. Subjects’ anticipation of problems (72.4%) was the most commonly cited reason, and “just deciding to stop” (58.6%) was reported often. Such self-initiated reasons for stopping were reported more often than were 100 90
80 70 60 50 40 30 20 10 0
FEELING BAD EMOTIONS
LEGAL PROBLEMS
FORMAL TRAINING
FEELING BAD
WORK
PHYSICALLY
PROBLEMS
REASON
OTHERS INTERVENTION
MARITA”
FAMILY PRCJBLEMS FOR STOPPING
DECIDED TO STOP
KNEW PROBLEMS
WOULD HAPPEN
OTHER REASONS NONA”A1L ALCOHOL
DRINKING
Fig. 2. Percentage of subjects reporting a reason for terminating a relapse episode. Thirtyone episodes were included in the analyses, but ns for each reason vary due to missing data. The n for all reasons = 30, except for n = 29 for decided to stop and nonavailability of alcohol.
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the more external factors of admission to formal treatment (30.0%) and others’ intervention (43.3%). Problems with spouse or other family members were cited by over half the subjects as contributing to relapse termination. Physical (50.0%) and emotional (66.7%) consequences of drinking also were cited frequently. Some problems that may be correlated with or exacerbated by drinking (work problems, legal problems) were reported by a relatively small proportion of subjects. RP group comparisons Relapse precipitants.
Of the 3 1 subjects who reported at least one relapse episode during the assessment period, seven had been assigned to the RP condition but had completed no sessions or too few sessions to be considered “treated.” Therefore, they were dropped from analyses of differences between subjects who did or did not receive RP. For the remaining subjects, 24 (12 in each group) reported at least one relapse after their beginning primary BMT and completed the Relapse Questionnaire. The RP subjects provided data on a total of 23 relapses that ranged from 1 to 63 days’ duration. The no-RP subjects reported on 20 relapses that lasted from 1 to 92 days. As predicted, RP subjects reported their first relapses lasted a shorter time than that no-RP subjects reported for their first relapses (M = 6.5 days and 21.8 days, respectively, t = 1.96, df = 22, p = .05, one-tailed). Further analysis of first relapses concerned the degree of influence of relapse precipitants. Because the relapse precipitants were classified a priori as situational or personal and because subjects tended to attribute involvement to more than one precipitant, these analyses concerned indices created by collapsing across items in a precipitant category. Two separate variables were created for each of the situational and personal precipitant categories. The first is the number of precipitants on which a subject received a score greater than zero, and the second is the sum of the influence score divided by the number of precipitants given a score of 21. The second index is called average degree of influence. The analysis showed no group differences in the number of situational precipitants with a score > 0. However, no-RP subjects reported a significantly higher number of personal factors than did RP subjects (M = 4.5 vs. 3.1, respectively, t (21) = 2.15, p = .04). No RP subjects also attributed a greater average degree of influence for the situational factors than did RP subjects (3.8 vs. 1.8, respectively, t (22) = 2.84, p = .Ol). RP and no-RP subjects did not differ on the average degree of influence reported for personal precipitants. Reasons for terminating relapse episodes. Analyses of RP group differences in reasons for terminating relapse episodes were not statistically significant for either the number of items scored >O or for the average degree of influence scores. Analyses of individual items showed group differences on one factor, admission to treatment. Because of the large number of comparisons this one significant finding could have been due to chance. The no-RP subjects reported this factor to be more influential than did RP subjects (t = 2.21, df = 22, p < .04). DISCUSSION
This initial study of our 12-month relapse data showed several findings of importance. The first of these is subjects’ perceptions that multiple factors contributed to
Relapse precipitants
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relapse events. In contrast to much of the cognitive-behavioral literature on relapse, these data suggest that individuals who relapse often perceive the episode to be due to the occurrence of a combination of high-risk situations. Similarly, the data from this and other studies (e.g., Amodeo et al., 1992) suggest that individuals view the factors influencing their terminating relapse episodes as complex. The data on relapse precipitants and reasons for termination of drinking also suggest that the multiple factors that subjects cite may not be substantially discriminable in their degree of influence on beginning or ending a relapse episode. Such data add to the argument against asking subjects who have relapsed to report just one main reason. Subjects may not be able to narrow the precipitants to their relapse or the reasons for ending them to only one factor. But if they conform to instructions and do so, their reports may have little clinical utility. In the relapse-precipitant data the citing of spouse by over 40% of subjects as contributing to relapse is consistent with our past studies of relapse following BMT and reiterates the importance of partner involvement in treatment (Maisto, O’Farrell, McKay et al., 1988). Similarly, the result that negative affect was important for over 40% of subjects is consistent with our own previous studies and the literature in general on relapse following alcohol treatment (Gossop, 1989). In addition, the apparent importance to subjects of the reasons desire to drink and availability of alcohol add further evidence to the idea advanced by Heather and Stallard (1989) that cognitive-behavioral models of relapse may have paid too little attention to alcohol-related cues and urges or strong desires to drink as important factors to relapse. Finally, our data showed that the precipitants of letting down one’s guard and feeling able to control alcohol were frequently reported, which is in accord with Litman, Stapleton, Oppenheim, Pelig, and Jackson’s (1983) extraction of a “lessened cognitive vigilance” (p. 385) factor in accounting for a significant proportion of variance in alcoholics’ ratings of “dangerousness” of different situations for resumption of undesired levels of alcohol use. The data on reasons for terminating relapses contribute to the sparse literature on this question (Amodeo, Kurtz, & Cutter, 1992). Our findings in this study are consistent with those of Maisto, O’Farrell, Connors et al. (1988) in showing the importance of self-control (anticipating negative consequences) in terminating relapse episodes. The occurrence or exacerbation of problems, however, were cited by fewer subjects in this study, with the exception of marital and family problems. Personal and physical consequences (emotional and physical) of drinking also were perceived to play a part in terminating relapses. The most important outcome regarding RP group differences was that RP subjects’ first relapse episodes as defined in this study were significantly briefer than those of no-RP subjects. This finding suggests that the RP treatment achieved one of its primary objectives, at least while subjects were actively involved in the treatment. The data also support Ito and Donovan’s (1986) conclusion that aftercare reduces the severity of drinking episodes but not their frequency. Unfortunately, our data do not allow an analysis of the components of the RP treatment that may have contributed to subjects’ having briefer first relapses if they did occur. This is an important question, considering that aftercare treatment often is recommended as a way to combat the problem of relapse. Other analyses showed no differences between RP and no-RP subjects in the number of situational factors they reported. Since all of the subjects in these analyses had received the primary BMT treatment, which had placed considerable emphasis
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on factors in our situational set, subjects may have retained the benefits of that treatment. Indeed, this sample of 24 subjects reported proportionately fewer situational than personal factors. However, if no-RP subjects did report the involvement of a situational precipitant in a relapse, they tended to attribute a greater degree of influence to it than did RP subjects. The data also showed that no-RP subjects reported a higher number of personal precipitants as having at least a small influence on their relapse episodes than did RP subjects, a result difficult to interpret with the data collected in this study. In conclusion, the results of this study are consistent with, and extend, previous research on factors triggering relapse episodes following alcohol treatment and on factors perceived as important in ending such episodes. Furthermore, the data suggest the need for cognitive-behavioral models of relapse to refine definitions of highrisk situations from a more multivariate perspective and to include variables in such models that previously have received less attention, such as desire to drink. Continued refinement of constructs and their measurement along these lines, coupled with the use of follow-up studies, likely will advance cognitive-behavioral models of relapse and their application to treatment. REFERENCES Amodeo, M., Kurtz, N., & Cutter, H. S. G. (1992). Abstinence, reasons for not drinking, and life satisfaction. The International Journal of the Addictions, 21, XV-716. Connors, G. J., O’Farrell, T. J., & Pelcovits, M. A. (1988). Drinking outcome expectancies among male alcoholics during relapse situations. British Journal of Addiction, 82, 561-566. Gossop, M. (Ed.) (1989). Relapse and addictive behavior. London: Tavistock/Routledge. Heather, N., & Stallard, A. (1989). Does the Marlatt model underestimate the importance of condition craving in the relapse process? In M. Gossop (Ed.), Relapse and addictive behavior (pp. 133-148). London: TavistocWRoutledge. Ito, J. R., & Donovan, D. M. (1986). Aftercare in alcoholism treatment: A review. In W. R. Miller, & N. Heather (Eds.), Treating addictive behaviors: Processes ofchange (pp. 435-456). New York: Plenum Press. Litman, G. K., Stapleton, J., Oppenheim, A. N., Pelig, M., & Jackson, P. (1983). Situations related to alcoholism relapse. British Journal of Addiction. 78, 381-389. Maisto, S. A., McKay, J. R., & O’Farrell, T. J. (1985). The Relapse Questionnaire. Unpublished measure, VA Medical Center and Harvard Medical School, Brockton, MA. Maisto, S. A., O’Farrell, T. J., Connors, G. J., McKay, J. R., & Pelcovits, M. (1988). Alcoholics’ attributions of factors affecting their relapse to drinking and reasons for terminating relapse episodes. Addictive
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Maisto, S. A., O’Farrell, T. J., McKay, J. R., Connors, G. J., & Pelcovits, M. (1988). Alcoholic and spouse concordance on attributions about relapse to drinking. Journal of Substance Abuse Treutment, 5, 179-181. Marlatt, G. A., & Gordon, J. R. (1980). Determinants of relapse: Implications for the maintenance of behavior change. In P. 0. Davidson & S. M. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 410-452). New York: Brunner/Mazel. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention. New York: Guilford. McKay, J. R., O’Farrell, T. J., Maisto, S. A., Connors, G. J., & Funder, D. C. (1989). Biases in relapse attributions made by alcoholics and their wives. Addictive Behaviors, 14, 513-522. O’Farrell, T. J. (1993a). A behavioral marital therapy couples group program for alcoholics and their spouses. In T. J. O’Farrell (Ed.), Treating ., alcohol vroblems: Marital and Ifumilv_ interventions (DD. .. . 170-209). New York: Guilford. O’Farrell, T. J. (1993b). Couples relapse prevention sessions after a behavioral marital therapy couples group program. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and Ifumilv _ interventions _ (pp. 305-326). New York: Guilford. O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., & McCourt, W. F. (1993). Behavioral marital therapy with and without additional relapse prevention sessions for alcoholics and their wives. Journal of Studies on Alcohol, 54, 652-666. O’Farrell, T. J., Cutter, H. S. G., Choquette, K. A., Floyd, F. J., & Bayog, R. (1992). Evaluating behavioral marital therapy for male alcoholics: Results on marital and drinking adjustment during the two years after treatment. Behavior Therapy, 23, 429-449.
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O’Farrell, T. J., Cutter, H. S. G., & Floyd, F. J. (1985). Evaluating behavioral marital therapy for male alcoholics: Effects on marital adjustment and communication from before to after therapy. Behavior Therapy, 16, 147-167. Selzer, M. L. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry. 127. 1653-1658. Skinner, H. A., & Allen, B. A. (1982). Alcohol dependence syndrome: Measurement and validation. Journal
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Sobell, L. C., & Sobell, M. B. (1992). Time-line follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten, & J. P. Allen (Eds.). Measaring alcohol cotzsrrmption (pp. 4172). Totowa, NJ: Humana Press. Zywiak, W. H., Westerberg, V. S., Connors, G. J., Maisto. S. A., & Waldron, D. J. (1994). Factor analysis of the Marlatt relapse taxonomy. Paper presented at the 28th Annual Meeting of the Association for the Advancement of Behavior Therapy, San Diego.
Pergamon
Behaviors, Vol. 20, No. 3. pp. 383-393. 1995 Copyright C 1995 Elsevier Science Ltd PrInted in the USA. All rights reserved
0306-4603195 59.50 + .OO
0306-4603(94)00079-4
RELAPSE PRECIPITANTS AND BEHAVIORAL MARITAL THERAPY STEPHEN
A. MAISTO
VA Medical Center, Pittsburgh, and University of Pittsburgh Medical School
JAMES R. MCKAY University of Pennsylvania
TIMOTHY
J. O’FARRELL
VA Medical Center, Brockton. and Harvard Medical School Abstract - The major purpose of this study was to provide descriptive data on the first relapse episodes and reasons for terminating relapses of subjects who completed a course of behavioral marital therapy (BMT) for alcoholism. Another aim of the study was to compare the relapse episodes and relapse terminations of subjects who received BMT with or without additional relapse prevention (RP) treatment for one year. The subjects were selected from a sample of 74 men who began an outpatient Department of Veterans Affairs BMT program. These men were evaluated pre- and post-BMT, and at 3, 6. 9. and I2 months after completing BMT. A total of 31 subjects relapsed at least once after they began BMT. The data showed that these men tended to report more than one situational or personal precipitant of their first relapses. Similarly, they tended to report more than one reason for ending their relapse episodes. Comparison of the subjects assigned to the two RP conditions revealed an equal number (12) of relapse episodes, but RP subjects’ relapse\ tended to last fewer days than did no-RP subjects’. The consistency of these findings with previous research on cognitive-behavioral models of relapse and the implicationa of these findings for the concept of high-risk situation, are discussed.
Clinicians have known for many years that relapse is a serious and persistent problem in the treatment of alcohol and other drug use disorders. Systematic research on the problem of relapse received a great stimulus by Marlatt and colleagues’ (Marlatt & Gordon, 1985) cognitive behavioral model of the relapse process. A central construct in Marlatt’s and other cognitive-behavioral models is the “high-risk situation.” This concerns factors internal (e.g., mood) or external (e.g., taverns) to the person that are associated with the past consumption of alcohol or other drugs at undesired levels. Accordingly, high-risk situations occasion a higher likelihood of undesired substance use. People who are trying to maintain changes in their substance use require behavioral skills or other resources to cope with high risk situations without abusing alcohol or other drugs. Our initial research on relapse following behavioral marital therapy (BMT) for alcoholism was heavily influenced by Marlatt’s model (Connors. O’Farrell. & Pelcovits, 1988; Maisto, O’Farrell, Connors, McKay, & Pelcovits, 1988; Maisto, O’Farrell, McKay, Connors, & Pelcovits, 1988; McKay, O’Farrell, Maisto, Connors, & Funder, 1989). These studies were based on reports by male patients and their spouses about the patient’s two most recent relapse episodes. The questions This research was supported by the Department of Veterans Affair\ and by grant R01 AA08637 from the National Institute on Alcohol Abuse and Alcoholism to the third author. Requestsfor reprints should be sent to Stephen A. Maisto. Ph.D.. Department of Psychology. Syrdcuse University, 430 Huntington Hall. Syracuse. NY 13244. 383
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about relapse precipitants were open-ended and replicated the questions that Marlatt and colleagues reported that they used in their early studies of relapse (Marlatt & Gordon, 1980). In our first studies of relapse, subjects were interviewed two years following their participation in a clinical trial of group BMT for alcoholism (O’Farrell, Cutter, Choquette, Floyd, & Bayog, 1992; O’Farrell, Cutter, & Floyd, 1985). The results of this research were the bases of the current series of studies of relapse and BMT. Data were collected from male patients and their spouses or partners who participated in an outpatient BMT program for alcoholism. In a randomized controlled clinical trial of relapse prevention (RP) following BMT (see O’Farrell, Choquette, Cutter, Brown, & McCourt, 1993) half of these couples then received aftercare in the form of individual BMT sessions over the course of one year, and half did not. This new series of studies on relapse feature several major improvements over our first efforts. First, subjects were assessed on a number of variables before beginning and after completing the BMT program and then multiple times over the subsequent 30 months. The RP treatment occurred in the first 12 of these 30 months post-BMT. Therefore, the findings reported in this paper are part of a prospective follow-up data base, compared to the long-term retrospective data from our first studies. Another major improvement is use of the Relapse Questionnaire (Maisto, McKay, & O’Farrell, 1985). This questionnaire represents an advance over previous relapse assessment techniques in several ways. Subjects indicate which of a list of possible relapse precipitants had any influence at all on their taking the first drink and they rate the degree of that influence. This information is provided in addition to openended questions about relapse precipitants, probably the most common method in this area of research. Therefore, the Relapse Questionnaire provides more quantitative as well as qualitative data on relapse precipitants. In the Relapse Questionnaire the same format and procedures are followed in obtaining information on reasons for terminating relapse episodes. Furthermore, subjects are free to report more than one precipitant or termination factor for a given relapse episode. The present study had two major purposes. The first was to present descriptive analyses of the quantitative data on the degree of influence of relapse precipitants and on reasons for terminating relapse episodes occurring in the first 12 months of follow-up. Part of this aim was to provide an initial evaluation of a more complex concept of high-risk situation, made possible by the fact that subjects were not restricted in the number of relapse precipitants they reported. In their early studies of relapse that were the bases of their cognitive-behavioral model, Marlatt and colleagues used a “hierarchical” method of coding in which only one main precipitant was coded for each relapse (Marlatt & Gordon, 1985). Such measurement procedures may have oversimplified the concept of high-risk situation, however, as some research suggests that high-risk situations may often involve more than one factor (Heather & Stallard, 1989; Zywiak, Westerberg, Connors, Maisto, & Waldron, 1994). The data on patients’ reasons for ending relapse episodes will provide information on a clinically important topic to which researchers have given little attention (Amodeo, Kurtz, & Cutter, 1992). The second objective of this paper was to compare subjects who received BMT with or without additional RP on the number of relapse episodes that occurred, duration of relapse events, reported relapse precipitants, and reported reasons for terminating relapse episodes. It was expected that RP subjects would report fewer and briefer relapse episodes than no-RP subjects. The analyses presented in this
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and for the subsequent
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METHOD
Subjects
The subjects were selected from a sample of 74 men who were in an outpatient Department of Veterans Affairs behavioral marital therapy alcohol treatment program. They met the following criteria for inclusion in the study: (a) aged 25 to 60; (b) married at least one year or living together in a stable common-law relationship for at least 3 years; (c) met DSM-III-R criteria for alcohol abuse or dependence; (d) scored 2 7 on the Michigan Alcoholism Screening Test (MAST; Selzer, 1971); (e) consumed alcohol in the 120 days prior to initial assessment; and (f) accepted the goal of abstinence from alcohol or nonprescribed drugs at least for the duration of the treatment. Criteria for exclusion were: (a) wife or partner also abused alcohol and had been abstinent for less than six months; (b) either spouse met DSM-III-R criteria for psychoactive substance use disorder (other than alcohol) in the past 6 months; (c) either spouse met DSM-III-R criteria for schizophrenia, delusional (paranoid) disorder, bipolar disorder, major depression, other psychotic disorder, or borderline personality disorder; and (d) couple were separated and unwilling to reconcile for the project. Subjects who provided data on their relapse episodes (n = 3 1) ranged in age from 26 to 56 (m = 41.30, SD = 8.04), all were White, and 76% were employed full-time. The sample averaged 12.86 (SD = 2.23) years of education, 13.9 (SD = 10.4) years of problem drinking, MAST scores of 34.90 (range 11-51, SD = 11.45), and Alcohol Dependence Scale (Skinner & Allen, 1982) scores of 18.06 (range 2-44, SD = 10.64). Procedure Primary treatment.
The BMT program consisted of 6 to 8 weekly pregroup sessions conducted conjointly with each couple and 10 weekly BMT couples group sessions. The BMT treatment package, which was designed to promote sobriety, positive activities, and better communication, is described in detail elsewhere (O’Farrell, 1993a). One week after the last BMT session, couples were randomly assigned either to receive or not to receive further treatment in the form of relapse prevention sessions. The one-year follow-up began at this point. Of the 74 couples who began the BMT groups, 64 attended at least five BMT sessions and completed the post-BMT assessments. Seven couples assigned to the RP condition either refused the additional treatment (n = 1) or discontinued the sessions very quickly (n = 6). Efforts were made to replace these dropouts with subsequent random assignments, with the result that 30 subjects were randomly assigned to the RP condition and 29 subjects to the no-RP group. There were no significant differences between subjects in the two groups on demographic and alcohol-related variables (see O’Farrell et al., 1993). RP intervention. Couples in the RP condition were scheduled to receive fifteen 50to 75minute conjoint sessions over a course of 12 months. The RP sessions had three major purposes: (a) to maintain marital and drinking improvements achieved in BMT, (b) to work on unresolved or newly emerged marital and drinking issues, and (c) to develop and rehearse a cognitive/behavioral relapse prevention plan that was
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focused on identifying high-risk situations and early warning signs for relapse, as described by Marlatt and Gordon (1985). A full description of the RP intervention is found in O’Farrell (1993b). Assessment of relapse episodes. At the end of the BMT program and at the 3-, 6-, 9-, and 12-month follow-ups, patients and partners provided information on the patients’ drinking behavior over the preceding 90 days. Time-line follow-back techniques were used to gather data on drinking behavior. These techniques have been shown to be highly effective in obtaining self-reports of daily drinking behavior with a high degree of reliability and accuracy (Sobell & Sobell, 1992). If, based on the time-line data, the patient experienced any relapse episodes during the preceding follow-up period, the Relapse Questionnaire was administered to both the patient and his partner. Consistent with our previous research, relapse was defined as a period of one day or more in which any drinking occurred, surrounded by 2 weeks or more of abstinence. When reviewing the relapse data it is important to keep in mind one consequence of this definition. It is possible that a relapse would not be recorded for a follow-up interval even if a subject were drinking during the entire time that it covers. For example, a subject could begin a relapse during the first follow-up interval and then continue drinking throughout the second interval. Nevertheless, because of this definition, a relapse would be recorded for the first interval but not for the second. Of the 74 subjects in the study, 31 had relapsed at some point during the BMT program or during the first 12 months of the follow-up and completed the Relapse Questionnaire. Some of these subjects had relapses in more than one period; in these cases, the first relapse to occur was retained for analysis.’ Relapse
Questionnaire
The Relapse Questionnaire (Maisto et al., 1985) is a IS-minute structured interview that is divided into three sections. In the first section, subjects provide information about the period of time in which the relapse occurred and the number of light and heavy drinking days during the relapse. In the second section, subjects indicate which of 6 situational factors and 8 personal factors were involved in the onset of their relapse episodes. This distinction between situational and personal factors was originally based in Marlatt and colleagues’ (Marlatt & Gordon, 1985) typology of relapse precipitants. Factors implicated in the relapse are then rated on a scale of 1 (small degree) to 5 (great degree), according to the degree of influence subjects perceive the factor had in initiating the relapse. If a subject reports that a factor was not involved in a relapse, he is assigned a score of zero for that factor. Conceptually, it was expected that there would be low to moderate correlations within and between situational and personal factor items in the Relapse Questionnaire. This hypothesis stemmed from the idea of the specificity of high-risk situations. In fact, based on the degree of influence data, Cronbach’s alpha for the situational factors (excluding the “other” item was .50, and for the personal factors (also excluding the “other” item) it was .47. Cronbach’s alpha for the 12 precipitant items (excluding the two “other” items) was .66. These findings were based on the first relapses of 31 subjects in the sample, as reported below. ‘In seven cases in which a subject relapse was retained for analysis.
had a relapse
during
BMT and another
during
the follow-up,
the latter
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In the third section of the Relapse Questionnaire, subjects indicate which of 11 factors led them to terminate their relapse episode. The factors that led to the end of the episode are then rated on a scale of 1 to 5, again according to the degree of influence subjects perceive the factor had in ending the drinking episode. RESULTS
Occurrence
of relapse
As noted, 31 of the 74 patients relapsed at least once following their beginning the primary BMT program and completed the Relapse Questionnaire. A total of 51 relapse episodes were reported by these 31 subjects to have occurred either during primary BMT or over the 12 months of follow-up. The relapse episodes lasted from 1 to 92 days. First relapses (N = 31), which were the bases of statistical analyses reported in this paper, averaged 14.3 days. A total of four of these episodes were reported to occur during the primary BMT treatment, ten during the first 3 months of the follow-up, seven during the next 3 months of the follow-up, and ten during months 7-12 of the follow-up. Relapse precipitants
Table 1 presents a list of the situational and personal relapse precipitants included in the Relapse Questionnaire, the number of subjects who indicated that a precipitant had any influence at all for their first relapse, and the mean influence rating for a respective precipitant reported by those latter subjects. As Table 1 suggests, subjects tended to perceive that more than one precipitant contributed to their relapse episodes. The mean number of situational influences reported was 1.97 (n = 31; range O-6), and the mean number of personal influences reported was 3.79 (n = 29, range l-8). The mean total number of precipitants reported was 5.45 (n = 29). Table 1 also shows that when subjects perceived that a factor did contribute to a relapse they tended to rate its degree of influence as at least moderate. Table I, Number of subjects indicating a precipitant contributed to beginning drinking. and mean degree of influence of each precipitant they reported Relapse precipitant Situational Wife Other family Other people Someone offered a drink Alcohol available Other situational Personal Feeling good Feeling angry Feeling down Feeling uptight Desire to drink or get high Let down guard about alcohol Feel could control drinking Other personal/psychological
n
No. of subjects
Mean influence
31 31 31 31 31 31
13 7 II 9 15 6
4.1 4.0 3.4 2.6 3.8 4.3
30 30 30 30 29 29 29 30
12 13 10 16 17 22 16 4
3.8 4.2 4.2 4.1 4.3 4.4 4.3 2.8
Note. Thirty-one relapse episodes were included in the analyses. Influence was rated on a 1 (small influence) to 5 (great influence) Likert-type scale. The number of subjects reporting about relapse precipitants and their influences vary because of missing data. Mean values are based on the numbers of subjects who reported tha a precipitant had any influence at all.
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100 r 90 80 70 60 50 40 30 20 -
L
10
0’ GE’
OTHER
ALCOtA
PEOPLE
AVAlLABLE
FEELING
OMER
OFFEREO
FAMILY
DRINK
GO00
OTHER
‘I
OOWN
ANGRY
/+a
SlTVATlONAL
I,
1
FEELING
UPTIGHT
GET HIGH
CONTROL DRINKING
LET DOWN
OTHER
PERSONAliSYCHOLOGlCAL
RELAPSE PRECIPITANT
Fig. 1. Percenage relapse episode. each precipitant 30 for personal,
of subjects reporting that a relapse precipitant influenced their beginning a Thirty-one relapse episodes were included in the analyses, but the ns for vary due to missing data. The n for all interpersonal precipitants = 31, n = n = 29 for desire to get high, let down guard, and control drinking.
Figure 1 shows the percentage of subjects who reported that a precipitant contributed to their relapse. The figure shows clearly that only for the unspecified “other” precipitants did fewer than 20% of the subjects report that a precipitant had at least a small influence on their relapses. Some clusters of precipitants are noteworthy. Wife was reported by over 40% of the subjects, which is highly relevant in a trial of BMT. The presence of alcohol (48.4%) and the desire to drink or get high (58.6%) were reported by a high proportion of subjects. Negative affect stood out as well. In this regard, 43.3% reported the precipitant feeling angry, 33.3% feeling down, and 53.3% feeling uptight. The precipitants able to control drinking (55.2%) and letting down one’s guard (75.9%) also were reported by high proportions of the subjects. Reasons for terminating
relapse episodes
Table 2 presents the 11 reasons for terminating relapses that are included on the Relapse Questionnaire, the frequency with which a reason was indicated as making any contribution to terminating relapses, and the mean degree of influence of those reasons that were reported. Table 2 suggests that subjects frequently reported more than one reason, as the mean number of reasons reported for the full sample was 4.21. Similar to reports of relapse precipitants, the reports represented in Table 2 reveal that if a reason for stopping drinking was reported at all it tended to be perceived as having at least a moderate influence.
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and behavioral marital therapy
Table 2. Number of subjects indicating a reason for stopping drinking was influential, and mean degree of influence of each reason they reported Reason for stopping
n
Feeling bad emotionally Feeling bad physically Admisison to formal treatment program Work problems Legal problems Marital or family problems Others’ intervention Knew problem would happen Just decided to stop Nonavailability of alcohol Other reasons
30 30 30 30 30 30 30 30 29 29 30
No. of subjects
Mean influence 4.3 4.3 4.3 2.5 3.0 4.6 3.x 4.8 4.5
20 15 9 4 4 17 13 21 17
I
1.0
1
1.0
Note. Thirty-one relapse episodes were included in the analyses. Influence was rated on a I (small influence) to 5 (great influence) Likert-type scale. The number of subjects reporting about reasons for terminating relapses and their degree of influence varies because of missing data. Mean values are based on the numbers of subjects who reported that a reason had any influence at all.
Figure 2 shows the proportion of subjects who reported each of 11 reasons for terminating their relapse episodes. Subjects’ anticipation of problems (72.4%) was the most commonly cited reason, and “just deciding to stop” (58.6%) was reported often. Such self-initiated reasons for stopping were reported more often than were 100 90
80 70 60 50 40 30 20 10 0
FEELING BAD EMOTIONS
LEGAL PROBLEMS
FORMAL TRAINING
FEELING BAD
WORK
PHYSICALLY
PROBLEMS
REASON
OTHERS INTERVENTION
MARITA”
FAMILY PRCJBLEMS FOR STOPPING
DECIDED TO STOP
KNEW PROBLEMS
WOULD HAPPEN
OTHER REASONS NONA”A1L ALCOHOL
DRINKING
Fig. 2. Percentage of subjects reporting a reason for terminating a relapse episode. Thirtyone episodes were included in the analyses, but ns for each reason vary due to missing data. The n for all reasons = 30, except for n = 29 for decided to stop and nonavailability of alcohol.
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the more external factors of admission to formal treatment (30.0%) and others’ intervention (43.3%). Problems with spouse or other family members were cited by over half the subjects as contributing to relapse termination. Physical (50.0%) and emotional (66.7%) consequences of drinking also were cited frequently. Some problems that may be correlated with or exacerbated by drinking (work problems, legal problems) were reported by a relatively small proportion of subjects. RP group comparisons Relapse precipitants.
Of the 3 1 subjects who reported at least one relapse episode during the assessment period, seven had been assigned to the RP condition but had completed no sessions or too few sessions to be considered “treated.” Therefore, they were dropped from analyses of differences between subjects who did or did not receive RP. For the remaining subjects, 24 (12 in each group) reported at least one relapse after their beginning primary BMT and completed the Relapse Questionnaire. The RP subjects provided data on a total of 23 relapses that ranged from 1 to 63 days’ duration. The no-RP subjects reported on 20 relapses that lasted from 1 to 92 days. As predicted, RP subjects reported their first relapses lasted a shorter time than that no-RP subjects reported for their first relapses (M = 6.5 days and 21.8 days, respectively, t = 1.96, df = 22, p = .05, one-tailed). Further analysis of first relapses concerned the degree of influence of relapse precipitants. Because the relapse precipitants were classified a priori as situational or personal and because subjects tended to attribute involvement to more than one precipitant, these analyses concerned indices created by collapsing across items in a precipitant category. Two separate variables were created for each of the situational and personal precipitant categories. The first is the number of precipitants on which a subject received a score greater than zero, and the second is the sum of the influence score divided by the number of precipitants given a score of 21. The second index is called average degree of influence. The analysis showed no group differences in the number of situational precipitants with a score > 0. However, no-RP subjects reported a significantly higher number of personal factors than did RP subjects (M = 4.5 vs. 3.1, respectively, t (21) = 2.15, p = .04). No RP subjects also attributed a greater average degree of influence for the situational factors than did RP subjects (3.8 vs. 1.8, respectively, t (22) = 2.84, p = .Ol). RP and no-RP subjects did not differ on the average degree of influence reported for personal precipitants. Reasons for terminating relapse episodes. Analyses of RP group differences in reasons for terminating relapse episodes were not statistically significant for either the number of items scored >O or for the average degree of influence scores. Analyses of individual items showed group differences on one factor, admission to treatment. Because of the large number of comparisons this one significant finding could have been due to chance. The no-RP subjects reported this factor to be more influential than did RP subjects (t = 2.21, df = 22, p < .04). DISCUSSION
This initial study of our 12-month relapse data showed several findings of importance. The first of these is subjects’ perceptions that multiple factors contributed to
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relapse events. In contrast to much of the cognitive-behavioral literature on relapse, these data suggest that individuals who relapse often perceive the episode to be due to the occurrence of a combination of high-risk situations. Similarly, the data from this and other studies (e.g., Amodeo et al., 1992) suggest that individuals view the factors influencing their terminating relapse episodes as complex. The data on relapse precipitants and reasons for termination of drinking also suggest that the multiple factors that subjects cite may not be substantially discriminable in their degree of influence on beginning or ending a relapse episode. Such data add to the argument against asking subjects who have relapsed to report just one main reason. Subjects may not be able to narrow the precipitants to their relapse or the reasons for ending them to only one factor. But if they conform to instructions and do so, their reports may have little clinical utility. In the relapse-precipitant data the citing of spouse by over 40% of subjects as contributing to relapse is consistent with our past studies of relapse following BMT and reiterates the importance of partner involvement in treatment (Maisto, O’Farrell, McKay et al., 1988). Similarly, the result that negative affect was important for over 40% of subjects is consistent with our own previous studies and the literature in general on relapse following alcohol treatment (Gossop, 1989). In addition, the apparent importance to subjects of the reasons desire to drink and availability of alcohol add further evidence to the idea advanced by Heather and Stallard (1989) that cognitive-behavioral models of relapse may have paid too little attention to alcohol-related cues and urges or strong desires to drink as important factors to relapse. Finally, our data showed that the precipitants of letting down one’s guard and feeling able to control alcohol were frequently reported, which is in accord with Litman, Stapleton, Oppenheim, Pelig, and Jackson’s (1983) extraction of a “lessened cognitive vigilance” (p. 385) factor in accounting for a significant proportion of variance in alcoholics’ ratings of “dangerousness” of different situations for resumption of undesired levels of alcohol use. The data on reasons for terminating relapses contribute to the sparse literature on this question (Amodeo, Kurtz, & Cutter, 1992). Our findings in this study are consistent with those of Maisto, O’Farrell, Connors et al. (1988) in showing the importance of self-control (anticipating negative consequences) in terminating relapse episodes. The occurrence or exacerbation of problems, however, were cited by fewer subjects in this study, with the exception of marital and family problems. Personal and physical consequences (emotional and physical) of drinking also were perceived to play a part in terminating relapses. The most important outcome regarding RP group differences was that RP subjects’ first relapse episodes as defined in this study were significantly briefer than those of no-RP subjects. This finding suggests that the RP treatment achieved one of its primary objectives, at least while subjects were actively involved in the treatment. The data also support Ito and Donovan’s (1986) conclusion that aftercare reduces the severity of drinking episodes but not their frequency. Unfortunately, our data do not allow an analysis of the components of the RP treatment that may have contributed to subjects’ having briefer first relapses if they did occur. This is an important question, considering that aftercare treatment often is recommended as a way to combat the problem of relapse. Other analyses showed no differences between RP and no-RP subjects in the number of situational factors they reported. Since all of the subjects in these analyses had received the primary BMT treatment, which had placed considerable emphasis
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on factors in our situational set, subjects may have retained the benefits of that treatment. Indeed, this sample of 24 subjects reported proportionately fewer situational than personal factors. However, if no-RP subjects did report the involvement of a situational precipitant in a relapse, they tended to attribute a greater degree of influence to it than did RP subjects. The data also showed that no-RP subjects reported a higher number of personal precipitants as having at least a small influence on their relapse episodes than did RP subjects, a result difficult to interpret with the data collected in this study. In conclusion, the results of this study are consistent with, and extend, previous research on factors triggering relapse episodes following alcohol treatment and on factors perceived as important in ending such episodes. Furthermore, the data suggest the need for cognitive-behavioral models of relapse to refine definitions of highrisk situations from a more multivariate perspective and to include variables in such models that previously have received less attention, such as desire to drink. Continued refinement of constructs and their measurement along these lines, coupled with the use of follow-up studies, likely will advance cognitive-behavioral models of relapse and their application to treatment. REFERENCES Amodeo, M., Kurtz, N., & Cutter, H. S. G. (1992). Abstinence, reasons for not drinking, and life satisfaction. The International Journal of the Addictions, 21, XV-716. Connors, G. J., O’Farrell, T. J., & Pelcovits, M. A. (1988). Drinking outcome expectancies among male alcoholics during relapse situations. British Journal of Addiction, 82, 561-566. Gossop, M. (Ed.) (1989). Relapse and addictive behavior. London: Tavistock/Routledge. Heather, N., & Stallard, A. (1989). Does the Marlatt model underestimate the importance of condition craving in the relapse process? In M. Gossop (Ed.), Relapse and addictive behavior (pp. 133-148). London: TavistocWRoutledge. Ito, J. R., & Donovan, D. M. (1986). Aftercare in alcoholism treatment: A review. In W. R. Miller, & N. Heather (Eds.), Treating addictive behaviors: Processes ofchange (pp. 435-456). New York: Plenum Press. Litman, G. K., Stapleton, J., Oppenheim, A. N., Pelig, M., & Jackson, P. (1983). Situations related to alcoholism relapse. British Journal of Addiction. 78, 381-389. Maisto, S. A., McKay, J. R., & O’Farrell, T. J. (1985). The Relapse Questionnaire. Unpublished measure, VA Medical Center and Harvard Medical School, Brockton, MA. Maisto, S. A., O’Farrell, T. J., Connors, G. J., McKay, J. R., & Pelcovits, M. (1988). Alcoholics’ attributions of factors affecting their relapse to drinking and reasons for terminating relapse episodes. Addictive
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Maisto, S. A., O’Farrell, T. J., McKay, J. R., Connors, G. J., & Pelcovits, M. (1988). Alcoholic and spouse concordance on attributions about relapse to drinking. Journal of Substance Abuse Treutment, 5, 179-181. Marlatt, G. A., & Gordon, J. R. (1980). Determinants of relapse: Implications for the maintenance of behavior change. In P. 0. Davidson & S. M. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 410-452). New York: Brunner/Mazel. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention. New York: Guilford. McKay, J. R., O’Farrell, T. J., Maisto, S. A., Connors, G. J., & Funder, D. C. (1989). Biases in relapse attributions made by alcoholics and their wives. Addictive Behaviors, 14, 513-522. O’Farrell, T. J. (1993a). A behavioral marital therapy couples group program for alcoholics and their spouses. In T. J. O’Farrell (Ed.), Treating ., alcohol vroblems: Marital and Ifumilv_ interventions (DD. .. . 170-209). New York: Guilford. O’Farrell, T. J. (1993b). Couples relapse prevention sessions after a behavioral marital therapy couples group program. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and Ifumilv _ interventions _ (pp. 305-326). New York: Guilford. O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., & McCourt, W. F. (1993). Behavioral marital therapy with and without additional relapse prevention sessions for alcoholics and their wives. Journal of Studies on Alcohol, 54, 652-666. O’Farrell, T. J., Cutter, H. S. G., Choquette, K. A., Floyd, F. J., & Bayog, R. (1992). Evaluating behavioral marital therapy for male alcoholics: Results on marital and drinking adjustment during the two years after treatment. Behavior Therapy, 23, 429-449.
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Sobell, L. C., & Sobell, M. B. (1992). Time-line follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten, & J. P. Allen (Eds.). Measaring alcohol cotzsrrmption (pp. 4172). Totowa, NJ: Humana Press. Zywiak, W. H., Westerberg, V. S., Connors, G. J., Maisto. S. A., & Waldron, D. J. (1994). Factor analysis of the Marlatt relapse taxonomy. Paper presented at the 28th Annual Meeting of the Association for the Advancement of Behavior Therapy, San Diego.