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Substance Abuse Treatment Modalities: Literature Review

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Recognizing High Risk Situations

The concept of high–risk situations had its origin in early learning theory approaches to the explanation of alcohol problems. These accounts took note of the fact that even persons with severe alcohol problems do not drink incessantly whenever alcohol is available. Rather, drinking was more likely to occur at certain times than others, although there appeared to be considerable variability among individuals in when drinking was likely to occur. For example, both Lazarus (1965) and Bandura (1969) considered situational factors to be discriminative stimuli for drinking. In lay terms, these situations set the occasion for drinking because persons with alcohol problems had learned that drinking in such situations would lead to immediately rewarding consequences (e.g., relaxation). Because such situations were highly idiosyncratic, a key component of a behavioural approach to treating alcohol problems became a functional analysis of drinking, which identified an individual's discriminative stimuli for drinking and also the consequences that tended to follow drinking in those circumstances.

In the mid–1970s, the idea that particular types of situations were associated with excessive consumption of alcohol was given additional meaning and refined by Marlatt, who was investigating the phenomenon of relapse (Marlatt, 1978). Since the vast majority of individuals in a treatment outcome study that he had conducted were found at follow–up to have relapsed, Marlatt systematically inquired of the relapsed subjects about the circumstances associated with their resumption of drinking. Their responses formed the basis of a program of research that investigated relapse precipitants in several other alcohol abusers, and subsequently in heroin addicts, and smokers. The key addition of Marlatt's approach was the identification of categories of relapse precipitants that seemed common across cases, and also the idea that these precipitants suggested that particular treatment interventions would be of benefit. The types of situations that posed a threat to an individual's sustained recovery were termed high–risk situations, indicating that the individual had a markedly increased probability of drinking in such situations. Associated interventions were aimed at preparing individuals to deal with high–risk situations by using constructive, nondrinking alternatives (e.g., Chaney, O'Leary, & Marlatt, 1978).

Marlatt eventually identified eight categories of relapse precipitants, five of which had to do with personal circumstances and three of which involved the presence of others. The five personal categories were: when in a negative emotional state (e.g., feeling anxious), when in a negative physical state (e.g., having a headache), experiencing urges and temptations (e.g., seeing a bottle of whiskey and desiring a drink), testing control (e.g., purposely going into a drinking establishment to see if one can endure the evening without consuming alcohol), and when in a positive emotional state (e.g., celebrating being given a raise at work). The three social categories were: when experiencing interpersonal conflict (e.g., having an argument with another), when under social pressure to drink (e.g., a friend urges the individual to drink), and pleasant times with others (watching sports while drinking at a pub with friends). Of these, three categories were found to be the most common across alcohol abusers, heroin addicts and smokers: negative emotional states, interpersonal conflict, and social pressure.

For alcohol abusers the two situations involving negative emotions were the most prominent forerunners of relapse, while for heroin addicts being in the presence of other addicts who were using was the most common relapse precipitant (Marlatt & Gordon, 1985). A detailed description of the eight categories of high–risk situations and the research supporting that classification can be found in Marlatt (1985). A substantial literature describes how to identify high–risk situations and the sorts of interventions that can be targeted at dealing with particular types of situations (e.g., Allsop & Saunders, 1989; Chaney, 1990; Curry & Marlatt, 1987; Monti, Abrams, Kadden, & Cooney, 1989; Sanchez–Craig, Wilkinson & Walker, 1987), because this is a fundamental approach to behavioural treatment of any problem.

Recently questionnaires to assess high–risk situations have been developed and evaluated. One such instrument is the Inventory of Drinking Situations, developed by Annis (Annis, Graham, & Davis, 1987). This instrument started with Marlatt's eight categories of high–risk situations. It presents respondents with examples of those situations and asks how frequently they drank heavily in those situations over the previous year. Subsequent analyses have reduced the categories to three main dimensions: negative affective states (including interpersonal conflict), positive affective states (including social pressure situations), and situations involving testing control over substance use (Cannon, Leeka, Patterson, & Baker, 1990; Isenhart, 1991; Isenhart, 1993). A similar questionnaire to assess high–risk situations for other drugs is presently under evaluation (Annis, Martin, & Graham, 1992).

A methodological note is pertinent regarding the nature of existing research on high–risk situations. Present data have mainly two derivations, each of which has associated problems. Marlatt's work, and the work of others using that same approach, use as their basis the retrospective reports of alcohol abusers who have relapsed. There are two difficulties with this method. First, it is highly dependent on memory and therefore prone to errors of forgetting and confusion. Second, it calls upon individuals to explain their seemingly self–destructive behaviour. In doing so, persons are likely to attribute their relapses to situational factors that make sense to them as explanations for their relapse (i.e., I drank when I went to this party filled with strangers, therefore I must have been anxious.)(Sutton, 1993). These may in fact be the actual precipitants of relapse, but it is important to recognise that the research methods used do not allow a conclusion that individuals' retrospective reports are valid. Although someone may have been feeling badly before relapsing, this does not conclusively indicate that they relapsed in order to deal with feeling badly. In order to draw cause and effect conclusions, it will be necessary to conduct prospective research where individuals sustaining a recovery are monitored as they relapse. Prospective methods eliminate problems due to forgetting and greatly reduce the likelihood that persons' attributional biases will influence their answers. Research of this sort is underway but has not yet been reported in the scientific literature.

The other major type of work on reported high–risk situations is based on the approach used by Annis in the Inventory of Drinking Situations. In this approach, individuals are asked about situations in which they have engaged in heavy drinking, but this is not necessarily the same as situations that initiated the drinking. For example, an individual may have had a conflict with his spouse and spent the night drinking at a bar with friends. The situation reported as associated with heavy drinking in such a case would most likely be pleasant times with friends or social pressure, when in fact the real precipitant of the drinking would have been interpersonal conflict. Finally, another procedure used to assess high–risk situations has been assessment during treatment. Such assessment typically involves having clients role play responses to standardized situations, and rating the adequacy of their responses. For example, the individual might be asked how he or she would respond if at a party and offered drinks by the host. Tests of this sort have been reported by Chaney et al.(1978), and Monti et al. (1989). An obvious difficulty with this method of assessment is that it is highly indirect. It is assumed that situations not handled with great skill by the individual when role playing in the treatment setting will constitute high–risk situations in the real world, but such a relationship may not in fact exist. For example, if an individual can successfully avoid being in party situations, then that individual's lack of skill at turning down offers of a drink at a party becomes of no consequence.

In view of the above methodological problems, evaluation of high–risk situations for any given individual is best based upon a sensitive clinical interview where the interviewer can clarify issues and rule out competing explanations. The research literature helps provide a framework for analyzing an individual's drinking, and instruments such as the Inventory of Drinking Situations and the Situational Competency Test can provide strong clues about likely high–risk situations, but these methods should supplement, and not replace, a well done clinical assessment.

References for Recognizing High Risk Situations:

Allsop, S., & Saunders, B. (1989), “Relapse and alcohol problems”, In M. Gossop (Ed.),Relapse and addictive behaviour.New York: Tavistock/Routledge.

Annis, H. M., Graham, J. M., & Davis, C. S. (1987), Inventory of Drinking Situations (IDS) user's guide, Addiction Research Foundation. Toronto, Ontario.

Annis, H., Martin, G., & Graham, J. M. (1992), Inventory of Drug–Taking Situations: Users' guide. Addiction Research Foundation. Toronto, Ontario.

Bandura, A. (1969), Principles of behavior modification, New York: Holt, Rinehart & Winston.

Cannon, D. S., Leeka, J. K., Patterson, E. T., & Baker, T. B. (1990), “Principal components analysis of the inventory of drinking situations: Empirical categories of drinking by alcoholics, Addictive Behaviors, 15, 265–269.

Chaney, E. F., O'Leary, M. R., & Marlatt, G. A. (1978), “Skill training with alcoholics94", Journal of Consulting and Clinical Psychology, 46, 1092–1104.

Chaney, E.F. (1990), “Social skills training” In R. K. Hester & W. R. Miller (Eds.),Handbook of alcoholism treatment approaches: Effective alternatives.New York: Pergamon.

Curry, S.G., & Marlatt, G.A. (1987), “Building self–confidence, self–efficacy and self–control”, In W. M. Cox, (Ed.). Treatment and prevention of alcohol problems: A resource manual, Orlando: Academic Press.

Isenhart, C. E. (1991), “Factor structure of the Inventory of Drinking Situations”, Journal of Substance Abuse, 3, 59–71.

Isenhart, C. E. (1993), “Psychometric evaluation of a short form of the Inventory of Drinking Situations”, Journal of Studies on Alcohol, 54, 345–349.

Lazarus, A.A. (1965), “Towards the understanding and effective treatment of alcoholism”, South African Medical Journal, 39, 736–741.

Marlatt, G. A. (1978), “Craving for alcohol, loss of control, and relapse”,. dans P. E. Nathan, G. A. Marlatt, & T. Løberg (éds.), Alcoholism: New directions in behavioral research and treatment (271–314),New York: Plenum Press.

Marlatt, G. A. (1985), “Situational determinants of relapse and skill–training interventions”, dans G. A. Marlatt, & J. R. Gordon, (éds.), Relapse prevention.New York: Guilford Press.

Marlatt, G. A., & Gordon, J. R. (éds.) (1985),Relapse prevention. New York: Guilford Press.

Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. T. (1989), Treating alcohol dependence.New York: Guilford Press.

Sanchez–Craig, M., Wilkinson, D.A., & Walker, K. (1987), “Theory and methods for secondary prevention of alcohol problems: A cognitively based approach”,dans W. M. Cox, (éd.), Treatment and prevention of alcohol problems: A resource manual. Orlando: Academic Press.

Sutton, S. R. (1993), “Is wearing clothes a high risk situation for relapse? The base rate problem in relapse prevention research”, Addiction, 88, 725–727.