To our knowledge, the TRQ is the first empirical measure to specifically assess the time factors involved in relapse. Three factors were identified: Sudden Relapse, Short Delay Relapse, and Long Delay Relapse. The 9-item TRQ demonstrates content validity and strong overall and within factor consistency.
Factor labels were chosen to be descriptive only, although they may guide factor-specific clinical approaches. Items composing the Sudden Relapse factor describe an unexpected and rapid (e.g., a few seconds) return to drug use, unaccompanied by planning or a conscious awareness of the impending relapse. This factor is similar to Tiffany’s (8
) concept of “autonomy,” reflecting rapid, well-learned, routinized behaviors that are carried out “without initiation through intention” (p. 153). These patients may benefit most from behavioral interventions that focus on the avoidance of stimuli or situations that provoke relapse. Subjects scoring high in Short Delay Relapse endorse a return a substance use without protracted consideration of use but deny the very rapid relapse identified in the Sudden Relapse subjects. Cognitive and behavioral interventions may include previously rehearsed techniques, such as visualization of outcome, progressive muscle relaxation, distractions, and/or calling therapist or 12-step sponsor. Long Delay Relapse suggests significant cognitive control and reflection that buffers the time to relapse and may indicate a greater ambivalence towards using. Relapse in these subjects may be more influenced by other factors, such as craving, environmental stressors, and overwhelming mood states. In addition to techniques already mentioned, these patients might have sufficient time to attend a 12-step meeting or meet with their therapist.
Other self-report questionnaires in addiction may be viewed as having overlapping constructs with the TRQ. A validation study of the Obsessive Compulsive Drinking Scale (OCDS) (19
) included an “automaticity” factor. However, item content in this factor reflected active efforts to resist thoughts, consumption, or cravings, a construct dissimilar to the concept of Sudden Relapse proposed by the TRQ. Furthermore, Bohn and colleagues (19
) suggest that for the OCDS to better assess automaticity, additional items would need to be added that assessed constructs such as speed
of drinking and the degree to which drinking was intentionally planned
, both of which are addressed by the TRQ. Recently, Guardia et al. (20
) has published a 16-question Impaired Response Inhibition Scale for Alcoholism (IRISA) that assesses impaired inhibition to relapse in alcohol-dependent patients. However, the IRISA identifies only a single factor (impaired inhibition) and is specific to alcohol relapse.
Measures of convergent validity suggest, albeit weakly, that Short Delay shares similarities with other measures of impulsivity. The absence of such associations with Sudden Relapse may indicate that this measure taps into a process distinct from generalized disinhibition. This may reflect different biological processes, i.e., disinhibition is primarily mediated by prefrontal cortical structures (6
) whereas automatic process are largely localized to basal ganglia, particularly the dorsal striatum (21
Both TRQ versions utilized a large sample size and included a wide-age range of non-Hispanic whites, African-Americans, and both sexes. The questionnaire is self-administered, non-intrusive, face valid, quick, and easily understood, suggesting it is appropriate for use in patient care settings. Elevated scores in a single dimension identified a third of the population and were equally distributed across the three dimensions. As with all questionnaires regarding prior relapse experience, the TRQ assumes the accurate recollection of cognitions and behaviors prior to relapse. Previous studies have suggested acceptable levels of reliability in patients’ recall of previous substance use (22
), albeit with some under reporting (24
). Similar moderate to high levels of reliability were also reported in ex-smokers recalling smoking behaviors several years previous (26
). Nevertheless, the reliability of recall of relapse behaviors is uncertain. However, the results from our self-administered questionnaire were similar to those obtained during our more focused and comprehensive interview in Group 1. As the predictive utility of the TRQ has also not been assessed, prospective studies utilizing this measure should assess the extent to which individual factor scores correlate with treatment outcome. The current instrument study is a necessary first step in the development of a clinical and research measure that empirically assesses automaticity in relapse.