The present study compared characteristic relapse patterns of adults and adolescents after drug and alcohol treatment. We found two classes of relapse patterns in both adolescents and adults with important differences between the age groups. Two-thirds of the adults relapsed in social situations in which they experienced urges and temptations to drink/use (Social and Urges class; 67%), and one-third relapsed when they were coping with a negative emotion and also urges and temptations to drink/use (Negative and Urges class; 33%). In contrast, most adolescents relapsed in social situations when they were trying to enhance a positive emotional state (Social and Positive; 69%), while a smaller group of adolescents relapsed when dealing with a conflictual interpersonal situation accompanied by negative emotions and efforts to cope with urges and social pressures to drink/use (Complex; 31%).
The results of this study provide insight into the complex nature of relapse in both adolescents and adults. Comparing the teen and adult latent class results is useful. Intrapersonal situations that were not negative (i.e., enhancing a positive emotional state, testing personal control, or giving into temptation in the presence or absence of cues) did not differentiate any of the classes in either age group. However, relapsing while in a positive emotional state was five times more common among adolescents than adults (41.0% of the teen sample vs. 8.8% of adult sample). Further, among the teen sample, a positive emotional state was more common for those in the Social and Positive
relapse class compared to those in the Complex
relapse group. Thus, adults tended to be dealing with urges and/or temptations when they were in negative emotional states and also when they were in social situations when they may have been confronted with direct or indirect pressures to use. By contrast, adolescents relapsed when they had urges or temptations most often when they were also experiencing negative emotions, a negative interpersonal situation, and while in the presence of others. Youth were more often using to enhance a positive emotional state when they were in social situations. These patterns are consistent with the overall finding that the most common individual relapse precursor in adults is a negative emotional state (Marlatt & Gordon, 1985
) and that in adolescents it is social situations (Brown et al., 1989
; Myers & Brown, 1990
Further, the adult relapse classes were less complex (two predominant precursors in each class) than youth relapse patterns. For example, the Complex
class of adolescents was made up of four of five possible relapse precursors (all except negative physiological states). This suggests that adolescents may have had limited experiences with alcohol and drug lapses or relapses compared to adults and thus exhibit less distinct patterns of relapse contexts. This is consistent with literature describing other important cognitive and behavioral constructs suggesting that adolescents have less distinctive patterns of thinking when they are young which become more specialized or crystallized throughout development. Constructs that have exhibited this refinement in the content of cognitions have been expectancies of the effects of alcohol (Christiansen, Goldman & Brown, 1985
; Deas, Riggs, Langenbucher, Goldman, & Brown, 2000
; Dunn & Goldman, 1998
) and coping self efficacy (Ramo, Myers, & Brown, in press
There are multiple treatment implications for the findings presented here. It is clear that among both adults and adolescents, multiple personal and environmental factors influence each relapse (Brown & Ramo, 2006
; Witkowitz & Marlatt, 2004
). Thus, these findings suggest that relapse prevention portions of substance abuse treatment programs should target multiple relapse antecedents rather than just one primary antecedent. Further, particular attention should be paid to urges as a precursor among adult users regardless of emotional state or social situation, whereas adolescents might need different relapse prevention foci depending on the emotional state that occurs most often (e.g., negative vs. positive).
This study benefits from a number of strengths, including making use of detailed clinician-rated information on relapse characteristics and the ability to examine relapse characteristics in both adolescents and adults using comparable methods. Further, our adult and teen samples offered ample power to detect relapse class structure. In addition, we applied a relatively novel technique (latent class analysis) to subtype patterns of relapses in adolescents and adults. Although previous studies have used analytic approaches to understand the way relapse situations cluster (Anderson et al., in press
; Tate et al., 2004
), these have tended to be variable-centered approaches rather than person-centered approaches. Our method allows clinicians to target relapse prevention to the clusters of situations that most often occur in adolescents and also adults.
The teen and adult samples used in this study represented concomitant psychopathology common among those in treatment for substance dependence and comorbid Axis I disorders. Since psychiatric comorbidity places both youth and adults at risk for a unique and potentially dangerous course of substance use following treatment (e.g., Compton, Cottler, Jacobs, Ben-Abdallah, & Spitznagel, 2003
; Greenfield et al., 1998
; Grella, Hser, Joshi, Rounds-Bryant, 2001
), it will be important in the future to examine how psychiatric symptoms might influence the relapse class to which a person belongs. In addition, our findings need to be extended to those with fewer types of comorbidity and to large enough samples so that subgroup analyses can determine generalizability across other demographic groups.
Another important consideration is that our sample of adults was largely male, which is consistent with enrollment in substance abuse treatment programs in the Veteran’s Administration Healthcare System. There were no specific hypotheses about gender differences in relapse patterns, as Marlatt’s taxonomy of relapse precursors holds for both males and females in substance abuse treatment (Rubin, Stout, & Longabaugh, 1996
). However, it would be useful to replicate these findings with a sample of adults that is more heterogeneous with respect to gender. Further, participants for this study took part in community- and hospital-based treatment programs which were largely practice-oriented. It would also be useful to know whether these latent classes hold for those individuals who have undergone clinical trials of substance-abuse interventions, or have participated in programs that have adopted evidence-based practices, since these since these programs tend to have somewhat lower relapse rates than the community-based programs (e.g., Project MATCH Research Group, 1998
). Finally, this study focused only on initial relapse circumstances, and future research should evaluate whether subsequent relapses follows similar patterns.
Findings from the current study underscore the utility of considering person-centered approaches in the study of alcohol and drug relapse patterns. This information can be applied to treatment settings in which relapse prevention is an active goal, including both substance abuse and psychiatric treatment. Clinicians can focus prevention efforts on the situations that are most common to a given client’s developmental stage and vulnerabilities (e.g., situations in which they commonly used before treatment). Knowledge about contextual patterns further helps to target the situations in which adolescents and adults might be most vulnerable to relapse after treatment.