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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Am J Health Behav. Author manuscript; available in PMC 2014 May 16.
Published in final edited form as:
PMCID: PMC4023909
NIHMSID: NIHMS576659

Understanding Recovery Barriers: Youth Perceptions About Substance Use Relapse

Rachel Gonzales, PhD, MPH, Research Psychologist, M. Douglas Anglin, PhD, Professor in Residence, Associate Director, Rebecca Beattie, MPH, Staff Research Associate, Chris Angelo Ong, MPH, Staff Research Associate, and Deborah C. Glik, ScD, Professor

Abstract

Objective

To qualitatively explore how treatment-involved youth retrospectively contextualize relapse from substance use.

Methods

Fourteen focus groups were conducted with 118 youth (78.3% male; 66.1% Latino) enrolled in participating substance abuse treatment programs (4 young adult and 10 adolescent) throughout Los Angeles County. Transcripts were analyzed for relapse perception themes.

Results

Dominant relapse themes include emotional reasons (90%), life stressors (85%), cognitive factors (75%), socialization processes (65%), and environmental issues (55%).

Conclusions

Youth perceptions about relapse during treatment should be used to better inform clinical approaches and shape early-intervention recovery agendas for substance-abusing youth.

Keywords: substance abuse treatment, relapse, youth perceptions, adolescents, young adults

Substance use problems among youth under 25 represent one of the major prevention and treatment issues in the United States: nearly 70% of all youth mortality (ages 15–24) has been attributed to unintended injuries, homicide, and suicide,1 all of which are highly correlated with substance use behaviors.2,3 Moreover, statistics from general population US-based prevalence surveys, national treatment admission data, and juvenile justice drug offense cases support the extent of problem. National (US) survey studies show that illicit substance use and binge drinking trends for youth are up from previous years: 10.0% of 12- to 17-year-olds and 21.2% of 18- to 25- year-olds report past-month use of illicit substances, and past-month binge drinking rates were 8.8% and 41.7% for 12- to 17-and 18-to-25-year-olds, respectively.4 Publicly funded treatment admissions are also high: 7.6% of admissions are under 18 and increase to 21.6% for those 18 to 25.5 Substance use-related juvenile/criminal court cases are common as well: 44.2% of all cases ages 10–24 were for drug offenses, 15.1% for juveniles 10–17 years of age.6

Given such public health complexities, much of the attention regarding addressing substance use issues among youth has been directed at interrupting drug use through treatment settings, where the main goals are to “effectively reduce substance use behaviors and improve critical areas of life functioning that are expected to be positively influenced by treatment.”7 Large-scale treatment outcome studies with youth demonstrate that treatment (in general) produces positive changes in substance use and other psychosocial outcomes;811 however, treatment benefits tend to diminish over time.12 Substance use “relapse” is of primary concern, which is typically about 65% in the first 90 days after treatment and increases to rates of about 85% during the post-year follow-up period.11,1320

Relapse has been contextualized both as a “discrete outcome” or “a process.” 21 Definitions of relapse also differ and typically have been either operationalized as “a return to any use” or “a return to original problematic use” before treatment.22,23 There have been several attempts to establish specific conceptual models for relapse among adult populations.2333

To date, conceptual models tend to categorize relapse using 4 major precursors/antecedents,34,35 including the specific drug (agent), characteristics of the user (personal), characteristics of the user’s social relationships/setting (interpersonal), and environmental (situational) factors. Relapse precursors that have received the most support include negative affective emotional states,34,36,37 cognitive-behavioral factors including self-efficacy/confidence,38 outcome expectancies,39 urges/temptations,40 coping,41,42 and motivation/readiness to change.34,44,45

Interpersonal determinants include relationship conflict,4648 social pressures,49 social support, and life stressors.5053 Environmental determinants include cue-situational exposures and geographic disadvantage, ie, high availability of drugs, crime and poverty.27,5457 Despite these findings, many studies conclude that relapse is often random, complex, and dynamic,5860 determined by an interaction of diverse physiological, individual, and situational factors,32,61 and cannot be solely captured by a single process model.62

Research on substance use relapse among youth is less extensive. Existing youth-based studies have identified similar relapse determinants as are found among adult samples6366; however, it is considered to be particularly more complex for several reasons: adolescents are still undergoing brain maturation and are in the midst of greater cognitive and social-emotional development processes;6769 have higher co-occurring mental health and psychosocial dysfunctions within family, school, and legal settings;7073 have greater influence from social agents/events;7476 have different clinical courses of substance use severity/diagnosis7780 and lower levels of treatment motivation.80,81

Although the literature is growing in the area of substance use relapse among youth populations, retrospective accounts of the relapse process are limited, and many substantive questions remain. This study employed a qualitative approach to examine the following research questions: (1) How do youth in treatment perceive their risk for substance use after treatment? (2) What are some major factors that are associated with relapse risk among treatment-involved youth? This study seeks to address these questions to identify some of the early warning signals indicating potential relapse for youth 24 years and younger to better inform clinical approaches to better meet the needs of substance-abusing youth as well as shape early-intervention recovery agendas.

METHODS

A convenience sample of youth aged 12–24 was drawn from participating substance abuse treatment programs (10 adolescent specific and 4 adult) in diverse Los Angeles areas (San Gabriel Valley, North Hollywood, West Los Angeles, San Fernando Valley, and Antelope Valley). Unlike the adolescent-specific programs used, this sample does not include young adult-specific programs, but rather a select set of participating adult programs that had designated young adult groups to capture youth 18–24. Hence, due to the participating treatment sites availability of young adults, there are fewer young adults groups available. Research procedures were approved by the Institutional Review Board of the University of California Los Angeles.

Participants

One-hundred eighteen youth between 12 and 24 constitute the study sample: average age was 17.4 ± 2.9 years; 78.3% male; 66.1% Latino and 25.2% white (25.2%); 69.5% were in outpatient treatment; and most reported marijuana (40.9%) or methamphetamine (30.4%) as their primary substances of abuse. Sample characteristics are representative of youth based on wide-scale California treatment evalautions: average age of youth admissions is 17, 68% male, and 59% Latino.84

Procedure

A total of 14 focus groups were conducted with 118 youth in participating substance abuse treatment programs between September 2010 and December 2010. Focus groups were 90 minutes in length and digitally audio-recorded. Each participant received a $10 gift card for incentive. The principal investigator (PI) moderated each group using scripted questions.34 A research assistant (RA) trained in focus group procedures assisted with moderating the focus groups.

The scripted questions covered youth perceptions and attitudes around substance use behaviors, substance use relapse, and substance use recovery. The focus group leader (PI) used a standardized script to discuss the relapse concept and provide a common level of understanding of relapse. For this, participants were asked to think about life after treatment and consider the most common situations or reasons that caused them to relapse (defined as both (1) using any alcohol or drugs again and (2) reverting back to their pretreatment pattern of drug use). Using the following scenario: “Jane/John went through treatment for substance use problems. After treatment (within the next 3 months), he/she relapsed. Finish my statement: ‘He/she relapsed because…?’ ” After general responses to the relapse scenario were noted (ie, stress), specific reasons related to each response were assessed (ie, family, school, legal, etc). In addition to participating in the focus group discussion, all participants anonymously completed a demographic questionnaire collecting age, gender, race/ethnicity, primary substances used, and treatment history information for descriptive purposes.

Data Analysis

Audio recordings for 14 focus groups were transcribed by 2 research assistants and edited and re-reviewed by the research team for accuracy and fidelity. Transcripts were coded using a systematic set of procedures based on grounded theory84 to inductively develop themes around relapse perceptions among youth. To ensure completeness and accuracy, 2 reviewers coded each transcript, and a third coder was used to resolve any discrepant coding by a consensus approach with the research team.85 Using ATLAS.Ti, a qualitative statistical software program for content and text analysis,86 focus group responses from all youth participants (N=118; 92 adolescents and 24 young adults) were assessed to obtain overall percentages for each theme identified and unique responses per theme by age-group. Responses to the brief demographic questionnaire were quantitatively analyzed using SPSS, version 18; however, because of the assured anonymity, demographic questionnaire data could not be linked to focus group responses; hence, these results are presented descriptively. Overall, themes reported in results are based on analysis of open-ended responses to focus group scripted questions. Where appropriate, focus group (age) differences (ie, adolescent versus young adult) are reported.

RESULTS

Table 1 provides 5 major themes that emerged in response to qualitative youth responses to the relapse scenario “He/She Relapsed Because…” This table is followed by examples of youth statements supporting each theme. It is important to note that some youth (from 10 adolescent focus groups, n=92) did not even know what relapse meant (10%). For these youth, they were asked to consider responding to the questions based on the definitions of relapse used in the field [defined as (1) using any alcohol or drugs again or (2) reverting back to their pretreatment pattern of drug use].

Table 1
General Themes of Substance Use Relapse Among Youth 12–24 (N=118)

Emotional Reasons

The dominant relapse theme for youth, including both adolescents (ages 12 through 17) and young adults (ages 18 through 24) was emotional reasons (90%), feeling unable to cope with negative emotions without drugs. Table 2 displays combined statements from youth supporting this theme.

Table 2
Combined Qualitative Youth (12–24) Statements of “Emotional Reasons”

Life Stressors

The second theme identified was life stressors (85%) for both adolescent and young adults as supported by statements such as “To take the stress away,” “To get away from life stressors,” “Because life and everything that comes with it – sucks.” However, when questioned more deeply about the reasons for stress, responses greatly differed for adolescent and young adult participants worth noting. For adolescents (12–17), stress was referred to more so because of parents (criticizing, nagging, mistrust, conflict, put-downs, no faith/confidence in us, not being around), school (failing classes, getting in trouble), and peer pressure (fitting in); whereas older-aged youth (18–24) were more likely express stress in terms of realities of life that had to do with intimate relationships (commitment), financial responsibility (debt, employment issues) and housing stress (rent and bills). Table 3 displays statements from both youth groups supporting this theme.

Table 3
Qualitative Statements of Life Stressors by Youth Group

Cognitive Factors

The third theme in response to “He/She Relapsed Because…” was cognitive (75%), with the dominant reasons for both adolescents and young adults alike being poor motivation, craving/urges, and low confidence. Table 4 displays combined statements from youth supporting this theme.

Table 4
Combined Qualitative Youth (12–24) Statements of Cognitive Factors

Socialization Processes

The fourth theme had to do with socialization processes (65%); however, responses regarding the type of social processes differed between adolescents and young adults. Specifically, adolescents were more likely to note peer pressure and media influence whereas young adults discussed issues related to social networks and social norms. Table 5 displays statements from both youth groups supporting this theme.

Table 5
Qualitative Statements of Socialization Processes by Youth Group

Environmental Issues

The final theme identified among both youth groups was environmental issues (55%), which included responses about access/availability and cues/triggers (55%). Table 6 displays statements from both youth groups supporting this theme.

Table 6
Combined Qualitative Youth (12–24) Statements of Environmental Issues

Discussion

Considering the relapse ecology of youth, our data highlight 5 major reasons for youth relapse: negative emotions, stress, cognitive factors, socialization processes, and environmental issues. Although this study contributes a qualitative assessment of the relapse process among treatment-involved youth, there is still significant complexity in understanding the developmental pathways to relapse.

As supported by our results, such pathways are best conceptualized as multifactorial,87,88 which fall into 3 general theoretical streams of influences: individual-level factors, socialization influences, and broader environmental influences. Specifically, individual-level influences included negative emotions, stress, and cognitive factors; socialization influences included peer pressure, social network/social norms, and media influence; and broader environmental influences included access/availability and cues/triggers, which merit separate discussions for each. It is important to note that, as discussed in the introduction, these relapse determinants are fairly similar to relapse factors observed among adult samples;6366 however, such relapse processes have more emphasis around social-emotional and environmental development processes, rather than personal clinical orientations around substance use severity.

Negative emotions

Research supports that the majority of youth with substance use problems also have one or more co-occurring problems such as depression, anxiety, traumatic stress, self-mutilation or suicidal thoughts, hyperactivity and conduct disorder, criminal or violent tendencies, etc. Prevailing beliefs under the psychoanalytic framework is that drug use is a symptom of an underlying psychological disorder.89 Accordingly, substance use is a secondary condition caused by underlying mental disturbances, known as the self-medication model, whereby individuals use drugs to self-medicate or relieve symptoms of psychological distress.90 Because relapse is likely to occur if these symptoms are not adequately addressed during treatment, a major goal of treatment programs is to include care and services (counseling interventions) that uncover and treat the underlying psychopathology feeding drug abuse behaviors.91,92 Although treatment programs are working to effectively address such multiple problems simultaneously (eg, standardized assessment for other problems and provision/coordination of case management services),16 extending these efforts beyond formal treatment is not a common practice.95 It is possible that the positive outcomes observed in treatment could be better sustained if posttreatment recovery maintenance services (ie, continuing care models) included emotion regulation and coping skills for dealing with negative emotions.

Stress

Stress has been well established as a significant risk factor for relapse.96101 We found developmental differences in relapse-associated stress that support the conceptualization of stress “as a relationship between an individual and his/her environment.”102 For adolescents, parental issues, peer pressure, and school problems were dominant stressors, whereas for young adults, stress was described more in terms of life circumstances, emerging adult responsibilities, and interpersonal romantic relationships that coincide with their current developmental period: “gaining greater independence” and “leaving the parent nest or family environment.”103 Many studies consistently show that parents, peers, and school serve as major socialization factors in predicting the initiation, maintenance, and exacerbation of substance abuse in adolescents; and the stress-related findings specific to young adults are similar to what is typically found with older adults in treatment, which is linked to pretreatment problems of legal issues, relationships, job loss, and financial debt.104,105 From a clinical and recovery support perspective, these results highlight the importance of integrating stress management efforts into programs rather than simply focusing on parental, school, or employment problems specifically as is done in most programs.76,106,107

Cognitive factors

Three important cognitive factors warrant further consideration in terms of understanding relapse among youth: motivation, cravings/urges, and confidence, ie, self-efficacy. As other studies have found, relapse or continued use of alcohol and drugs, is related to the fact that few youth with substance use problems are motivated to be in treatment as they rarely express desires to quit or any strong commitments to maintain abstinence.81,108,109 Further, most youth presenting for treatment are not self-referred. Instead, they are coerced by a parent, juvenile justice system official (judge, probation or parole officer), school official, child welfare worker, or representative of some other community institution.8,10 These findings highlight the need for relapse prevention models in both clinical and recovery support settings to take into account the extent to which youth are motivated or ready to change their substance use behaviors.44,110 Future research on youth relapse needs to consider the potential differences in perceptions among youth mandated to treatment versus youth voluntarily in treatment. By ignoring motivation at treatment admission, assessments of outcomes become complicated and often limit interpretation of relapse prevention models.

Confidence (self-efficacy) was also cited as an important cognitive factor related to relapse as has been found in other studies.111 However, the confidence expressed by youth had more to do with one’s ability to abstain from drugs in the face of life stressors or internal/social cues/triggers, such as the stress of fitting in, rather than on peer pressure associated with being “forced” to use drugs. This result highlights the importance of integrating stress management skills (in addition to peer resistance skills) into youth relapse-prevention models. Lastly, an interesting area of research worthy of further inquiry has to do with continued substance use after treatment that is not related to one’s primary drug of choice, particularly tobacco use. As others have noted, a major issue facing individuals in treatment (in general) is a drug-use recovery environment that far too often facilitates tobacco use.112

Socialization processes

All youth support the view that relapse is a byproduct or function of socialization processes that influence developmental vulnerability for relapse. Although we observed differences in socialization processes between adolescent and young adults, the circumstances and extent to which relapse occurs is largely regulated by peer/social norms, customs, traditions, and standards.113 In general, adolescents reported friendships and peer pressure along with media influence as important relapse triggers; whereas young adults tended to highlight social networks and social norms as dominant features of their social surrounding that influenced relapse.

Numerous studies have established that peer-group and social norm processes are strong influencers of drug use behaviors,86,115,116 as they foster positive expectancies about drug use and create prosocial norms, and both serve to encourage drug use behavior.117,118 It is important to point out that for most adolescents, cliques or friendship bonds are an important and a common feature during social/emotional development contributing to substance use risk behaviors.114,115,120,121 However, as our data indicate, the peer/friendship clique might not be as important for young adults as they have “developed and matured” over time into a web of social relationships and social networks more associated with larger social processes operating.122

Moreover, although not as apparent for older youth, media depictions of drugs were noted as important determinants of relapse by many adolescents. Other research supports this view, such that the tobacco and alcohol industries alone spend billions of dollars each year aggressively marketing their products to adolescents through depicting images of glamour, success, and independence – all highly esteemed social values within American society.123 Such marketing strategies have paid off as noted by several studies showing a positive impact on youth decisions to smoke or drink.124,125 Overall, such socialization processes that youth experience are complex issues that create obstacles for those attempting to develop a drug-free recovery lifestyle (ie, break free from peer pressure and extant social norms that promote and normalize substance use).

Environmental issues

As reflected by our data, environmental factors of access/availability and cues/triggers also play a critical role in facilitating relapse for youth. According to most, drugs are readily available and accessible to them. National survey data from Monitoring the Future highlight the importance of the positive relationship between perceived availability of drugs and trends in use among adolescent youth.126

To date, most attention on relapse determinants has been directed at individual-level factors, promoting the view that the responsibility for one’s relapse ultimately falls on oneself and shifting attention away from larger environmental forces that also may be influencing relapse behavior. However, such environmental influences on relapse are important to consider as “the individual cannot be conceptualized as an autonomous actor making self-governing decisions in a social vacuum.”129 For clinical and recovery support programs to be effective, they must also address such structural influences.

Limitations

The present study must be considered in light of its limitations. The accuracy of relapse descriptions or circumstances among this clinical sample must be questioned as they are retrospectively providing aggregate perceptions of relapse rather than any specific experiences. Also, the data were from a single time point, thereby limiting conclusions regarding the process of posttreatment relapse. Additionally, the results cannot be overgeneralized to treatment-involved youth in other treatment settings given the variability between the treatment sites used to conduct the qualitative work as well as the nature of the sample used (convenience). Finally, focus group thematic results are only presented descriptively. Although it may be that the general risk for substance use relapse among youth as a whole may be similar, with some general differences noted among age-groups, there may be important gender or other differences in relapse risk factors among treatment-involved youth that this study did not consider due to confidentiality limitations associated with anonymous data collection. Further research should find procedures to remedy such deficiencies.

Conclusion

This study contributes to the extant literature on relapse specific to youth populations. Results add clarity to the dynamic process of relapse in youth as they explicate the actual experiences and perceptions of treatment-involved youth. Overall, there is no single variable sufficient to predict relapse among youth alone. Although individual (personal)-level factors have been shown to account for much of the variance explaining proneness to youth initiation and maintenance of substance use,84,108 there is still a wide array of social and environmental forces that contribute to the progression of substance use behavior.128,129 Hence, the interrelations among key individual, socialization, and broader environmental variables are likely to be of increasing importance for understanding the developmental relapse trajectories of treatment-involved youth.

Furthermore, because treatment for substance use and related problems tends to be treated acutely and for a relatively short period (less than 3 months),130 a systems issue to consider is the need for ongoing interventions (continuing care) to promote the necessary skills acquired during treatment, as they may not carry over or be sustainable posttreatment. It needs to be recognized that most treatment-involved youth are in a structured clinical environment and when it is removed they struggle with the loss of structure as they transition into a less unstructured world. In the transition they continue to experience co-occurring issues that can hijack emotions, be exposed to drug using friends, encounter repeated life stressors, face competing social norms that reinforce drug use, enter into a broader environment where drugs and alcohol are frequently available, and continue to be triggered or cued to drug use. To minimize adverse effects, continuing care models must be developed addressing such complex, interrelated issues.

Acknowledgments

The authors would like to thank the administrative and treatment staff at the participating treatment programs for their support. This study was supported by a grant provided by the National Institute on Drug Abuse (NIDA), grant number DA027754-01A1.

Contributor Information

Rachel Gonzales, Integrated Substance Abuse Programs, University of California, Los Angeles, CA, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA.

M. Douglas Anglin, Integrated Substance Abuse Programs, University of California, Los Angeles, CA, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Rebecca Beattie, Integrated Substance Abuse Programs, University of California, Los Angeles, CA, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Chris Angelo Ong, Integrated Substance Abuse Programs, University of California, Los Angeles, CA, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Deborah C. Glik, School of Public Health, University of California, Los Angeles, CA.

References

1. Centers for Disease Control and Prevention. [Accessed March 10, 2011];Youth Risk Behavior Survey. 2009 Available at: www.cdc.gov/yrbss.
2. American Academy of Pediatrics. Practicing adolescent medicine: Priority health behaviors in adolescents: Health promotion in the clinical setting. [Accessed March 10, 2011];Adolescent Health Update. 1991 3(2) Available at: www.aap.org.
3. Robert Wood Johnson Foundation. [Accessed February 12, 2004];Reclaiming Futures: Quick Facts. Retrieved Available at: www.reclaimingfutures.org/quickfacts.asp.
4. Substance Abuse and Mental Health Services Administration. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586 Findings) Rockville, MD: 2010a. Results from the 2009 National Survey on Drug Use and Health: Volume I. Available at: http://www.cdc.gov/nchs/data/hus/hus10.pdf#061.
5. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Rockville, MD: U.S. Department of Health and Human Services; 2010.
6. U.S. Department of Justice, Federal Bureau of Investigation. [Accessed September 16, 2009];Crime in the United States. Available at: http://www2.fbi.gov/ucr/cius2008/data/table_38.html.
7. McLellan AT, Chalk M, Bartlett J. Outcomes, performance, and quality – What’s the difference? J Subst Abuse Treat. 2007;32:331–340. [PubMed]
8. Dennis ML. Global Appraisal of Individual Needs Manual: Administration, Scoring and Interpretation. Bloomington, IL: Lighthouse; 1998.
9. Brown SA, D’Amicio EJ, McCarthy DM, et al. Four-year outcomes from adolescent alcohol and drug treatment. J Stud Alcohol. 2001;62:381–388. [PubMed]
10. Hser YI, Grella CE, Hubbard RL, et al. An evaluation of drug treatments for adolescents in 4 cities. Arch Gen Psychiatry. 2001;58:689–695. [PubMed]
11. Winters KC, Stinchfield RD, Opland E, et al. The effectiveness of the Minnesota Model approach in the treatment of adolescent drug abusers. Addiction. 2000;95:601–612. [PubMed]
12. Brown SA, Vik PW, Creamer VA. Characteristics of relapse following adolescent substance abuse treatment. Addict Behav. 1989;14:291–300. [PubMed]
13. Brown SA, Mott M, Myers MG. Adolescent alcohol and drug treatment outcome. In: Watson RR, editor. Drug and Alcohol Abuse Prevention. Totowa, NJ: Humana Press; 1990.
14. Brown SA, Gleghorn A, Schuckit MA, et al. Conduct disorder among adolescent alcohol and drug abusers. J Stud Alcohol. 1996;57:314–324. [PubMed]
15. Williams RJ, Chang SY. Addiction Centre Adolescent Research Group. A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clin Psychol: Sci Prac. 2000;7:138–166.
16. Kaminer Y, Burleson JA, Burke RH. Efficacy of outpatient aftercare for adolescents with alcohol use disorders: a randomized controlled study. J Am Acad Child Adolesc Psychiatry. 2008;47:1405–1412. [PMC free article] [PubMed]
17. Brown S, Tapert S, Granholm E, et al. Neurocognitive functioning of adolescents: effects of protracted alcohol use. Alcohol Clin Exp Res. 2000;24(2):164–171. [PubMed]
18. Lewis RA, Piercy FP, Sprenkle DH, et al. Family-based interventions for helping drug abusing adolescents. J Adolesc Res. 1990;50:82–95.
19. Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment (CYT) Study: main findings from two randomized trials. J Subst Abuse Treat. 2004;27:197–213. [PubMed]
20. Cornelius JR, Maisto SA, Pollock NK, et al. Rapid relapse generally follows treatment for substance use disorders among adolescents. Addict Behav. 2003;28:381–386. [PubMed]
21. Milkman H, Weiner SE, Sunderwirth S. Addiction relapse. Adv Alcohol Subst Abuse. 1984;3:119–134. [PubMed]
22. Polivy J, Herman CP. If at first you don’t succeed: false hopes of self-change. Am Psychol. 2002;57(9):677–689. [PubMed]
23. Marlatt GA, Gordon JR. Determinants of relapse: Implications for the maintenance of behavior change. In: Davidson PO, Davidson SM, editors. Behavioral Medicine: Changing Health Lifestyles. Elmsford, NY: Pergamon; 1980. pp. 410–452.
24. Abrams DB, Niaura RS, Carey KB, et al. Understanding relapse and recovery in alcohol abuse. Ann Behav Med. 1986;8:27–32.
25. Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychologist. 2004;59:224–235. [PubMed]
26. Davis JR, Tunks E. Environments and addiction: a proposed taxonomy. Int J Addict. 1990;25:805–826. [PubMed]
27. Tucker JA, Vuchinich RE, Gladsjo JA. Environmental influences on relapse in substance use disorders. Int J Addict. 1991;25(7A/8A):017–1050. [PubMed]
28. Dielman TE, Butchart AT, Shope JT, et al. Environmental correlates of adolescent substance use and misuse: implications for prevention programs. Int J Addict. 1991;25:855–880. [PubMed]
29. Rosenhow DJ, Niaura RS, Childress AR, et al. Cue reactivity in addictive behaviors: theoretical and treatment implications. Int J Addict. 1991;25:957–994. [PubMed]
30. Simpson DD, Joe GW, Brown BS. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS) Psychol Addict Behav. 1997;11:294–307.
31. Gifford R, Hine DW. Substance misuse and the physical environment: the early action of a newly completed field. Int J Addict. 1991;25:827–853. [PubMed]
32. Brownell KD, Marlatt GA, Lichtenstein E, et al. Understanding and preventing relapse. Am Psychologist. 1986;41:765–785. [PubMed]
33. Marlatt GA, Baer JS, Quigley LA. Self-efficacy and addictive behaviour. In: Banura A, editor. Self-efficacy in Changing Societies. New York, NY: Cambridge University Press; 1995. pp. 289–315.
34. Miller WR, Westerberg VS, Harris RJ, et al. What predicts relapse? Prospective testing of antecedent models. Addiction. 2002;91(12s1):155–172. [PubMed]
35. Miller WR, Carroll K. Rethinking Substance Abuse: What the Science Shows, and What We Should Do About it. New York, NY: Guilford Press; 2006.
36. De Leon G. Integrative recovery: a stage paradigm. Subst Abuse. 1996;17:15–63.
37. Cornelius JR, Maisto SA, Wood DS, et al. Major depression associated with earlier alcohol relapse in treated teens with alcohol use disorder. Addict Behav. 2004;29:1035–1038. [PubMed]
38. McKay JR, Rutherford MJ, Alterman AI, et al. An examination of the cocaine relapse process. Drug Alcohol Depend. 1995;38:35–43. [PubMed]
39. Jones BT, Corbin W, Fromme K. A review of expectancy theory and alcohol consumption. Addiction. 2001;96:57–72. [PubMed]
40. Niaura R. Cognitive social learning and related perspectives on drug craving. Addiction. 2000;95:155–163. [PubMed]
41. Moos RH. Coping Responses Inventory. Odessa, FL: Psychological Assessment Resources; 1993.
42. Drummond DC, Litten RZ, Lowman C, et al. Craving research: future directions. Addiction. 2000;95(Suppl 2):247–255. [PubMed]
43. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol. 2003;71(5):843–861. [PubMed]
44. Simpson DD, Curry SJ. Drug abuse treatment outcome studies. Psychol Addict Behav. 1997;11:211–337.
45. Joe GW, Simpson DD, Sells SB. Treatment process and relapse to opioid use during methadone maintenance. Am J Drug Alcohol Use. 1994;20:173–197. [PubMed]
46. Dobkin PL, Civita M, Paraherakis A, et al. The role of functional social support in treatment retention and outcomes among outpatient adult substance abusers. Addiction. 2002;97(3):347–356. [PubMed]
47. Anderson KG, Frissell KC, Brown SA. Contexts of post-treatment use for substance abusing adolescents with comorbid psychopathology. J Child Adolesc Subst Abuse. 2007;17:65–82.
48. Ulrich RS, Simons RF, Losito BD, et al. Stress recovery during exposure to natural and urban environments. J Environment Psychol. 1991;11:201–230.
49. Ennett ST, Flewelling RL, Lindrooth RC, et al. School and neighborhood characteristics associated with school rates of alcohol, cigarette, and marijuana use. J Health Social Beh. 1997;38:55–71. [PubMed]
50. Anglin MD, Hser Y-I. In: Treatment of Drug Abuse Drugs & Crime. Tonry M, Wilson JQ, editors. Chicago, IL: The University of Chicago Press; 1990.
51. Beattie MC, Longabaugh R. General and alcohol specific social support following treatment. Addict Behav. 1999;24(5):593–606. [PubMed]
52. Moos RH, Finney JW, Cronkite RC. Alcoholism Treatment: Context, Process and Outcome. New York, NY: Oxford University Press; 1990.
53. Lang MA, Belenko S. Predicting retention in a residential drug treatment alternative to prison program. J Subst Abuse Treat. 2000;19:145–160. [PubMed]
54. De Leon G, Hawke J, Jainchill N, et al. Therapeutic communities enhancing retention in treatment using “senior professor” staff. J Subst Abuse Treat. 2000;19:375–382. [PubMed]
55. Lillie-Blanton M, Anthony JC, Schuster CR. Probing the meaning of racial/ethnic group comparisons in crack cocaine smoking. JAMA. 1993;269:993–997. [PubMed]
56. Agnew JA, Duncan JS. The Power of Place. Boston, MA: Unwin Hyman; 1989.
57. Boardman JD, Finch BK, Ellison CG, et al. Neighborhood disadvantage, stress, and drug use among adults. J Health Soc Behav. 2001;42:151–165. [PubMed]
58. Buhringer G. Testing CBT mechanisms of action: humans behave in a more complex way than our treatment studies would predict. Addiction. 2000;95(11):1715–1716. [PubMed]
59. Dononvan DM. Marlatt’s classification of replase precipitants: is the emperor still wearing clothes? Addiction. 1996;91(Suppl):131–137. [PubMed]
60. Longabaugh R, Rubin A, Stout RL, et al. The reliability of Marlatt’s taxonomy for classifying relapses. Addiction. 1996;91(Suppl):73–88. [PubMed]
61. Carroll KM. Relapse prevention as a psychosocial treatment: a review of controlled clinical trials. Exp Clin Psychopharmacol. 1996;4:46–54.
62. Irvin JE, Bowers CA, Dunn ME, et al. Efficacy of relapse prevention: a meta-analytic review. J Consult Clin Psychol. 1999;67(4):563–570. [PubMed]
63. Brown SA, D’Amico EA. Outcomes of alcohol treatment for adolescents. In: Galanter M, editor. Recent Developments in Alcoholism. Vol. 16. New York, NY: Kluwer Academic/Plenum; 2003. pp. 289–312. [PubMed]
64. Myers RJ, Smith JE. Clincal Guide to Alcohol Treatment: The Community Reinforcement Approach. New York, NY: Guilford Press; 1995.
65. Brown SA, Vik PW, Craemer VA. Characteristics of relapse following adolescent substance abuse treatment. Addict Behav. 1989;14:291–300. [PubMed]
66. Brown SA. Measuring youth outcomes from alcohol and drug treatment. Addiction. 2004;99(Suppl 2):38–46. [PubMed]
67. Labouvie EW, Bates M. Reasons for alcohol use in young adulthood: validation of a three-dimensional measure. J Stud Alcohol. 2002;63:145–155. [PubMed]
68. Millman RB, Botvin GJ. Substance use, abuse, and dependence. In: Levine M, Carey NB, Crocker AC, Gross RT, editors. Developmental-behavioral Pediatrics. New York, NY: W. B. Saunders; 1992. pp. 451–467.
69. McNeal RB, Hansen WB. Developmental patterns associated with the onset of drug use: changes in postulated mediators during adolescence. J Drug Issues. 1999;29(2):381–400.
70. Jessor RS, Chase JD, Donovan JE. Psychosocial correlates of marijuana use and problem drinking in a national sample of adolescents. Am J Public Health. 1980;70:604–613. [PubMed]
71. Grella CE, Hser Y, Joshi V, Rounds-Bryant J. Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. J Nerv Ment Dis. 2001;189:384–392. [PubMed]
72. Morral AR, McCaffrey DF, Ridgeway G. Effectiveness of community-based treatment for substance-abusing adolescents: 12-month outcomes of youths entering Phoenix Academy or alternative probation dispositions. Addict Behav. 2004;18(3):257–268. [PubMed]
73. Stein JA, Newcombe MD, Bentler PM. An 8-year study of multiple influences on drug use and drug use consequences. J Pers Soc Psychol. 1987;53:1094–1105. [PubMed]
74. Oetting ER, Donnermyer JF. Primary socialization theory: the etiology of drug use and deviance I. Subst Use Misuse. 1998;33(4):995–1026. [PubMed]
75. Jessor R. Risk behavior in adolescence: a psychosocial framework for understanding and action. J Adolesc Health. 1991;12:597–605. [PubMed]
76. Sameroff AJ, Seifer R, Bartko WT. Environmental perspectives on adaptation during childhood and adolescence. In: Luthar SS, Burak JA, Cicchetti D, et al., editors. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. New York, NY: Cambridge University Press; 1997. pp. 507–526.
77. Liddle H, Rowe C, editors. Treating Adolescent Substance Abuse: State of the Science. Cambridge, UK: Cambridge University Press; 2006.
78. Oetting ER. Primary socialization theory. Developmental stages, spirituality, government institutions, sensation seeking, and theoretical implications. V Subst Use Misuse. 1999;34(7):947–82. [PubMed]
79. Waldron HB, Slesnick N, Brody JL, et al. Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. J Consult Clin Psychol. 2001;69:802–813. [PubMed]
80. Maisto SA, Martin CS, Pollock NK, et al. Non-problem drinking outcomes in adolescents treated for alcohol use disorders. Exp Clin Psychopharmacol. 2002;10:324–331. [PubMed]
81. Ramo DE, Anderson KG, Tate SR, et al. Characteristics of relapse to substance use in comorbid adolescents. Addict Behav. 2005;30:1811–1823. [PubMed]
82. Rawson RA, Gonzales R. Evaluation of the Substance Abuse Treatment System. Los Angeles: UCLA Integr. Subst. Abuse Progr; 2009. [Accessed March 4, 2011]. CalOMS. Available at: http://www.uclaisap.org/caloms/documents/CalOMSEvaluationReport.pdf.
83. Huba GJ, Bentler PM. A developmental theory of drug use: derivation and assessment of a causal modeling approach. In: Baltes PB, Brim OG Jr, editors. Lifespan Development and Behavior. Vol. 4. New York: Academic Press; 1982. pp. 47–203.
84. McNeal RB, Hansen WB. Developmental patterns associated with the onset of drug use: changes in postulated mediators during adolescence. J Drug Issues. 1999;29(2):381–400.
85. Krueger RA. Moderating Focus Groups. Thousand Oaks, CA: Sage; 1998.
86. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2. Thousand Oaks, CA: Sage; 1994.
87. Alexander BK. What can professional psychotherapists do about heroin addiction? Medicine and Law. 1986;5(4):323–330. [PubMed]
88. Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood. Implications for substance abuse prevention. Psychol Bull. 1992;112:64–105. [PubMed]
89. Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;142:1259–1264. [PubMed]
90. Hwang S. Utilizing qualitative data analysis software: a review of Atlas.ti. Social Science Computer Review. 2008;26(4):519–527.
91. Aarons GA, Brown SA, Hough RL, et al. Prevalence of adolescent substance use disorders across five sectors of care. J Am Acad Child Adolesc Psychi. 2001;40:419–426. [PubMed]
92. Kaminer Y, Napolitano C. Dial for therapy: aftercare for adolescent substance use disorders. J Am Academy Child Adolesc Psychiatry. 2004;43:1171–1174. [PubMed]
93. Dennis ML, Titus JC, Diamond G, et al. The Cannabis Youth Treatment (CYT) experiment: Rationale, study design and analysis plans. Addiction. 2002;97(Suppl 1):84–97. [PubMed]
94. Kaminer Y, Napolitano C. Dial for therapy: aftercare for adolescent substance use disorders. J Am Academy Child Adolesc Psychiatry. 2004;43:1171–1174. [PubMed]
95. Godley MD, Kahn JH, Dennis ML, et al. The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence. Psychol Addict Behav. 2005;19:62–70. [PubMed]
96. Preston KL, Epstein DH. Stress in the daily lives of cocaine and heroin users: relationship to mood, craving, relapse triggers, and cocaine use. [Accessed March 6, 2011];Psychopharmacol (Berl) 2011 (Published online ahead of print 12 February 2011) Available aat: http://www.springerlink.com/content/j82465x385448145/ [PMC free article] [PubMed]
97. Goeders NE. The impact of stress on addiction. European Neuropsychopharmacol. 2003;13:435–441. [PubMed]
98. Goeders NE. Stress and cocaine addiction. J Pharmacol Exp Ther. 2002;301:785–789. [PubMed]
99. Sinha R, Fuse T, Aubin LR, et al. Psychological stress, drug-related cues and cocaine craving. Psychopharmacol. 2000;152:140–148. [PubMed]
100. Sinha R. How does stress increase risk of drug abuse and relapse? Psychopharmacol. 2001;158:343–359. [PubMed]
101. Wills TA. Stress, coping, tobacco and alcohol use in early adolescence. In: Shiffman S, Wills TA, editors. Coping and Substance Use. New York, NY: Academic Press; 1986.
102. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer; 1984.
103. Wilks J. The relative importance of parents and friends in adolescent decision making. J Youth Adolescence. 1986;15:323–334. [PubMed]
104. Chassin L, Presson CC, Sherman SJ, et al. Changes in peer and parental influence during adolescence: longitudinal versus cross-sectional perspectives on smoking initiation. Dev Psychol. 1986;22:327–334.
105. Whiston SC. The relationship among family interaction patterns and career indecision and career decision-making self-efficacy. J Career Dev. 1996;23:137–149.
106. Jessor R, Donovan JE, Costa FM. Beyond Adolescence: Problem Behavior and Young Adult Development. New York, NY: Cambridge University Press; 1991.
107. King KM, Chassin L. Mediating and moderated effects of adolescent behavioral under control and parenting in the prediction of drug use disorders in emerging adulthood. Psychol Addict Behav. 2004;18(3):239–249. [PubMed]
108. Cornelius JR, Maisto SA, Pollock NK, et al. Rapid relapse generally follows treatment for substance use disorders among adolescents. Addict Beh. 2003;28:381–386. [PubMed]
109. Chung T, Maisto SA. Review and reconsideration of relapse as a change point in clinical course in treated adolescents. Clin Psychol Rev. 2006;26:149–161. [PubMed]
110. Godley SH, Godley MD, Dennis ML. The assertive aftercare protocol for adolescent substance abusers. In: Wagner E, Waldron H, editors. Innovations in Adolescent Substance Abuse Interventions. Elsevier Science; New York: 2001.
111. Bobo JK, Slade J, Hoffman AL. Nicotine addiction counseling for chemically dependent patients. Psychiatr Svcs. 1995;46:945–947. [PubMed]
112. Burleson JA, Kaminer Y. Self-efficacy as a predictor of treatment outcome in adolescent substance use disorders. Addict Behav. 2005;30:1751–1764. [PubMed]
113. Berkowitz AD. The Social Norms Approach: Theory, Research, and Annotated Bibliography. Newton, MA: Higher Education Center for Alcohol and Other Drug Prevention; 2001.
114. Dishion TJ. Cross-setting consistency in early adolescent psychopathology: deviant friendships and problem behavior sequelae. J Pers. 2000;68(6):1109–1126. [PubMed]
115. Vandell DL. Parents, peer groups, and other socializing influences. Dev Psychol. 2000;36(6):699–710. [PubMed]
116. Clapp JD, McDonnell AL. The relationship of perceptions of alcohol promotion and peer drinking norms to alcohol problems reported by college students. J Coll Stud Dev. 2000;41:19–26.
117. Dishion TJ, Capaldi DM, Spracklen KM, Li F. Peer ecology of male adolescent drug use. Dev Psychopathol. 1995;7:803–824.
118. Duncan TE, Duncan SC, Hops H. The effects of family cohesiveness and peer encouragement on the development of adolescent alcohol use: a cohort sequential approach to the analysis of longitudinal data. J Stud Alcohol. 1994;55:588–599. [PubMed]
119. Hartup WW. The company they keep: Friendships and their developmental significance. Child Dev. 1996;67:1–13. [PubMed]
120. Elliot D, Huizinga D, Ageton S. Explaining Delinquency and Drug Use. Newbury Park, California: Sage Publications, Inc; 1985.
121. Kandel DB. Processes of peer influence in adolescence. In: Silberstein RK, Eyferth K, Rudinger G, editors. Development as Action in Context: Problem Behavior and Normal Youth Development. New York, NY: Springer-Verlag; 1986. pp. 203–227.
122. Perry CL, Baranowski T, Parcel GS. How Individual, Environments, and Health Behavior Interact: Social Learning Theory. San Francisco: Jossey-Bass; 1997.
123. Arnett J. Adolescents’ uses of media for self-socialization. J Youth Adolesc. 1995;24(5):519–533.
124. Kelly K, Donohew L. Media and primary socialization theory. Subst Use Misuse. 1999;34(7):1033–1045. [PubMed]
125. Moore DJ, Williams JD, Qualls WJ. Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethn Dis. 1996;6(12):83–98. [PubMed]
126. Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2005. Bethesda, MD: National Institute on Drug Abuse; 2006. (NIH Publication No. 06-5882)
127. Thombs DL, Wolcott BJ, Farkash LG. Social context, perceived norms and drinking behavior in young people. J Subst Abuse. 1997;9:257–267. [PubMed]
128. Sussman S, Dent CW, Galaif ER. The Correlates of substance abuse and dependence among adolescents at high risk for drug abuse. J Subst Abuse. 1997;9:241–255. [PubMed]
129. Oetting ER, Donnermyer JF, Deffenbacher JL. Primary socialization theory: the influence of the community on drug use and deviance III. Subst Use Misuse. 1998;33(8):1629–1665. [PubMed]
130. Becker SJ, Curry JF. Outpatient interventions for adolescent substance abuse: a quality of evidence review. J Consult Clin Psychol. 2008;76:531–543. [PubMed]