Personality, stress, and social support in cocaine relapse prediction

Journal of Substance Abuse Treatment 21 (2001) 77 – 87

Regular article

Personality, stress, and social support in cocaine relapse prediction Robert C. McMahon Ph.D.* Department of Educational and Psychological Studies-Counseling Psychology Program, University of Miami, Miami, FL, USA Received 4 August 2000; received in revised form 13 April 2001; accepted 1 May 2001

Abstract This study identified prospective psychosocial predictors of relapse status and drug abuse severity in male subjects in the first year after residential treatment for cocaine dependence. Personality, stress, and social support measures from an intake assessment, and stress and support measures reflecting status during the three-month period prior to the one in which relapse was identified were used as predictors. A number of hypotheses were confirmed. Detached personality and stress predicted both cocaine relapse and outcome drug abuse severity. Perceived social support quality and social network size predicted cocaine relapse. Implications for relapse prevention are presented. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Cocaine; Relapse; Prediction

1. Introduction A substantial literature indicates the importance of stress, social support, and personality factors as predictors of relapse to various substances of abuse. A link between life stress and relapse has been demonstrated in studies of smokers (Cummings, Jaen, Giovino, 1985; Mermelstein, Cohen Lichtenstein, & Kamarck, 1986); alcoholics (Billings & Moos, 1983; Cronkite & Moos, 1980; Finney & Moos, 1981; Finney, Moos, & Newborn, 1980; Litman, Stapleton, Oppenheim, Peleg, & Jackson, 1983; Moos, Finney, & Chan, 1981); and opiate addicts (Chaney & Roszell, 1985; Kosten, Rounsaville, & Kleber, 1983; Krueger, 1981; Rhodes, 1983). Similarly, various indicators of quality and quantity of social support have predicted relapse in studies of smokers (Nides, Rakos, Gonzales, & Murray, 1995) and alcoholics (Brown, Vik, Patterson, Grant, & Schuckit, 1995; Barber & Crisp, 1995). Havassy, Hall, and Wasserman (1991) found that social integration and abstinence-specific functional support predicted lower risk of relapse to tobacco, alcohol, and opiates. Various personality and symptom characteristics have also predicted substance abuse relapse. Antisocial personality traits predicted relapse after completion of treatment for alcohol dependence (Mather, 1987; Sandahl, 1984) and

* Tel.: +1-305-284-5064; fax: +1-305-284-3003. E-mail address: [email protected] (R.C. McMahon).

antisocial personality diagnosis has been linked with less favorable outcome in drug abuse treatment (Alterman & Cacciola, 1991). More recently, however, several researchers have not found less favorable outcomes for cocaine-dependent patients with antisocial personality disorder (Carroll et al., 1994; Cacciola, Alterman, Rutherford, Snider, 1995). Avoidant, schizoid, and antisocial qualities have predicted early relapse in a group consisting primarily of cocaine and heroin users (Fals-Stewart, 1992). There is strong evidence for a connection between depression and other negative mood states and substance abuse relapse. Indeed, negative affect has been found to figure prominently in relapse to tobacco, opiate, and alcohol use (Wills, 1990). Relatively few studies have examined stress, support, and personality predictors of cocaine relapse (Hall et al., 1991; Carroll et al., 1994; Cacciola et al., 1995). Although evidence exists for similarity in factors that predict relapse across substances (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Hall, Havassy, & Wasserman, 1990), Hall, Havassy, and Wasserman (1991) have argued that the factors which predict relapse to cocaine may differ for a number of reasons. In contrast to several other commonly studied substances, cocaine produces an intense euphoria, often in connection with high-dose binges, it is associated with abstinence-related anhedonia, and it is linked with particularly intense craving between episodes of use. Given these special characteristics, investigation of the relevance to cocaine of psychosocial models of relapse established for other drugs is warranted.

0740-5472/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 1 ) 0 0 1 8 7 - 8

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R.C. McMahon / Journal of Substance Abuse Treatment 21 (2001) 77–87

There are other limitations associated with the current drug relapse literature. Although there have been a number of studies of stress, support, and personality effects on relapse, most have not adequately explored interrelationships among these predictors (Wills, 1990). For example, it is possible that the negative life events and limitations in quantity and quality of social support which have predicted relapse may be attributable to underlying psychopathology (Wills, 1990). Models that anticipate interrelationships among personality, stress, and social support should contribute to a fuller understanding of each (Mertens, Moos, & Brennan, 1996; Monroe & Steiner, 1986). A number of researchers have drawn upon Millon’s (1981) theory of personality and psychopathology as a framework for understanding the effects of personality and relations among personality, stress, and social support processes hypothesized to underlie relapse proneness and resistance among substance abusers (e.g., Fals-Stewart, 1992; McMahon, Kelley, & Kouzekanani, 1993; McMahon, Schram, & Davidson, 1993). The dimensions of personality and psychopathology articulated in Millon’s theory are measured by the Millon Clinical Multiaxial Inventory (MCMI) (Millon, 1983, 1987). A series of factor-analytic studies of original and revised versions of the MCMI have identified detached, dependent, and antisocial personality dimensions among substance abusers (Flynn & McMahon, 1984; McMahon, Gersh, & Davidson, 1988; McMahon & Applegate, 1990; Millon, 1987). An accumulating body of research suggests that these three broad personality dimensions have significant implications regarding stress vulnerability and recovery from substance abuse (Fals-Stewart, 1992; McMahon, 1988; McMahon & Davidson, 1985, 1986; McMahon & Tyson, 1990; McMahon et al., 1993; Millon, 1987; Craig, 1993). The detached dimension is defined by high loadings on the MCMI-II Avoidant, Schizoid, and Schizotypal scales and moderate loadings on the Dysthymic and Major Depression scales (McMahon et al., 1988; McMahon & Applegate, 1990). Vulnerability to relapse in detached personalities is hypothesized to be associated with a number of factors. Those with prominent detached personality features are assumed to be preoccupied by disturbing and conflictual cognitions which interfere with social communication and lead to dysphoric affect. Further, detached personalities are hypothesized to be vulnerable to the negative effects of life stressors because they have never learned complex coping skills. Although they may desire social acceptance, they are unable to tolerate close relationships and are expected to show limited ability of profit from social support. The dependent factor includes moderate to high loadings on the Passive-Dependent, Anxiety, Dysthymic, and Somatoform scales of the MCMI-II (McMahon et al., 1988; McMahon & Applegate, 1990). Vulnerability to relapse in those with prominent dependent characteristics is thought to be associated with their excessive reliance upon others for feelings of worth and adequacy. They show little initiative,

autonomy, or adult responsibility. Dependent types are hypothesized to be vulnerable to a wide range of life stressors because they have limited coping resources and experience pervasive feelings of inadequacy (Millon, 1981; Millon & Davis, 1996). The predominant coping strategy adopted by dependent types involves efforts to develop secure relationships with caretakers perceived as more competent than themselves. Thus, in contrast to detached types, those with prominent dependent characteristics are hypothesized to experience reduced relapse risk in a posttreatment environment that includes high levels of perceived social support. Finally, the Antisocial factor is defined by high loadings on the Antisocial and Aggressive scales of the MCMI-II. Moderate or higher loadings are also found on the Narcissistic, Histrionic, and Paranoid scales. Those high on this factor tend to look to themselves as sources of need fulfillment either because of a deeply rooted confidence in themselves and/or because of pervasive mistrust of others (Millon, 1981; Millon & Davis, 1996). They tend to be interpersonally manipulative and exploitive and are either unaware of, or unconcerned with, the needs and expectations of others. Their fierce sense of independence and selfsufficiency makes them relatively resistant both to the effects of negative life events and to supportive social influences. They are expected to perceive comparatively few negative consequences associated with cocaine use and to resist social pressure for changes in attitude or behavior regarding substance use. For these reasons, it was predicted that antisocial types are considered unlikely to make a serious commitment to treatment or recovery in the posttreatment period. They were assumed likely to return to a sensation-seeking, rather than a stress-coping, pattern of substance abuse. This study was designed to examine stress, social support, and personality as predictors of both cocaine relapse and drug abuse severity in cocaine-dependent males during the 12 months after residential treatment. It was hypothesized that these relapse-related outcomes would be associated with (a) levels of detached, dependent, and antisocial personality; (b) levels of negative life events, perceived social support quality, and support network size; and (c) interactive effects of detached and dependent personality and negative life events and dependent personality and perceived support quality as previously outlined.

2. Methods 2.1. Patient sample, treatment facilities, and research procedures The sample was drawn from cocaine-dependent males who were recruited from three residential therapeutic communities for the treatment of drug dependence. Program 1 was a large, private, nonprofit therapeutic community from


which we recruited 120 subjects who were rather diverse with respect to racial, ethnic, and socioeconomic backgrounds. Program 2 was a large, county-funded, therapeutic community from which we recruited 141 subjects. The majority of subjects from this program were African Americans. We drew 43 subjects from Program 3, which was a 30-day, hospital-based, residential program. Shortly after treatment admission, all English-speaking residents who were at least 18 years of age, and who were self-identified as primary cocaine abusers, received a brief description of the research project from a member of the professional treatment staff. Within a few days after this initial contact, residents were given a detailed description of the study by a member of the research team. As part of this description, subjects were shown and read a Certificate of Confidentiality issued by the National Institute on Drug Abuse. This Certificate included an assurance that the identities of participants would not be revealed and that the information they provided could not be subpoenaed by local, state, or federal authorities. Three hundred four program participants provided written informed consent, were evaluated, and met DSM III-R criteria for current cocaine dependence. The initial evaluation was conducted after detoxification but within two weeks after treatment admission. Follow-up evaluations were conducted prior to treatment discharge and at 3, 6, 9, and 12 months after treatment completion. Individually administered intake and follow-up evaluations were conducted by trained Ph.D. students in counseling psychology. Intake and predischarge assessments were conducted in private conference rooms on residential treatment sites. Follow-up evaluations were conducted within a week before or after 3-, 6-, 9-, and 12-month treatment discharge follow-up dates. These evaluations were conducted in a variety of settings (aftercare meetings at treatment centers, project research office, or during prescheduled telephone conferences). Efforts were made to ensure confidentiality in each case. Extensive efforts were made to locate subjects for follow-up, including telephone contacts with subjects prior to scheduled follow-up ses-

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sions, and in cases of difficulty reaching subjects, communications with individuals identified by subjects as ‘‘contact persons.’’ All subjects recruited had completed a minimum of three weeks of residential treatment (see Table 1 for mean days of treatment by Group). Urine samples were collected regularly during residential treatment, and no positive tests were found for study participants. Thus, we have reasonable assurance that those who eventually relapsed experienced a minimum of 21 days of abstinence in treatment. For the majority, the period of abstinence during and after residential treatment was considerably longer. Approximately two-thirds of the 304 subjects (66.1%) used cocaine 10 days or more in the 30 days before intake into treatment. Slightly more than one quarter (25.7%) reported using cocaine every day. Approximately 19% used cocaine primarily or exclusively intranasally, 70% primarily or exclusively smoked crack or freebase. The remaining subjects (11%) reported various other patterns of usage. About three-fourths (74.3%) used alcohol in the 30 days before intake, although more than half (53.6%) reported use on seven or fewer days. Forty-five percent reported some use of marijuana, but most of these (77.6%) used on seven or fewer days in the 30 days before intake. Ten percent of those who used marijuana reported daily use of this drug. Fewer than 5% of subjects reported any use of heroin, other opiates/analgesics, barbiturates, tranquilizers, amphetamines, hallucinogens, or inhalants in the month before intake. Almost half (46.7%) of subjects were African American, another one-third (34.2%) were Caucasian, and most of the rest (12.5%) were Hispanic. The mean age was 29.3 years (SD = 6.5) and the average level of education was 12.2 years (SD = 2.2). Relatively few (13.2%) were currently married and living with a spouse prior to treatment entry. The average number of days worked in the 30 days prior to intake was 12.9 (SD = 11.1). Reported income during that same period ranged from none to $5,000. Subjects were paid $10 for completion of each follow-up assessment.

Table 1 Intake personal background, drug use, and treatment history of cocaine relapsers/lost to follow-up and nonrelapsers Relapsers/Lost (n = 172)

Nonrelapsers (n = 123)

Variable

m

SD

m

SD

Age Years of education Length of current treatment (Days) Number of previous drug treatments Days of cocaine use in last 30 Lifetime months of cocaine use Days of alcohol use to intoxication in last 30 Lifetime months of alcohol use to intoxication Days of marijuana use in last 30 Lifetime months of marijuana use ASI intake drug abuse severity Longest full time job in months

29.1 11.9 49.9 2.1 18.0 80.4 8.0 67.0 6.0 97.6 0.28 56.0

6.2 2.0 35.8 1.7 10.6 64.1 11.4 73.7 10.2 80.4 0.09 53.8

29.7 12.6 51.5 2.2 14.6 76.0 6.1 76.4 3.7 85.6 0.25 63.5

7.0 2.5 36.1 1.6 11.2 60.1 10.9 91.8 8.3 69.3 0.10 55.8

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2.2. Measures 2.2.1. Life Experience Survey The Life Experience Survey (LES) was designed to measure the effects of life event stressors (Sarason, Johnson, & Siegel, 1978). The LES lists 47 life events that occur with reasonable frequency in clinical populations and permits respondents to add and rate up to three events not listed. It requires an evaluation of the perceived desirability or undesirability, as well as of the degree of impact, of identified events. Events were rated on a 7-point scale ranging from extremely positive ( + 3) to extremely negative ( 3). In this study, scores were derived by summing impact ratings from all events perceived as negative during the rated period. Thus, if an individual identified four events as negatively impactful and rated each a 3, the negative life event score would be 12. Evidence is available that the perceived undesirability of an event is important in determining its stress-inducing properties (Mechanic, 1975; Vinokur & Selzer, 1975). 2.2.2. Perceived Support Network Inventory Sarason, Levine, Basham, & Sarason (1983) indicate that irrespective of how social support is conceptualized, it appears to have two fundamental elements. The first element involves a sense that there is a satisfactory number of individuals who are available in times of need. The second involves a perception of satisfaction with the quality of available support. The Perceived Social Network Inventory (PSNI) taps these two dimensions. Perceived social network size is reflected by the number of supportive individuals reported to be available during stressful periods. Perceived support quality is gauged by a composite index that reflects initiation of support seeking behavior, support availability, satisfaction with support received, support multidimensionality, support reciprocity, and social network conflict. Orit, Paul, and Behrman (1985) reported total social support values for a clinical sample (m = 27.35, SD = 3.57) and for a nonclinical sample (m = 30.39, SD = 3.6) in the PSNI scale development effort. Use of this support quantity – support quality dichotomy is supported by results of a factor analysis of the PSNI in the current study. In this analysis, two factors accounted for the majority of the variance associated with the seven PSNI variables. On one, moderate to high ( > 0.7) loadings were found on support initiation, availability, satisfaction, multidimensionality, reciprocity, and conflict. On a second, a single high loading (> 0.8) was found on PSNI network size. Orit and colleagues (1985) presented evidence of quite adequate test-retest reliability (r = 0.88), internal consistency (0.77), and convergent and discriminant validity for the PSNI composite index in the Inventory development effort. In the current investigation, Chronbach’s alpha was 0.81.

2.2.3. Millon Clinical Multiaxial Inventory-II The Millon Clinical Multiaxial Inventory-II (MCMI-II) was developed to assess and differentiate among various pathological personality styles and a variety of clinical symptom syndromes. A substantial body of published work reflects favorably on the reliability and stability (McMahon, Flynn, & Davidson, 1985; Piersma, 1986), construct validity (McMahon & Davidson, 1985, 1986; McMahon, Gersh, & Davidson, 1989; McMahon, Davidson, Gersh, & Flynn, 1991; Millon, 1987), and clinical utility (Craig, Verinis, & Wexler, 1985; McMahon et al., 1985; Millon, 1987; FalsStewart, 1992) of the MCMI in studies of substance abusers. Several reasonably comprehensive reviews of theoretically and clinically relevant research on the MCMI-II are available (Millon, 1987, 1997; Craig, 1993). Results of a factor analysis of MCMI-II, involving an initial principal components extraction and varimax rotation, in the current investigation are consistent with those previously described in the background section (Flynn & McMahon, 1984; McMahon et al., 1988; McMahon & Applegate, 1990). The first factor accounts for 45.4% of the variance and has high factor loadings (> 0.80) on the Antisocial, Aggressive, and Narcissistic scales. The second factor accounts for 15.6% of the variance and includes high (> 0.80) loadings on the Schizoid and Avoidant scales and moderate (> 0.50) loadings on the Dysthymic and Depression scales. The third factor accounts for an additional 9% of the variance and has moderate to high (> 0.60) loadings on the Dependent, Anxiety, Somatoform, and Dysthymic scales. A three-factor model was utilized because the first three factors account for 70% of the total variance and have eigenvalues greater than one (Norusis, 1988). In the current investigation, factor scores were used to represent the three MCMI-II dimensions. The distribution of each factor’s scores has a mean of zero and an SD of 1. Although these factors are referred to as ‘‘antisocial,’’ ‘‘detached,’’ and ‘‘dependent,’’ it is emphasized that a number of conceptually related MCMI-II scales contributed to each. Notably, the ‘‘detached’’ factor has moderate loadings on the Dysthymic Disorder and Major Depression scales and the ‘‘dependent’’ factor has moderate loadings on the Anxiety, Somatoform, and Dysthymic Disorder scales. 2.2.4. Addiction Severity Index The Addiction Severity Index (ASI) is a structured clinical/research interview schedule that is designed to evaluate problems affecting substance abusers in several areas. In addition to the detailed assessment of alcohol and drug use, it covers medical, employment, legal, family relationship, and psychiatric problems. The Guide to the Addiction Severity Index: Background, Administration, and Field Results (National Institute on Drug Abuse, 1985) provides a detailed report on the rationale, design, development, reliability, and validity of the ASI. The ASI was used for a number of purposes in this study. Data regarding age, education, pretreatment drug problem severity, and


drug treatment history from the ASI intake administration were utilized in covariate analyses. Measures of relapse relevant outcomes were obtained from follow-up administrations of the drug section of the ASI. One involved use of the Drug Composite Index derived from a set of interrelated items covering use of 10 specific drugs during the past 30 days, perceived drug problem severity, and need for treatment. This measure of drug abuse severity was selected because it gauges resumption of a troublesome pattern of substance use which includes, but is not limited to, cocaine. McLellan et al. (1985) reported high (> 0.9) levels of both inter-rater and test-retest reliability for the Drug Composite Index. A detailed description of procedures for derivation of the Drug Composite Index is provided in the ASI manual (Cacciola, Griffith, & McLellan, 1985). We modified standard ASI administration procedures in order to gauge drug usage during the four 90-day follow-up periods. Subjects were initially asked how many days they used various drugs during the past 30 consistent with normal ASI administration procedures. An inquiry was then made about the number of days of such drug use in the 60 days prior to the most recent 30-day period. Although we are not aware of reports dealing with the validity of ASI reports of drug use over periods longer than 30 days, Cacciola, Koppenhaver, McKay, and Alterman (1999) provide evidence of good test-retest (m = 50 days) reliabilities for ASI substance use items involving lifetime years of use of alcohol (ICC = 0.73) cocaine (ICC = 0.76) marijuana, ICC = 0.86). 2.3. Relapse-Related Outcomes This study was designed to identify relatively enduring personality and contextual factors (stress, social support) useful in predicting clinically significant return to cocaine use after a period of abstinence achieved during treatment. Although there have been efforts to distinguish relatively limited episodes of use, commonly referred to as slips or lapses, from those that involve more enduring return to use (Marlatt & Gordon, 1985), no specific criteria have been widely adopted (McKay, Alterman, Mulvancy, & Koppenhaver, 1999; Donovan, 1996). Indeed, in the research literature, relapse is generally defined as either any use of a substance following a week or more of abstinence or a day of ‘‘heavy use’’ following abstinence, during a period in which the individual is attempting to refrain from use (McKay et al., 1999). However, this approach does not distinguish between those who might experience a single day or two of use (i.e., a lapse) and more repetitive or enduring return to use (Marlatt & Gordon, 1985). In the current investigation, we classified participants as having relapsed if they reported, during the ASI drug interview, at least seven days of cocaine use during any one of the four three-month follow-up periods after treatment completion. Relapsers averaged 29.4 days

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(SD = 23.0) of cocaine use, 13.5 days (SD = 22.1) of alcohol use to intoxication, and 7.9 days (SD = 14.8) of marijuana use during the 90-day follow-up period in which relapse was identified. Nonrelapsers averaged less than one day of use of cocaine, alcohol, and marijuana during comparable periods. We decided exclude a group (n = 7) of subjects who used cocaine between three and six days in any three-month follow-up period because these individuals exceeded what we judged to be very limited use but did not reach the threshold of substantial repetitive use. However, these seven individuals were included in the analysis involving prediction of outcome drug abuse severity. In this analysis, relapsers, nonrelapsers, and those who used cocaine between three and six days during one or more three-month follow-up periods were combined and scores derived from the ASI Drug Composite Index were used to gauge outcome. As mentioned previously, this measure of drug abuse severity was selected because it gauges resumption of a troublesome pattern of substance use, which includes, but is not limited to, cocaine. Although concerns have been expressed about reliance on self-reports of abstinence by treated cocaine abusers, we took a number of steps to enhance self-report validity (Skinner, 1984). Interviewers emphasized that they were not members of the treatment staff and would not share information with staff members. Strong assurances of confidentiality were further enhanced by presentation of a Certificate of Confidentiality issued by the National Institute on Drug Abuse. Subjects were encouraged to recall anchoring dates (birthdays, holidays, etc.) to facilitate recollection (Sobell, Maisto, Sobell, & Cooper, 1979). Correspondence between time-line follow-back reports of cocaine use and urine samples collected during treatment and at follow-up have previously been found to be very good. For example, McKay et al. (1997) found that less than 7% of those who reported no cocaine use at three- or six-month follow-up had a cocaine-positive urine sample among cocaine-dependent patients. Similarly, Hall and associates (1991) reported that only 6.8% of urine specimens were positive for those who had reported abstinence from cocaine use at treatment follow-up. 2.4. Analytic strategy and preliminary analyses Treatment Outcomes. The first analysis involved a comparison of the subjects (n = 172) who relapsed or were lost to follow-up during one or more of the four threemonth follow-up periods with those subjects (n = 123) who reported little or no cocaine use during any follow-up period. Cocaine relapse was coded as a dichotomous variable. Among the 60 self-reported relapsers, 24 (40%) reported their first use of cocaine for at least seven days during the first follow-up period, 16 (27.6%) did so during the second follow-up period, 14 (23%) during the third, and an additional six (10%) during the fourth follow-up

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period. Among subjects lost to follow-up, 56 subjects were lost for the first time at the three-month follow-up, 21 at the six-month follow-up, 18 at the nine-month follow-up, and 17 at the twelve-month follow-up. These subjects were assumed likely to have relapsed during the three-month period prior to their first missed follow-up interview. All subjects who were first lost at the second, third, and fourth follow-up points met nonrelapse criteria (i.e., two or fewer days of cocaine use) prior to the period of loss to followup. Thus, of the 172 who either self-reported relapse or were lost during one of the four three-month follow-up periods, 80 (46%) were first identified as such at follow-up 1, 37 (21.5%) were so at follow-up 2, 32 (18.6%) at follow-up 3, and 23 (13.3%) at follow-up 4. Prediction of relapse involved personality measures from the intake assessment (T1) and stress and social support values from the intake assessment (T1) as well as from follow-up assessments reflecting status in the three months prior to (T2) the period of first relapse/loss. Thus, for those who relapsed or were lost in the period between three and six months after treatment, predictions of relapse involved personality measures from the intake assessment (T1) and stress and social support measures from the intake assessment (T1) as well as from follow-up assessments reflecting status in the three months prior to (T2), the relapse/lost period. Thus, in this case, T2 stress and support values reflected stress and support perceived between treatment discharge and the three-month follow-up. In order to compare the relapser/lost group with those who used little or no cocaine during any of the four followup periods (n = 123), we formed a comparison group from which we drew T2 stress and support values from the first, second, third, and fourth follow-up periods in approximately the same proportions as for the relapse/lost group (i.e., from the predischarge period in roughly half the cases, from the period between discharge and three-month follow-up in about 22% of cases, from the period between three and six

months postdischarge in 19% of cases, and from the period between six and nine months postdischarge in 13% of cases). Table 1 provides information regarding personal background, drug use, and treatment history for relapser/lost and nonrelapser groups. Table 2 provides a comparison of cocaine relapser/lost and nonrelapser groups on personality, life events, and social support variables. Table 3 includes personality, life events, and social support values for those who relapsed or were lost at 3, 6, 9, or 12 month follow-up assessments and for non-relapse comparison group members at each of these follow-up points. In the analysis involving prediction of drug abuse severity, self-reported relapsers, nonrelapsers, and those who reported use of cocaine between three and six days during one or more three-month follow-up periods were combined and scores derived from the ASI Drug Composite Index were used to gauge outcome. For self-reported relapsers, ASI Drug Composite scores were drawn from the period of first use of cocaine for seven days or more. For those who used cocaine between three and six days, Drug Composite scores were drawn from the first period in which such use was demonstrated. For nonrelapsers, Drug Composite scores were drawn from the first follow-up period in about half the cases, from the second follow-up period in about 22% of cases, from the third in about 19% of cases, and from the fourth follow-up period in about 13% of cases. Personality, stress, and social support values were selected in the same manner as described previously for the relapse group analysis.

3. Results 3.1. Prediction of relapse/loss 3.1.1. Covariate analyses Analyses were conducted to identify potentially important demographic variables (ethnicity, age, marital sta-

Table 2 Comparison of cocaine relapser/lost and nonrelapser groups on personality, negative life events, and social support Relapsers/Lost (n = 172) Variable Antisocial Personality Factor Detached Personality Factor Dependent Personality Factor

m

Nonrelapsers (n = 123) SD

m

SD

0.06 0.15 0.09

0.95 1.00 1.00

0.04 0.21 0.15

1.04 0.95 0.98

Negative Life Events: Time 1 Time 2

13.44 4.09

8.84 4.67

12.03 2.29

8.29 3.49

Social Support Quality Time 1 Time 2

27.79 28.12

8.83 9.77

26.57 31.84

9.51 4.42

3.71 2.70

2.54 2.00

4.12 3.80

3.06 2.89

Size of Support Network Time 1 Time 2


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Table 3 Comparison of relapse/lost group versus abstinent groups at 3-, 6-, 9-, and 12-month follow-ups Time 1 Values

Relapsed/Lost at 3 Months (n = 80) Abstinent at 3 Months (n = 62) Relapsed/Lost at 6 Months (n = 37) Abstinent at 6 Months (n = 24) Relapsed/Lost at 9 Months (n = 32) Abstinent at 9 Months (n = 21) Relapsed/Lost at 12 Months (n = 23) Abstinent at 12 Months (n = 16)

Time 1 Values

Antisocial Personality

Detached Personality

Dependent Personality

m

m

m

SD 0.13 0.00 0.11 0.25 0.01 0.05 0.12 0.22

0.93 1.01 0.91 1.09 0.94 1.14 1.11 1.02

SD 0.10 0.19 0.17 0.45 0.25 0.16 0.18 0.05

1.07 0.93 0.95 0.92 1.07 1.00 0.79 1.06

0.00 0.17 0.12 0.26 0.22 0.28 0.19 0.24

tus, education), drug-related variables (route of cocaine administration, intake drug abuse severity), and treatment background factors (number of previous treatments, length of most recent treatment, program attended). Variables were grouped conceptually and entered in blocks in a logistic regression analysis. Among the demographic, drug-related, and treatment variables analyzed, only number of days of cocaine use prior to intake contributed significantly to prediction of relapse group. This variable was entered first in the subsequent overall logistic regression analyses. 3.1.2. T1 prospective analyses Days of pretreatment cocaine use was entered in the first block [c2(df = 1) = 6.48; p = 0.010]. The antisocial, detached, and dependent personality factors entered sequentially in the second block and this block contributed a significant increment to prediction of relapse group membership [c2(df = 3) = 12.39, p = 0.006]. T1 stress, social network size, and social support quality were entered sequentially in the third block but did not contribute significantly to prediction [c2(df = 3) = 4.31, p = 0.228]. Variables reflecting interactions between personality factors and stress and support were entered in the fourth block. This block also did not contribute significantly [c2(df = 6) = 2.11, p = 0.908]. The overall T1 logistic regression model was significant [c2(df = 7) = 23.39, p = 0.001]. Among variables in the T1 model, detached personality contributed most to prediction of relapse group membership [Wald(df = 1) = 8.84, p = 0.004]. Social support also made a significant contribution to prediction [Wald(df = 1) = 4.08, p = 0.043]. 3.1.3. T2 prospective analyses Variables reflecting stress, social network size, and social support quality experienced during the three-month period prior to the one in which relapse was identified were entered sequentially in a single block. This block contributed significantly to prediction [c2(df = 3) = 30.83, p = 0.001] after controlling for all previously entered T1 variables. Finally, variables reflecting interactions between personality factors and T2 stress and T2 support were entered in the

Time 2 Values

Social Support

Stress SD

m

Support Network

SD

m

0.95 0.97 1.26 1.08 0.95 1.11 0.79 0.72

14.2 9.0 26.6 9.8 3.5 12.0 7.3 26.6 9.9 3.8 13.6 10.1 28.5 8.2 4.1 12.1 9.6 27.8 9.4 4.4 12.5 7.9 28.2 8.1 3.5 11.5 8.4 26.7 8.0 5.9 11.6 7.2 29.8 6.6 3.8 11.5 9.2 26.4 8.4 2.8

SD m

Stress

Social Support

SD

m

SD m

2.3 3.0 2.6 3.2 2.6 2.6 3.0 1.1

4.5 2.4 5.1 2.5 2.8 1.6 2.6 2.0

4.8 4.0 5.7 3.2 2.6 2.3 3.4 3.0

SD

Support Network m

26.6 9.8 2.7 31.2 4.4 3.8 29.0 9.9 2.1 33.7 3.8 3.9 29.7 8.7 2.7 31.9 3.4 4.4 29.3 10.6 3.2 30.1 5.2 2.9

SD 1.9 3.0 1.8 2.9 1.8 3.0 2.4 2.1

fourth block. This block did not contribute significantly [c2(df = 6) = 4.77, p = 0.573]. 3.1.4. Final model The final logistic regression model was significant [c2(df = 10) = 54.22, p = 0.0001]. Detached personality [Wald(df = 1) = 5.85, p = 0.015], T1 social support (Wald(df = 1) = 4.87, p = 0.027], T2 stress (Wald(df = 1) = 5.02, p = 0.024], T2 social support [Wald(df = 1) = 9.77, p = 0.001], and T2 support network size (Wald(df = 1) = 6.38, p = 0.011], contributed significantly to prediction of relapse group membership. Higher levels of detached personality and T2 stress and lower levels of T2 social support and fewer T2 support network members predicted relapse. Contrary to expectation, more perceived social support at T1 predicted relapse. Follow-up within group repeated measure analyses reveal that the nonrelapse group showed a significant increase in average social support between T1 and T2 [T(1, 122) = – 5.84, p < 0.001]. The relapse/lost group did not change between T1 and T2 [T(1, 173) = – 0.35, p = 0.724]. 3.2. Prediction of T3 drug abuse severity 3.2.1. Covariate analyses Preliminary analyses were conducted to identify potentially important demographic variables (ethnicity, age, marital status, education), drug-related variables (route of cocaine administration, intake drug abuse severity), and treatment background factors (number of previous treatments, length of most recent treatment, program attended). Among the demographic, drug-related, and treatment variables analyzed, only intake (T1) drug abuse severity contributed significantly to prediction of outcome (T3) drug abuse severity. This variable was entered first in the subsequent overall multiple regression analyses. 3.2.2. T1 and T2 prospective predictors T1 drug abuse severity was entered in the first block and contributed significantly to prediction of outcome drug abuse severity [T(1, 176) = 2.82, p = 0.005].The three

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personality factors assessed at intake were entered next and the detached personality factor provided a significant increment to the prediction of outcome drug abuse severity, T(1, 176) = 2.87, p = 0.005. After this step, with intake drug abuse severity and detached personality in the equation, R2 = 0.076, F(2, 175) = 8.30, p < 0.001. Main effect analyses involving T1 and T2 social support and T1 stress, as well as analyses involving interactions between personality, stress, and social support, were not significant. However, T2 stress accounted for slightly more than 9% of the variance in outcome drug abuse severity, T(1, 176) = 4.36, p < 0.001, after adjusting for the contribution of previously entered variables. After this step, with intake drug abuse severity, detached personality, and T2 stress, in the equation, model R2 = 0.177, F(3, 174) = 12.45, p < 0.001.

4. Discussion This longitudinal study examined the main effects and interactive relationships of personality, negative life events, and social support to cocaine relapse and drug abuse severity at treatment follow-up. The contributions of personality, life events, and social support to predicting major outcomes will be discussed in turn. Antisocial and dependent personality factors did not predict either relapse status or outcome drug abuse severity. However, higher levels of detached personality predicted both cocaine relapse and drug abuse severity prospectively in main effect analyses. The higher probability of relapse and greater drug abuse severity in those with this orientation may be related to their difficulty in participating fully in therapeutic communities which emphasize social participation and confrontation of attitudes and behaviors relevant to drug use. Further, the unavailability of treatment focused on long-standing personality problems may contribute to increased likelihood of relapse. A clinical implication is that more ‘‘personalitysensitive’’ residential or aftercare treatment components may be indicated for cocaine abusers with detached personality characteristics (Beck & Freeman, 1990). Millon and Davis (1996) suggest that those with avoidant personality features have special difficulties becoming involved in treatment because they have doubts regarding the integrity of treatment providers and because of their reluctance to confront distressing memories. Indeed, traditional residential drug treatment approaches may attack their most basic defense, which is detachment. It has been suggested that those with significant detached personality features must be approached gradually and supportively in treatment. Initially, a focus on positive attributes and on development of social skills designed to enhance confidence and self-esteem is recommended (Millon, 1981; Millon & Davis, 1996; Beck & Freeman, 1990). This may contrast notably with more traditionally confrontational approaches associated with therapeutic communityoriented treatment.

Current findings are consistent with those which have established a link between underlying psychopathology and relapse to various substances of abuse (e.g., Fals-Stewart, 1992; LaPorte, McLellan, O’Brien, & Marshall, 1981; McLellan, Erdlen, Erdlen, & O’Brien, 1981). Because the MCMI-II factor which predicted cocaine relapse and outcome abuse severity had at least moderate loadings on anxiety and depression scales, results reveal consistency with the commonly found association between negative affective states and relapse among those treated for alcohol, smoking, and opiate addictions (Wills, 1990; Brownell, Marlatt, Lichtenstein, & Wilson, 1986). Although it is not clear what factors contributed to our failure to establish links between dependent and antisocial personality characteristics and relapse, several factors seem worthy of consideration. Relatively few individuals earned clinically significant elevations on the dependent scale. Very few showed such elevations in the absence of similar or more pronounced elevations on one or several other scales (e.g., antisocial). It appears that dependent characteristics were not particularly salient in the personalities of most participants. We may well have had insufficient numbers with prominent dependent characteristics to enable a test of the significance of such characteristics in predicting relapse. In contrast, more than 80% scored in the clinically elevated range on the antisocial scale. Many investigators have found that antisocial personality is common in AOD abusing populations. In this investigation, there may have been too few participants without antisocial characteristics to allow for an adequate test of the relationship between antisociality and relapse. However, it is noteworthy that current findings are consistent with those of Carroll et al. (1994) and Cacciola et al. (1995), who also failed to find poorer outcomes for cocaine-dependent patients with antisocial personality. Hypotheses involving interactions between personality and both stress and support were not confirmed. However, important direct stress and support effects were found. Wills (1990) suggested it is possible that negative life events and limitations in social support predict relapse due to their link with underlying psychopathology. In this investigation, both stress and social support prospectively predicted relapse and stress and prospectively predicted outcome drug abuse severity after controlling for three separate dimensions of psychopathology. Negative life events experienced in the three-month period prior to the relapse period predicted both relapse group membership and outcome drug abuse severity. These findings are consistent with previous studies in which prospective relationships have been found between stress and relapse among substance abusers (e.g., Mermelstein, Cohen, Lichtenstein, & Kamarck, 1986). However, current results contrast with those of Hall and associates, who found no prospective stress effects on relapse in studies involving alcoholics, opiate addicts, cigarette smokers, and notably, cocaine abusers (Hall, Havassy, & Wasserman, 1990, 1991).


Prospective stress-relapse relationships are more often found in studies in which stress and relapse events are aggregated over somewhat extended periods (e.g., three months to one year). Hall and associates have emphasized shorter (e.g., one week) lags between stress exposure and relapse (Hall et al., 1990,1991). It is possible that those who provide treatment aftercare should place more emphasis on the management of cumulative stress effects. Current results also reveal the importance of social support characteristics in understanding the relapse process. Contrary to prediction, relapsers reported slightly more support quality than did nonrelapsers at treatment intake. However, the hypothesized relationship emerged in the T2 analysis reflecting significantly less perceived support quality among relapsers during the three-month period just prior to relapse than among nonrelapsers. While maintenance of abstinence was associated with having somewhat less adequate perceived social support at treatment intake, it was also linked with experiencing significant improvement in support quality after treatment discharge. Relapsers failed to show such improvement. Supportive relationships at treatment intake for those who eventually relapsed might have involved stable links with those who encouraged or enabled drug use. Protective support effects among nonrelapsers may have been associated with the increased availability of those who provide opportunities for intimate and reciprocal relating, various forms of assistance in coping with stressful encounters, and perhaps encouragement of health-promoting behaviors including abstinence during the crucial posttreatment period. Perhaps increased attention should be devoted to encouraging development of such relationships both during residential treatment and in aftercare (Table 2). In general, current findings suggest that personality, stress, and social support characteristics which have been useful in the prediction of relapse to alcohol, opiates, tobacco, and other drugs are also useful in predicting cocaine relapse. Assessment of these characteristics may assist in understanding the likelihood of relapse and in planning effective treatments. Interventions designed to address certain long-standing personality disturbances, as well as those that assist patients in coping with cumulative stress effects and in remedying social support deficiencies, should continue to be planned and evaluated. Although, in general, psychosocial factors assessed in the period immediately preceding relapse were most useful in the final prospective model, drug abuse severity, detached personality, and perceived support quality assessed at intake made meaningful contributions. 4.1. Limitations Results of this study may not generalize to other populations of cocaine abusers for a number of reasons. This study was limited to men. Further, the men in this study demonstrated very high levels of dysfunctional personality charac-

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teristics not seen in other AOD abusing groups (Flynn & McMahon, 1998). Personality-relapse relationships that emerged in this study might differ from those found in others. Another limitation of this study is that the primary outcomes were measured with participants’ self-reports, which might have been unintentionally or intentionally inaccurate (Malow, Gustman, Ziskind, McMahon, & St. Lawrence, 1998). However, we used several strategies, such as anchoring significant events on a time line, using calendars, and ensuring and emphasizing confidentiality, to enhance participants’ ability to recall and to motivate honest responding (Malow et al., 1998). Nonetheless, self-reports regarding substance use, in particular, represented ‘‘best approximations.’’ Some underestimation of AOD use seems likely. Further, despite concerted efforts to locate all participants for follow-up, a significant number were lost. A somewhat different pattern might have emerged if we had achieved a higher follow-up rate. Despite these limitations, current findings contribute to understanding of psychosocial characteristics that may influence relapse among cocaine-dependent individuals after treatment and, as such, have important implications for future research and program development in the area of relapse prevention.

Acknowledgments This study was supported by a grant (DA#5433) from the National Institute on Drug Abuse to Robert C. McMahon.

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