Relapse
An individual who has recovered from an illness or has entered a period of stability in a chronic illness and who subsequently suffers a recurrence of symptoms is said to have experienced a relapse. In the addictions, there has been some controversy over whether the term relapse can be used to indicate any use following a period of abstinence, or whether it should be reserved for more significant episodes of substance use that might indicate a return to problematic use or in some cases dependence. At the present time, there is some consensus in the field that the term lapse should be used for minor episodes of use following a period of abstinence, whereas relapse should be used to connote major episodes of use, such as drinking five or more drinks on two or more consecutive days.
Among the addictions, rates of relapse are relatively high among individuals who achieve abstinence with or without formal treatment. For example, up to 60 percent of alcoholics, heroin addicts, and smokers relapse within three months of the end of treatment. Although relapse episodes are common, most substance abusers do experience substantial reductions in the frequency and severity of use for extended periods after treatment. Addictions are now thought to be chronic, relapsing disorders in which afflicted individuals cycle through periods of heavy use, treatment, abstinence or reduced use, and relapse.
A number of models have been proposed to explain the relapse process. One of the more influential and widely accepted of these is the cognitive-behavioral model. According to this model, individuals experience an increased risk of relapse when they encounter so-called high-risk situations, which are situations that have been associated with substance use in the past. The model postulates that one of two processes occurs when a substance abuser encounters a high-risk situation. If the individual has high self-efficacy, or the belief that he or she can manage the situation without using alcohol or drugs (i.e., relapsing), a coping response is performed and relapse is avoided. However, if the individual has lower self-efficacy, a coping response is not performed and relapse ensues. Therefore, in this model relapse is seen largely as a function of whether one (1) encounters high-risk situations, and (2) is able to mount an effective coping response. Other cognitive features of the model include outcome expectancies (i.e., what will happen as a result of either substance use or the exercise of a coping behavior) and attributions for one's behavior.
Related models of relapse, which encompass enduring personal characteristics and background variables, in addition to immediate precipitants and coping responses, have also been proposed. According to these models, individuals with characteristics such as a family history of substance abuse, concurrent psychiatric problems, and more severe substance-use histories are at increased risk for relapse during periods of abstinence. Risk for relapse is further increased by factors such as major life events, protracted life stressors, low social support, and low motivation for self-improvement. When individuals with these characteristics encounter a high-risk situation, they are less likely to be able to mount an effective coping response.
Other models of relapse place much less emphasis on conscious, cognitive processes. For example, one classical conditioning model proposes that sudden urges to use, or cravings, are triggered when an individual encounters a situation or experience that has been frequently paired with substance use in the past. For example, a former substance abuser might suddenly experience craving for cocaine when he encounters someone with whom he used to smoke cocaine. Another model postulates that relapses are frequently governed by ingrained, automatic processes that occur below the level of conscious thought. This might explain why in some cases, substance abusers appear to have very little insight into the factors that led them to relapse. Athird model is focused on the importance of WITHDRAWAL symptoms in the onset of relapse. This last model would seem to better account for relapses that occur within a few days of the onset of abstinence than relapses that occur after months of abstinence. However, there is some evidence that individuals who have been abstinent for significant periods of time could have experiences that trigger the onset of withdrawal-like feelings through classical conditioning processes described above.
Although the models briefly described here tend to focus on particular factors or mechanisms that are hypothesized within each model to play important roles in relapse, it is widely believed that the process of relapse is actually determined by a host of factors, including motivation, mood states, craving, and coping behaviors, as well as other cognitive, biological, and interpersonal factors. Moreover, individuals probably differ with regard to the relative importance of various factors in the onset of their relapse episodes. It is also possible that the processes which bring about relapses that occur relatively quickly differ to some degree from those that lead to relapse after long periods of abstinence or nonproblematic use.
One of the problems in developing a valid model of the relapse process is that it is very diffi-cult to study. It is usually not possible to interview or observe substance abusers immediately prior to relapse, so researchers have often had to rely on accounts of events leading up to relapse gathered at some point after the episode to obtain information on relapse precipitants. Unfortunately, there is considerable evidence that retrospective reports such as these can be inaccurate or biased because substance abusers are either unaware of what brought on a relapse or their memory is distorted. Recently, researchers studying NICOTINE relapse have begun to use palm-sized, portable computers to systematically record in near real time information about the mood states, cognitions, and situations that smokers experience, and to link these factors to the onset of smoking relapse, which are also recorded on the computers. It is not clear whether this new technology will work adequately with abusers of other substances, such as ALCOHOL and COCAINE. Final determinations of the validity of various models of relapse will likely have to await the development of better technologies with which to study the process.
Bibliography
BROWNELL, K. D., ET AL. (1986). Understanding and preventing relapse. American Psychologist, 41, 765-782.
CONNORS, G.J.ET AL. (1996). Conceptualizations of relapse: A summary of psychological and psychobiological models. Addiction, 91, S5-S14.
DONOVAN, D. M. (1996). Assessment issues and domains in the prediction of relapse. Addiction, 91, S29-S36. MCKAY, J. R. (1999). Studies of factors in relapse to alcohol, drug, and nicotine use: A critical review of methodologies and findings. Journal of Studies on Alcohol, 60, 566-576.
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