According to Breining (2008) a relapse is: “The recurrence of symptoms of a disease after improvement. In CD [chemical dependency]: A single event (taking a drink pill or fix) =lapse, and a serial event (a drinking or drugging binge) = relapse” (p. 410). Relapse prevention is defined as, “A treatment technique that focuses on preventing the recovering addict from using again“ (Inaba & Cohen, 2007, p. 573). According to McLellan (2003) relapse prevention is a vital part of a patient’s treatment for chemical dependency (alcoholism, drug addiction), because relapse is common following treatment. Alcoholics or drug addicts in recovery can come to understand their general precipitants and personal triggers of relapse, which makes relapse preventable. It is evident that psychologists, psychotherapists, and counselors within the professional alcohol and drug treatment community take relapse prevention seriously, as 87% of treatment centers include relapse prevention in their treatment of people with addictions on a regular basis and 9% use relapse prevention sometimes. Only 4% of treatment centers never used relapse prevention, or did not know about this approach according to the National Survey of Substance Abuse Treatment Services (N-SSATS) report (National, 2010). To illuminate relapse and relapse prevention this article will examine relapse potential in recovering addicts, relapse rates, and gender differences in addiction and relapse.
Gorski and Miller (1986) maintained that, “Although addictive disease can be controlled, it can never be cured. There is always the possibility of relapse. Unless measures are taken on a long-term basis to control the disease, relapse is likely” (p. 83). Complete abstinence is a key factor for recovery, as research shows that controlled use of alcohol and drugs is not possible for an addict (Ibid). In a number of studies conducted through the Haight Ashbury Free Clinics, San Francisco, USA, it was found that in 95% of the cases when people had a “slip,” in other words, just used their substance of choice once, a slip turned into a full-blown relapse over time (Inaba & Cohen, 2007). Larimer, Palmer, and Marlatt (1999) acknowledged this research finding but maintained, “The progression from lapse to relapse is not inevitable” (p. 153). They asserted that techniques to avert the progression can be acquired through relapse prevention. Other researchers showed that before 1980 persons in treatment were hardly ever informed about what to do in the case of a slip/lapse, or relapse. The thought was that such information would cause a self-fulfilling prophecy and that people would slip and go into a full relapse. Today, psychologists, psychotherapists and counselors provide education and positive reinforcement to not let a slip become a full relapse. The general approach is to apply cognitive-behavioral and self-management interventions that help patients cope with their slip. Unlike in the past, psychologists, psychotherapists, and counselors are not confrontational and do not label the patient negatively (Substance Abuse, 2005).
Today’s mainstream approach among psychologists, psychotherapists, and counselors in the field of substance abuse treatment is to assist patients in achieving abstinence and helping them maintain long-term sobriety. The question that arises is: How common are relapse rates among individuals in recovery? Surprisingly, alcohol and drug relapse rates are similar to relapse rates for other chronic lifestyle-related illnesses. When comparing relapse rates of addicts to those of other chronic diseases, such as diabetes, hypertension, and asthma, one finds that the rates are comparable. Drug relapses average is 40-60%, for type I diabetes 30-50%, for hypertension 50-70%, and for asthma 50-70%. Since addiction and chronic diseases are similar in that they both have biological and behavioral components long-term recovery requires repeated episodes of treatment and support programs. Relapse should serve as a trigger for additional intervention by psychologists, psychotherapists or counselors and not be judged as a failure (Relapse, n.d.).
A research study showed that extended abstinence is predictive of sustained recovery. It indicated that in the first year of abstinence 64% relapsed, from 1-3 years 34% relapsed, from 3-5 years 14% relapsed, and from 5 and more years 14% relapsed. This data shows that after the 3rd year the recovery odds continue to be high and stable. The conclusion based on this information is that addiction requires ongoing counseling supporting disease management and treatment, especially in the beginning years of sobriety (Extended, n.d.). This data also validates that for many relapses is part of the process of obtaining long-term sobriety and that there will always be a certain percentage of people who chronically relapse.
In the general community, there might be the perception that a person in recovery is doing well and just one day, without notice, “falls of the wagon.” Psychologists, psychotherapists, and counselors in the chemical dependency treatment community understand relapse is not an isolated event.
… it is a process of becoming unable to cope with life in sobriety. The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs. Relapse prevention therapy teaches people to recognize and manage these warning signs so that they can interrupt the progression early and return to the process of recovery. (Counselor’s, n.d., para. 1)
Before examining gender differences in relapse, it is interesting to look at why people use drugs and alcohol in general, and women and men specifically. According to the National Institute on Drug Abuse (NIDA) research has revealed that people take drugs to feel good or to feel better. Feeling good was seen as having novel feelings pertaining to sensations, experiences and to share them. Feeling better was seen as an attempt to lessen anxiety, worries, fears, depression, and hopelessness (Why, n.d.). NIDA states that those who want to feel better are dealing with difficult situations, stress, trauma, and symptoms of mental disorders (Why would, n.d.).
Iliff (2008) maintains that women typically begin using chemicals for other reasons than men do. She attributes the onset of use for men to recreational reasons because they like the effect of the drug. For women, on the other hand, the onset of use was attributed to a variety of reasons, such as use to lose weight, to reduce sexual inhibition, relieve stress, improve mood, increase self-confidence, belong to their group, or avoid hurting someone’s feelings by declining a drug or drink. Illiff lists the following factors as high-risk situations for women in recovery:
1. Beginning and ending a romantic relationship
2. Physical pain
3. Spending time alone
4. Hormonal changes
5. High stress
6. Milestones in recovery (“anniversary freakies”)
When examining gender differences of relapse rates concerning alcohol, research findings indicate that men and women experience the same rates of relapse. When relapse rates in relation to drugs were compared between the sexes, women tended to have lower relapse rates than men. When marital and family factors are considered, a pattern emerges in which married women with fewer children in the household have higher relapse rates than men. This finding reflects that women with substance dependency are more likely to be married to men who are problem drinkers or substance abusers. Conversely, married substance dependent men are less likely to be married to problem drinkers. This line of research also found that there is more conflict in marriages when spouses have different drinking patters as would be the case of one spouse drinking heavily and the other lightly. In this context, it was also found that women report drinking in response to conflict and men report conflict because of their drinking (Walitzer & Dearing, 2006).
Recent NIDA funded studies also found that women in drug abuse treatment have lower rates of relapse than men. Researchers considered a number of theories to explain this disparity and found one plausible explanation: Women attended more group counseling sessions as compared to men. It is believed that women are more inclined to seek professional help than men. Men and women attended individual and family counseling sessions in equally which was attributed to the fact that they were limited in number. If an unlimited number of individual and family counseling sessions were available a valid hypothesis is that women would attend in greater numbers than men (Stocker, 1998).
According to Stocker (1998), Dr. Roger Weiss and his colleges also conducted a NIDA funded study in which he theorized that women have lower drug relapse rates because they are more motivated to succeed. He found that women, as compared to men, had to negotiate more obstacles to get into drug treatment and were thus more motivated to succeed. What made entry into treatment harder for women were childcare difficulties, dealing with the negative stigma of being a female addict, and the predominance of male patients and staff.
Scientists also studied gender differences in drug abusers’ experiences before and during relapse.
Dr. James McKay and his colleagues found that women in treatment for cocaine addiction were more likely than men to report negative emotions and interpersonal problems before they relapsed. The men, on the other hand, were more likely to report positive experiences prior to relapsing and were more likely to engage in self-justification and rationalizing afterward. (Stocker, 1998, p. 57)
Another interesting finding of this study was that women were significantly more likely to be compulsive in their return to cocaine use. In this study 56% of the women and only17% of the men reported relapsing right after the thought of use occurred to them (Ibid.).
Based on the prevalence of relapse of the chronic disease of substance use disorders, considerable research has focused on this topic. Clearly, psychologists, psychotherapists and counselors know that relapse prevention planning must take place for everybody in treatment for this disease, without exception. It is also important to remember in this context that abstention rates increase over time and that the first year is the most critical. What adds to the complexity of relapse prevention is how motivated a person is to change and why people begin using in the first place. Individuals hold varying attitudes about how exciting life should be, and many have mental health conditions for which they seek relief. Adding to this complexity are gender differences in why men and women use and relapse. Skilled psychologists, psychotherapists and counselors know that good relapse-prevention education requires intense individualized attention to address patients’ unique backgrounds and needs. The therapeutic process also enhances personal development, general life skills, addresses life challenges, and focuses any underlying mental health issues thereby setting the stage for a balanced life.
List of References:
Breining Institute (2008). The addiction professional: Manual for counselor competency (2nd ed.). Orangevale CA: Breining Institute
Counselor’s manual for relapse prevention with chemically dependent criminal offenders Technical Assistance Publication (TAP) Series 19 / Chapter 3-Relapse (n.d.). U.S. Department of Health and Human Services: SAMHSA, Office of Applied Studies. Retrieved July 03, 2011, from http://www.kap.samhsa.gov/products/manuals/taps/19b.htm
Extended abstinence is predictive of sustained recovery. National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching8.html
Gorkski & Miller (1986). Staying sober: A guide for relapse prevention. Independence, MO: Herald House/Independence Press
Iliff, B. (2008). A woman’s guide to recovery. Minnesota: Hazelton Foundation
Inaba & Cohen (2007). Uppers, downers and all arounders: Physical and mental effects of psychoactive drugs, 6th, edition. Medford, Oregon: CNS Publications, Inc.
Larimer, M., Palmer, R. & Marlatt, G. (1999). Relapse prevention: An overview of Marlatt’s cognitive-behavioral model. Retrieved Jul 01, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf
Marlatt, A, Parks, G. & Witkiewitz (2002). Clinical guidelines for implementing relapse prevention therapy. Behavioral Health Recovery Management. Retrieved Jul 07, from http://www.bhrm.org/guidelines/RPT%20guideline.pdf
McLellan, T. (2003). Forward: Relapse – Removing the taboos on the topic and promoting honest efforts to address it. Retrieved Jul 01, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf
National Survey of Substance Abuse Treatment Services: The N-SSATS Report (2010, October 14). Clinical or therapeutic approaches used by substance abuse treatment facilities. U.S. Department of Health and Human Services: SAMHSA, Office of Applied Studies. Retrieved July 02, 2011, from http://www.oas.samhsa.gov/2k10/238/238ClinicalAp2k10Web.pdf
Relapse rates for drug addiction are similar to those of other well-characterized chronic illnesses (n.d.). National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching8.html
Stocker, S. (1998). Men and women in drug abuse treatment relapse at different rate and for different reasons. NIDA Research Findings, 13 (4). Retrieved Jul 07, 2011, from http://nhts.net/media/NIDA%20Notes%20-%20Women%20and%20Gender%20Differences%20Research%20(40).pdf
Substance Abuse Relapse Prevention for Older Adults: A Group Treatment Approach (2005). U.S. Department of Health and Human Services: SAMHSA, Office of Applied Studies. Retrieved Jul 02, 2011, from http://www.kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf
Walitzer, K. & Dearing, R. (2006). Gender difference in alcohol and substance use relapse. Clinical Psychology Review, 26, 128-148. Retrieved Jul 06, 2011, from http://www.genderbias.net/docs/resources/guideline/Gender%20differences.pdf
Why do people take drugs in the first place? (n.d.). National Institute on Drug Abuse (NIDA).Retrieved Jul 05, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/largegifs/Slide12.gif
Why would anyone abuse drugs? (n.d.). National Institute on Drug Abuse (NIDA). Retrieved Jul 05, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching3.html