gender and marital status effects on relapse web viewthis is also discussed in pemberton’s...

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Running Head: Alcohol Relapse after Treatment: The Influence of Marital Status and Gender

Alcohol Relapse after Treatment: The Influence of Marital Status and Gender

Stephanie L. Hood

J. Scott Tonigan, PhD

The Center on Alcoholism, Substance Abuse, and Addictions

University of New Mexico

ALCOHOL RELAPSE AFTER TREATMENT: THE INFLUENCE OF GENDER AND MARITAL STATUS

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Abstract:

Background: To date, studies have not investigated the effects of gender, marital status, and

interaction in spite of its clear importance to understanding the mechanisms accounting for

alcohol relapse. Such an investigation, using Project MATCH is a prerequisite to understanding

how, if at all, coping is important in Marlatt’s Relapse Prevention model.

Methods: Using Reasons for Relapse Questionnaire from Project MATCH, the 1,726

participants self reported influential factors of alcohol relapse. Using SPSS 18.0, all general

linear models (GLM) models included gender, marital status, and the interaction between gender

and marital status. All inferential tests were evaluated at p < .05.

Results: At three months, spousal support played a greater significant role for females than

males (p <.019) and amongst married individuals (p<.026). Conversely non-married individuals

and the relationship between gender and marital status played a significant role for “people

outside the family” (both at p<.000). Females also reported greater significance than males for

“feeling down or blue.” (p<.026). At nine months, males reported greater significance than

females about “feeling good” (p<.001), females reported greater significance about feeling

“uptight or anxious” (p<.016), and for married individuals reported having greater significance

than non-married individuals for “letting down your guard about alcohol”. Lastly at 15 months,

married individuals reported a greater significance for spousal or spousal equivalent (p<.034),

and females continually reporting significance for “feeling uptight or anxious” (p<.002).

Conclusion: This study compared the retrospective reasons men and women provided for a

relapse, with attention given to how these reasons may be influenced by patient marital status.

Key Words: Marlatt’s Relapse Prevention Model, Alcoholism, Gender, Marital Status, Project

MATCH


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Alcohol is the most frequently abused substance in the country, with nearly 85,000 deaths

yearly. Unknown to many, alcohol is the only drug known to result in death from withdrawals

(Mokdad et al., 2004; Schneider et. al., 2003). In spite of effective and evidence-base treatments

relapse is common. Approximately 93% of all problem drinkers, for example, resume alcohol

use in the time-span of 5 years (Emrick and Hansen, 1983). One of the prominent models of

relapse (Marlatt and Gordon, 1985) argues that patients are poorly equipped to identify relapse

prone situations and therefore patients must learn to identify relapse situations and appropriate

responses to prevent relapse. In this light, Marlatt’s approach includes environmental and

emotional considerations. They categorize these into two groups; one is immediate determinants

(ex. high risk situations, coping skills, and outcome expectancies) and, the second, covert

antecedents which include lifestyle imbalance (stress, sadness, etc.) and urges and cravings for

alcohol. Further, their relapse prevention (RP) model includes therapist-patient interactions

intended to identify high risk situations and the conditions under which they may or may not

drink. Central to avoiding relapse is abstinence self-efficacy or the confidence one has in

avoiding the use of alcohol. Marlatt and Gordon’s model therefore seeks to provide the patient

with the “big picture” in trying to control these situations (Larimer, et al., 1999). Within this

model therapists seek to elicit patient responsibility for their drinking, and to encourage patients

to take a more immediate view of relapse triggers. Marlatt also describes that therapists must

have their patients examine the myths, placebos, and misperceptions they hold about the positive

effects of alcohol. This allows therapists to interpret patient’s alcohol expectancies before they

drink which are often based on these myths and placebos (ex. how they will feel, the high, etc.)

versus what the real side effects are, which a majority of them are negative side effects

(sleepiness, emotional instability, etc.). The RP suggest that one can manage lapse or relapse by


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identifying triggers or high-risk situations and using cognitive restructuring techniques learned in

therapy to avoid drinking.

Although the RP model has gained widespread acceptance and its use of empirical

support has been mixed about its’ validity. To illustrate, the Relapse Replication & Extension

Project (RREP), which was funded by the National Institute on Alcohol Abuse and Alcoholism

(Larimer, et al., 1999), studied predictors of relapse every two months for a year. At each

assessment, they measured five different domains: (1) the occurrence of negative life events; (2)

cognitive appraisal variables including self-efficacy, alcohol expectancies, and motivation for

change; (3) client coping resources; (4) craving experiences; and (5) affective/mood status. This

study’s impact is important because as a multi-site trial with a large sample substantial

confidence can be placed in study findings. Surprisingly, high-risk situations did not predict later

relapse as suggested by Marlatt, suggesting that individuals are especially good at identifying

high risk situations. In contrast, coping skills were predictive of relapse as proposed in the

model, with positive approach and negative avoidance coping, predicting 85% of the cases that

had relapsed at six-months.

An important question is, do men and women differ in their relapse rates? Based upon a

large meta-analytic study (Vannicelli & Nash, 1984) this deceptively simple question appears to

have an elusive answer. First, according to these authors women were underrepresented in

alcohol research. To illustrate, women comprise about 20-25% of alcohol dependent adults in

treatment but in reviewing 259 studies only 7.8% of the study participants were female. Jarvis

(1992) meta-analytically analyzed Vanicelli & Nash’s study to determine if women have poorer

prognoses than men. Jarvis found no support for the claim that gender moderated outcome.

Similar conclusions were drawn by Annis and Liban (1980) in their review of 23 studies. Here,


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men and women had relatively similar treatment outcomes although these authors highlighted

that predisposing factors predicting relapse (men vs. women) have not been explored. With

Jarvis’ meta-analysis of qualitative and quantitative research she looked at relapse from 3-6

months, 7-12 months, and 12+ months. Jarvis concluded from her review that: (1) men have had

better inpatient results then women, (2) men and women have better outcomes with different

treatments, (3) women have a lower alcohol intake than men, which might result in

successful/non successful treatment outcomes, and (4) women respond better to one-on-one

therapy due to high stigma linked to the “role” of women with alcoholism and that they can

discuss more issues in confidence rather than in a group. Unlike with men, Jarvis notes that men

like to discuss their problems amongst other men who are going through the same thing and

would rather do this in a group setting. This is also discussed in Pemberton’s article which 50

females were admitted to the hospital and evaluated by different factors about their drinking

onset. Their findings supported Jarvis conclusions; men feel more comfortable discussing their

alcohol issues amongst others, while women remained secretive about their alcoholism. Jarvis

found that gender difference was very small and that women have better outcomes in the first

year, while men do better past 12+ months. Regarding treatment, Krentzman, et. al’s study

discovered no gender difference in one year sobriety for their study (who identified themselves

as AA members). These women’s demographic information were statistically different than

males which were more likely to be White, more educated, and were more employed. This goes

against Rubin and colleague’s study who found gender differences that women drink to

intoxication more than men, while men experienced more positive mood states during relapse

than women. Walton, et al., 2003 reports that men have higher self-efficacy, which predicts

lower alcohol use, and women report greater resource needs, which predicted more drug use.


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Furthermore, in Timko, et al.’s results found that there are gender differences in baseline status

and help-seeking at their 8 year follow up.

Evidence suggests a complex relationship between relapse and gender; one that may be

moderated by patient marital status. To begin, Walton, et al., (2003) followed 180 participants

after treatment, and interviewed them at 1-month and two years. It should be noted that Walton,

et al., 2003 studied alcohol as well as general substance abuse. He divided results into two

graphs (alcohol and drugs). Within this sample, 25.4% were never married, 1.3% was widowed,

and 40.8% separated or divorced. They found that alcohol relapse correlated with income,

marital status, cravings, leisure activities, self-efficacy (previously mentioned with RP), and

resource needs. Marital status which is our main concern, was significantly directed both in

interpersonal assets (.45) and also social/environmental (.46). Adding to that, Pemberton’s

research found that females find it more difficult to establish a satisfying role amongst their

family due to a demanding husband, another illness they might be suffering from, or failure to

adapt to the loss of their husband. Self-efficacy significantly mediated indirect effects of income,

gender, marital status, and problem severity in Walton’s study. Markers of low self-efficacy

included lower income, being female, greater problem severity, and being unmarried. Walton, et

al. (2003) found that coping in this study did not predict post treatment alcohol as suggested by

Marlatt and Gordon. Previous work (Cronkite & Moos, 1984) has found that being married is

associated with more positive treatment outcome for male substance abusers, but the impact of

being married on women’s relapse is not consistent and needs further research. Schneider et al,

(1995), states that results indicated being married is consistently related to less drinking for men,

while for women, being married contributes to relapse in the short term.


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Central in the RP model is how people identify and cope with stressful situation.

According to Noone et al., (1999) the lack of coping resources, poor social support, low efficacy,

loss of control, and negative coping can all lead to relapse. A moderator of stress that has not

been tested is cognitive hardiness, which is the motivation and high efficacy personality needed

to reduce stress which could decrease the rate of relapse. The health belief model also helps

reduce drinking behavior by describing in depth to patients that drinking deteriorates health and

resorting to sobriety can improve these health implications like liver disease, alcoholic hepatitis,

and severe abnormalities to the brain. In this study, stress was assessed by their health, work,

financial stability, family, environmental, and social hassles. The only demographic variable

which showed a significant multivariate effect was level of education. Of course, high efficacy

and high social support decreased drinking according to Noone et al., (1999) and also Brown, et.

al., 1995. Noone’s findings were that 26% remained abstinent and 28% drank at harmful levels

of 6+ drinks a day. Stressors in the patients’ lives were measured a month prior before their

follow-up date and was said to be a significant predictor. Social support is very important to help

recovering alcoholics and concludes that treatments should include stress management

techniques, encouragement for patients to utilize ongoing social support, and positive coping

strategies to increase self-efficacy.

The scope of this study is to investigate the attributions people make about why they

relapse. To date, studies have not investigated this topic in spite of its clear importance to

understanding the mechanisms accounting for alcohol relapse. Specifically, this study will

compare the retrospective reasons men and women provided for a relapse, with attention given to

how these reasons may be influenced by patient marital status. Such an investigation is a

prerequisite to understanding how, if at all, coping is important in the RP model. The context for


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this investigation is a large multi-site clinical trial (PMRG, 1998; 2002) studying the

effectiveness of cognitive behavioral, motivational enhancement and 12-step outpatient

treatment. In examine reasons for relapse we will adopt the practice of grouping reasons

according to whether they are situation or emotional in nature. Given that relapse typically

occurs rapidly after treatment, our study will focus on the first 12 months after the outpatient

experience or 15 months after the initiation of treatment.

METHOD

Project MATCH aftercare (N = 774) and outpatient (N = 952) samples were used in this

retrospective study. Briefly, Project MATCH was a multi-site clinical trial investigating client-

treatment matching, and findings have been reported elsewhere (e.g., PMRG, 1997; 1998).

Following recruitment into the study, clients were randomly assigned to one of three

psychosocial treatments: Cognitive Behavioral Therapy (CBT; Kadden et al., 1992),

Motivational Enhancement Therapy (MET; Miller et al., 1992) or Twelve Step Facilitation (TSF;

Nowinski et al., 1992). Therapy lasted twelve weeks, and therapists were nested within therapy

conditions. Follow-up assessments were conducted in three month intervals from randomization

which corresponded to an end of treatment assessment and follow-up interviews 3, 6, 9, and 12

months after treatment.

A noteworthy contribution of the Project MATCH research group was the aggressive

attention paid to the training of therapists and research assistants, documentation of treatment

fidelity, high follow-up rate (exceeding 90% at all follow-ups), and use of an exhaustive number

of instruments, nearly all of which had published psychometric data. Full descriptions of these

aspects of Project MATCH have been provided elsewhere (Connors et al., 1994; Zweben et al.,


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1998). In addition, a test-retest exercise was conducted (N = 82) to evaluate the reliability of

instruments that were developed specifically for Project MATCH, instruments which form the

core assessments for this study (Tonigan et al., 1997)

Quick Screen Interview. This interview was conducted to make a final determination

about eligibility and to collect basic demographic information. Information critical for this study

collected measure included participant gender and marital status.

The Form 90 family of instruments was developed for Project MATCH as the central

measure of client drinking (Miller, 1996). The Form 90 is a semi-structured interview that

combines grid (Miller & Marlatt, 1984) and calendar-based approaches to reconstruct day-by-

day drinking and health-related activities over a 90-day period. Measures of percent days

abstinent (by month) and drinks per drinking day (by month) have good reliability (Tonigan et

al., 1997), as do measures of the frequency of health-related experiences, e.g., emergency room

visits for medical care.

Reasons for Relapse Questionnaire. This was a self-report survey that included a total of

45 items that asked about two domains, reasons for relapse and methods for staying sober. This

study examined response to section 1, which was divided into situational influences (6 items),

personal influences (8 items), and (11 items) general influences. Of these, we focused on

situational and personal influences (14 items) because they corresponded most closely to

Marlatt's RP model.

(Reasons For Relapse and Methods For Staying Sober questionnaire about here)

Statistical Analyses. In addition to descriptive statistics, e.g., means and standard

deviation (SD), used to describe the sample we used SPSS version 18.0 to conduct General

Linear Model (GLM) tests. The dependent measures in these analyses included the 14 items in


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the Reasons for Relapse Questionnaire, all which straddled the fence between ordinal and

interval scaled data (1 through 5, Likert scale with anchors of small to great influence). Our two

independent variables were marital status (married versus not married), and gender. In the

analysis, these factors were considered fixed. All GLM models included the marital, gender, and

marital times gender interaction. All inferential tests were evaluated at p< .05 (1 in 20 chances of

being wrong). However, we planned to conduct 14 tests which inflated Type I error.

RESULTS

Displayed in Table 1 are the samples’ characteristics. The total sample of this study was

1,726 participants; 1,305 males and 421 females. Amongst this sample the average age amongst

both men and women was 40 and nearly the same level of education of 13 years. The alcohol

severity was recorded for males at 52.81 and 48.12 for women which is extremely severe.

Anyone over 20 is considered alcohol dependent. This study had many categories of the patient’s

status (married, divorced, separated, widowed, etc.), but with sole concern on the patients marital

status, males had a percentage of 34.8% being married and women were at a lower rate of

26.84%. A majority of the study was Caucasian, with a variety of Hispanic background. An

estimated 22% of this study was unemployed amongst males and females.

(Insert table 1 about here)

Table 2 summarizes the hypothesis of the situational and personal influences on reasons

for relapse. There was over 108 tests ran; 12 influences were measured at 3 months, 6 months,

and 15 months, and for gender, marital status, and the interaction. Only the significant tests are

reported as the others were not sensitive measures of relapse.

(Insert table 2 about here)


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Examining at three months after assessment, spousal support played a greater significant

role for females p <.019 and also a significant finding amongst married individuals at p<.026.

People outside the family had an influence at three months for non married individuals

and the relationship between gender and marital status played a significant

role (both at p<.000). Females also reported “feeling down or blue” as more

significant than males at p<.026. At nine months, there was a significant increase in

situational levels with patients feeling good, specifically with males (p<.001), feeling uptight or

anxious for females (p<.016) and patients having difficulty with married individuals letting their

guard down (p<.034). Very little change was reported later in treatment at 15 months, with the

only significant variable for spousal support for married individuals (p<.034) and feeling uptight

or anxious for females (p<.002).

Discussion

This study examined the effects of gender, marital status, and their interaction on alcohol

relapse. We found, for example, specifically, the first three months after treatment female and

married participants showed significance for spousal support, while non-married individuals

showed significance for support outside of the family. Females also reported if they felt “down

or blue” was significance. Nine months following treatment, males reported “feeling good” was

highly significant more than females, which might have correlation with Walton et al.’s (2003)

study concluding men having higher self efficacy and if they feel positive might result into

relapse. While females, feel more negative affect (“uptight or anxious”), and married individuals

having difficulty letting their guard down about alcohol which might be related to Pemberton’s

findings of women having a demanding family. At 15 months, spousal support and the emotions

of feeling “uptight or anxious” continually reported as significant. Even though, previous studies


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reported no gender difference, both men and women did not report significance for the same

items resulting that both men and women different in their reasons for relapse. Marital status has

difference showing that married individuals demonstrated higher significance from their spouse

and letting down their guard. The only interaction amongst gender and marital status was

“people outside of the family” at three months after treatment. Several implications should be

noted, females showed significance in social settings, specifically through spousal support. This

may allow females to seek out treatment (ex. 12-step facilitation) that is social, yet is an

abstinence environment to allow sobriety to occur. Females also reported repeatedly negative

affect to result into relapse. In our study, they reported “feeling down or blue” at three months,

and “feeling uptight or anxious” both at nine months and 15 months. This allowing females to

become vulnerable when these emotions arise, making females seek out alternative activities to

remain sober. Study findings partially support Marlatt’s model. The RP model includes negative

affect for relapse to occur. If someone is feeling angry or down or blue the RP model states that

relapse will occur. If you examine item 12 of our study “feeling angry” was not reported at all

significant at 3, 9, or 15 months. Gender examined closer, females did report “feeling down or

blue” as significant, but not for males. Marlatt’s RP model did not necessarily include family and

people relationships, rather environmental cues. Clear utility of the RP model is in clinical

settings; yet our findings suggest that specific elements are poorly understood.

Some study limitations should be noted. One is the retrospective time frame of the

assessment procedure. Specifically, MATCH participants answered this questionnaire after they

had relapsed, potentially biasing recall of the factors precipitating the relapse. Another limitation

is our definition of gender. Participants reported what gender they considered themselves. This

can go much more in depth if they are females, but have high masculinity or male and having


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high femininity. Likewise, sexual orientation was not countered for. Another limitation focuses

on how “relapse” is to be defined. In this study relapse was considered to have occurred when

any alcohol was consumed. This definition, however, did not discriminate between lapse and

relapse, and it should be noted that such distinctions may produce different findings. Another

limitation involves the cross-sectional nature of the data analyses. At one extreme, different

people could have relapsed at each follow-up interview. This possibility would make it

problematic to know whether reasons for relapse change over time or if different people have

different reasons for relapse. Our analyses indicated that relapse group membership was

relatively unstable at early follow-up, but stabilized in later follow-up. Some may argue with our

decision to define marital status as only a legally binding relationship, thus not including

cohabitating relationships. While a valid concern, and an alternative which should be explored,

our choice was based upon the assumption that termination of a legally binding relationship was

qualitatively different than for cohabitating couples thus deepening the influence of a

relationship partner (positive and negative). Finally, our exploratory study conducted 108

inferential tests and therefore had a significant Type I error rate. Our pattern of findings,

however, suggests that many of the results were not spurious. Future investigations may elect to

narrow the number of inferential tests based upon our findings. Concluding this study, rare

views of gender and marital status have been explored to explain alcohol relapse. Through

Project MATCH and the personal and situational influences reported throughout this study the

effects of gender and marital status on alcohol relapse can help further the addiction field in

correspondence to Marlatt’s Relapse Prevention model.


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References

Annis, H. M. & Liban, C. B. (1980). Alcoholism in women: treatment modalities and outcomes, in: KALANT, O. J. (Ed.) Alcohol and Drug Problems in Women: Research Advances in Alcohol and Drug Problems Vol 5, pp. 384-422 (New York, Plenum).

Brown, S. A., Vik, P. W., Patterson, T. L., Grant, I., & Schuckit, M. A. (1995). Stress, vulnerability, and adult alcohol relapse. Journal of Studies on Alcohol, 56, 538–545.

Cronkite, R., & Moos, R. (1984). The role of predisposing and moderating factors in the stress–illness relationship. Journal of Health and Social Behavior, 25, 372–393.

Jarvis, T. J. (1992). Implications of gender for alcohol treatment research: a quantitative and qualitative review. British Journal of Addiction, 87, 1249–1261.

Krentzman, A., Brower, K., Cranford J., Bradley J.C., Robinson, E. (2012). Gender and Extroversion as Moderators of the Association between Alcoholics Anonymous and Sobriety. J. Stud. Alcohol Drugs, 73, 44-52.

Larimer, M. E., Palmer R., and Marlatt A., (1999). Relapse Prevention. An Overview of Marlatt’s Cognitive-Behavioral Mode. Alcohol Research & Health, Vol. 23, No. 2. 151-160.

Miller, W.R., Westerberg, V.S., Harris, R.J., Tonigan, J.S., (1996). Extensions of Relapse Predictors beyond High-Risk Situations. What predicts relapse? Prospective testing of antecedent models, 91 (Supplement):S155-S171.

Mokdad A, Marks, J., Stroup D., Gerberding J. (2000). Actual Causes of Death in the United States. JAMA. 2004; 291(10):1238-1245. doi:10.1001/jama.291.10.1238.

Noone, M., Dua, J., Markham, R., (1999). Stress, Cognitive Factors, and Coping Resources as Predictors of Relapse in Alcoholics. Addictive Behaviors, Vol. 24, No. 5, pp. 687–693.

Pemberton, D.A. (1967) A comparison of the outcome of treatment in female and male alcoholics, British Journal of Psychiatry, 113, pp. 367-373.

Rubin, A., Stout, R.T., Longabaugh R., (1996). Gender Differences in Relapse Situations. Addiction, 91 Suppl: S111-20


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Schneider, U., Kroemer-Olbrisch, T., Wedegartner, F., Cimander K. F., and Wetterling T., (2004). Wishes and Expectancies of Alcoholic Patients Concerning their Therapy. Alcohol & Alcoholism Vol. 39, No. 2, pp. 141–145, 2004. doi:10.1093/alcalc/agh029.

Timko, C., Moos, R., Finney, J., Connell E. (2011). Gender differences in help-utilization and the 8-year course of alcohol abuse. Addiction 97, 877-889.

Vannicelli, M. & Nash, L. (1984) Effect of sex bias on women's studies on alcoholism, Alcoholism: Clinical and Experimental Research, 8, pp. 334-336.

Walton M., Blow F., Bingham R., Chermack S. (2003). Individual and social/environmental predictors of alcohol and drug use 2 years following substance abuse treatment. Addictive Behaviors 28 (2003) 627–642.


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Reasons for Relapse and Methods for Staying Sober questionnaire


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Table 1:Sample Characteristics

Male (N=1305) Female (N=421)

Years of Education 13.22 (2.11%) 13.40 (2.12%)

Age 40.28 (10.81%) 40.08 (11.58%)

Alcohol Severity 52.81 (23.34%) 48.12 (22.80%)

% Married 454 (34.80%) 113 (26.84%)

% Caucasian 1046 (80.15%) 336 (79.81%)

% Hispanic 70 (5.36%) 30 (7.13%)

% Unemployed 129 (9.89%) 49 (11.64%)


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Table 2:

Gender by Marital Responses to the Reasons for Relapse and Methods for Staying Sober:Summary of GLM Analyses

Item Stem 3 months 9 months 15 months

Situational Influences

Spouse influence (5) Gender, p< .019 ------------ Marital, p<.034

Marital, p<.026

Family members (6) ------------ ------------ ------------People outside the family(7) Marital, p < .001

Marital*Gender, p <.001------------ ------------

Someone offering a drink (8) ------------ ------------ ------------Alcohol readily available (9) ------------ ------------ ------------

Personal Influences

Feeling good (11) ------------ Gender, p <.001 ------------Feeling angry (12) ------------ ------------ ------------Feeling down or blue (13) Gender, p <.026 ------------ ------------Feeling uptight or anxious (14) ----------- Gender, p <.016 Gender, p.<.002Desire to drink or get high (15) ------------ ------------ ------------Letting down your guard (16) ------------ Marital, p<.034------------


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Feeling in control (17) ------------ ------------ ------------

gender and marital status effects on relapse web viewthis is also discussed in pemberton’s...

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