What Is Relapse? a Contemporary View of Treatment for Alcoholism
Guitele J. Rahill, MSW, Florida International University, Elsa Pinto, MS, Florida International University, Anna Vanderbiest, BSW, Florida International University, and Christopher Rice, PhD, Florida International University.
Problem: Traditionally, outcome from alcoholism treatment was considered a binary event, either the person was drinking or the person was abstinent. More recently, outcome data from clinical trials with extended follow-up suggest a different perspective is warranted. The issue is particularly salient for clients whose assessment, treatment and post-treatment monitoring often involve interaction with a multi-disciplinary team whose members and agencies have differing standards for what constitutes relapse. The purpose of this work was to perform a systematic analysis of articles that define relapse within the context of treatment settings, paying particular attention to conceptual and relational analysis of the definition of relapse. Method: Guided by standardized selection criteria, a systematic search of randomized clinical trials for alcoholism treatment published from 1990 to 2006 was conducted. Studies that used behavioral treatment approaches alone or in combination with other treatment approaches were included. Excluded from the sample were studies that did not include a follow up period of at least 6 months. As a result, 43 articles were selected for analysis. Standardized evaluation criteria were used to extract definitional phrases of relapse as the unit of analysis. Atlas_ti (version 5.0) was used to facilitate coding of relapse definitions and subsequent organization of relapse categories. Results: A total of 15 definitions of relapse were identified in the sample of articles. Content analysis revealed differences according to the period of time in which relapse may occur. Relapse was considered to occur during treatment, post-treatment, or after a specified period of abstinence. Definitions were similar in establishing a minimum number of drinks to consider as relapse. These ranged from any alcohol consumption to gender-specific criteria of heavy drinking. Relapse was also expressed in terms of problems in life-functioning and to the combination of quantity of drinks and life-functioning problems. Discussion: These findings suggest that the multiple definitions of relapse can pose different consequences for social work clients, based upon the perspectives and requirements of the various agencies with which they are involved. Defining relapse in different contexts and with different criteria limits the ability to compare the outcomes of different treatment approaches. It may also fail to capture the sometimes subtle changes in drinking an individual tends to go through before achieving abstinence. Post-treatment outcome is not always marked by an abrupt switch from drinking to sustained abstinence. For many people post-treatment behavior involves sequential periods of abstinence and drinking which viewed over time form a trajectory that may approach total abstinence or that may approach a return to pre-treatment levels of drinking. Varying definitions of relapse can have serious implications for whether or not the client is viewed as successful, or whether a client faces serious legal consequences. The contemporary questions regarding relapse are: 1) how to accommodate to a state that observation suggests is dynamic; and, 2) how to obtain multi-disciplinary consensus on a definition that maximizes effective communication among team members and results in coordination of post-discharge services and improved service delivery to clients.