Addiction (1999) 94(5), 709± 713

RESEARCH REPORT

A comparison of the beliefs of Indianalcohol-dependent patients and their closefamily members on their reasons for relapse

SAMEER MALHOTRA, SAVITA MALHOTRA & DEBASISH BASU

Department of Psychiatry, Postgraduate Institute of Medical Education and Research,Chandigarh 160012, India

Abstract

Aims. To study and compare the perspectives of relapsed alcohol-dependent patients and their familymembers regarding relapse precipitants. Design. Observational, cross-sectional survey. Setting. An

addiction centre in northern India. Participants. Thirty consecutive male patients attending the centre with

relapse of alcohol dependence following previous inpatient treatment, and their repsective family members.Measurements. Relapse precipitants, as generated by a 25-item, three-factor, self-report inventory eliciting

the subjects’ beliefs about events or circumstances leading to relapse. Findings. Both the patients and their

families listed items related to `reduced cognitive vigilance’ as the most common relapse precipitants. Reasonspertaining to external situations and euphoric states as well as unpleasant mood states were also frequently

reported by them. The rank order correlation between the items by patients and their families was positive and

statistically signi® cant (r 5 0.80, p , 0.001). Individual item-wise comparison by chi-squared test yieldedstatistically signi® cant difference in only one of 25 items. Conclusions. There was a high degree of

concordance between the patients and their family members regarding beliefs about precipitants of alcoholic

relapse.

Introduction

Although it is generally recognized that thespouse and other family members may play apart in an individual’ s alcohol problems andtheir recovery,1,2 the family members’ perspec-tive on the relapse process following treatmentdoes not seem to have received a great deal ofattention. A MEDLINE as well as a manualsearch on this topic identi® ed only two publica-tions from a study from the West3,4 on alcoholicrelapse in male patients. These revealed a lowconcordance between the perspective of patients

(who made more situational attributions) andthat of their spouses (who made more attribu-tions related to the patients’ disposition).

The knowledge of the attributional styles ofpatients vis-aÁ -vis their family members could in-directly help re¯ ect the quality of interactionbetween them. Knowledge of such an interac-tion, in turn, could help in establishing a smoothworking relationship and planning furthermanagement.

In India, despite an interactive and largelypreserved family structure, studies comparing

Correspondence to: Dr D. Basu, Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh 160 012,India. Tel: 1 91 172 545807; fax: 1 91 172 540401, 543078, 540450; e± mail: medinst@pgi.chd.nic.in

Submitted 31st March 1998; initial review completed 10th July 1998; ® nal version accepted 6th November 1998.

0965± 2140/99/050709± 05 $9.50 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing, Taylor & Francis Ltd

710 Sameer Malhotra et al.

the perspectives of patients and their attendantson alcoholic relapse are lacking. The currentstudy was, thus, designed to assess the alcoholicrelapse precipitants from the dual perspectives ofthe patients as well as close family members.

Method

The work reported in this paper is based on across-sectional study carried out in 1996± 97 ona sample of relapsed alcoholic patients and theirclose family members attending the DrugDeaddiction and Treatment Centre (DDTC) atthe Department of Psychiatry, PostgraduateInstitute of Medical Education and Research(PGIMER), Chandigarh, India. The centre pro-vides both inpatient and outpatient treatmentfacilities to patients, the majority of them comingfrom the northern and western states of thecountry. The treatment package for inpatientsconsists of detoxi® cation, behavioural manage-ment, group, family and psychosocial interven-tions and liaison with Alcoholics Anonymous. Inbehavioural management, awareness and man-agement of relapse-related cues is taught.

The patient group consisted of a consecutivesample of 30 male patients with alcohol depen-dence diagnosed following the ICD-10 Diagnostic

Criteria for Research (ICD-10 DCR).5 Thesepatients had relapsed after inpatient treatment atDDTC and subsequently reported back to seekhelp from the Centre. Relapse, for the purpose ofthe study, was de® ned as recurrence of fullalcohol dependence syndrome following ICD-10DCR for at least 1 month following discharge inan improved condition after inpatient treatment.The minimum period of remission before relapsewould be the duration of inpatient stay (usually4± 6 weeks but not less than 2 weeks). Infor-mation regarding previous admission(s), treat-ment and `discharge in improved condition’ wasgathered from the previous hospitalizationrecords of the patient based on factors such astotal abstinence during ward stay, freedom fromwithdrawal symptoms, absence of any other psy-chiatric symptoms, satisfaction expressed by thepatient and family members, patient-complianceand co-operation with ward staff in treatmentand participation in group activities.

Patients with other substance dependence,co-morbid major mental disorder or any majordebilitating physical illness, organic brain syn-

drome or mental retardation were excluded fromthe study.

One respective family member per patient,chosen for the study, was a close relative of thepatient (parent/spouse/sibling), aged $ 18 years,living with the patient for $ 2 years and involvedin care-giving. Informed consent was obtainedfrom all these subjects (both patients and familymembers). The study protocol was approved bythe Institute Ethics Committee.

Information regarding precipitants of currentalcoholic relapse was gathered by administrationof the Relapse Precipitants Inventory (RPI)6 tothe patient and the family member separately.The RPI is a self-report questionnaire. It consistsof 25 items which are descriptions of situationsthat are most likely to cause resumption of heavydrinking. The items can be reduced to threefactors, namely: unpleasant mood states (14items), external events and euphoric states (eightitems) and reduced cognitive vigilance (threeitems).6 The items refer to precipitants of fullrelapse and not the ® rst lapse or `slip’ .

Before obtaining information from thepatients, it was ensured that their blood alcohollevel was below 100% mg (using a breathalyzerALCOL TEST-ED 308, supplied by KasyRadhakrishnan and Company Pvt. Ltd, Madras,India). For ease of administration of the RPI tothe family members, the questions in the inven-tory were converted into the third person, e.g.the word `I’ was replaced by `he’ . The patientand his family member were administered theRPI in separate rooms concurrently so thatmutual consultation was ruled out. Furthermore,there was no discussion between the doctors andthe patients and their family members prior tothe completion of the RPI.

Results

The majority of the family members (80%) werespouses of the patients, while in 20% of cases thefamily members were parents. Mean duration ofalcohol dependence in the patients was 10.1years (SD 7.9). The majority of the patients were® rst-time relapsers (63.3%) with a history ofhaving received inpatient treatment once in thepast. The mean duration of the inpatient stayduring the previous admission was 34.5 days(SD 17.4).

The three most common relapse precipitantsattributed by the patients were related to the

Patients vs. family perspectives on alcohol relapse 711

Table 1. Rank order of relapse precipitants on RPI1: attributions of patients vs. family members

Family members (n 5 30)Patients (n 5 30)

Sr.no. No. of familyof item No. of pts *Ranking by members *Ranking byin RPI Item description endorsing (%) endorsement endorsing (%) endorsement

25 When already taken some drink 26 (86.7) 1 29 (96.7) 119 On thinking that not 23 (76.7) 2.5 28 (93.3) 2

really hooked on alcohol6 On thinking that just one 23 (76.7) 2.5 26 (86.7) 3

drink won’t harm18 When in a party 22 (73.3) 4 25 (83.3) 421 On special occasions 21 (70) 5 24 (80) 517 When irritable 18 (60) 6 20 (66.6) 9.513 When having money to spend 17 (56.7) 8 22 (73.3) 6.522 When frustrated/feeling 17 (56.7) 8 13 (43.3) 18.5

fed up with life4 When tense 17 (56.7) 8 21 (70) 85 On having to meet people 16 (53.3) 11.5 19 (63.3) 122 When with other people 16 (53.3) 11.5 19 (63.3) 12

who are drinking7 When depressed 16 (53.3) 11.5 16 (53.3) 15.59 When get a feeling of 16 (53.3) 11.5 11 (36.7) 21

being punished unjustly23 While feeling tired 15 (50) 15 22 (73.3) 6.511 On a holiday 15 (50) 15 18 (60) 1412 When feeling happy with 15 (50) 15 19 (63.3) 12

everything15 When there are rows and 14 (46.7) 18 13 (43.3) 18.5

arguments at home16 When full of resentments 14 (46.7) 18 15 (50) 1724 When disappointed that 14 (46.7) 18 7 (23.3) 23

others are letting down1 On passing by a pub 13 (43.3) 21.5 20 (66.7) 9.58 When there are problems 13 (43.3) 21.5 16 (53.3) 15.5

at work20 When angry 13 (43.3) 21.5 12 (40) 2014 On remembering good times 13 (43.3) 21.5 10 (33.3) 22

of having a drink3 On feeling that no one cares 12 (40) 24 4 (13.3) 25

whatever happens10 On feeling afraid 5 (16.7) 25 5 (16.7) 24

* Rank± order correlation coef® cient (r) 5 0.80 (p , 0.001). 1RPI: relapse precipitants inventory.6

factor of reduced cognitive vigilance (`whenalready taken some drink’ ; `on thinking that notreally hooked on alcohol’ ; and `on thinking thatjust one drink won’ t harm’). Reasons pertainingto external situations and euphoric states as wellas negative mood states were also reported fre-quently by the patients. The least frequentlyreported reason by the patients was the negativemood state of feeling afraid (Table 1).

The three most common attributions made bythe attendants as reasons for current relapse inthe patient were also related to reduced cognitivevigilance. A high degree of concordance was seen

between the patients’ and attendants’ perspec-tives regarding reasons precipitating currentrelapse (Table 1).

On comparison between patients’ and familymember’ s attributes on each item of RPI, astatistically signi® cant difference ( c 2 5 5.45;p , 0.05) emerged from only one of 25 items.Signi® cantly more patients (40%) than theirfamily members (13.3%) attributed the feeling of`no one cares whatever happens’ as a reason forcurrent relapse in the patient, despite lowendorsements on the particular item by bothpatients as well as the family members.

712 Sameer Malhotra et al.

Table 2. Comparison between patients’ and family members’ attributes on factors of the RPI

Max. Patient score Family member t value*Factor score (mean 6 SD) score (mean 6 SD) (df 5 58)

1. Reduced cognitive vigilance 3 2.4 6 0.93 2.77 6 0.63 t 5 1.792. External events and euphoria 8 4.47 6 2.50 5.27 6 2.26 t 5 1.303. Unpleasant mood states 14 6.67 6 4.30 6.50 6 3.61 t 5 0.61

* All values NS.

The information on the RPI was then orga-nized into factor structures of reduced cognitivevigilance, external events and euphoric states,and unpleasant mood states as proposed byLitman et al.6 (Table 2). No signi® cantdifference emerged between the scores on thepatients’ and the family members’ attributesacross the three factors of the RPI.

Discussion

A high degree of concordance was foundbetween the patients’ and their family members’perspectives on alcoholic relapse precipitants inthe patient. This is contrary to the ® ndings ofMaisto et al.3 and McKay et al.4 This may haveoccurred for two reasons. First, the integratednature of the family structure and functioning inIndian settings may foster greater involvement ofthe family member with the patient, resulting inthe family member’ s better understanding of theproblems faced by the patient. Secondly, it couldbe due to the differences in the initial treatmentregime offered in the current study compared tothe behavioural marital therapy or couples groupinteractional therapy offered in the study byMaisto et al.3 and McKay et al.,4 respectively.

It should be emphasized that the attribution ofrelapse precipitants by both the patients as wellas their families merely represent their percep-tion of the precipitants and not necessarily theactual precipitants themselves. The fact thatthese represent perspectives of patients and theirfamily members is, however, important in itself,without the need for extrapolation of the ® ndingsto the real events leading to relapse. As men-tioned earlier, the high attributional concordanceitself can help in formulation of initial treatmentstrategies for relapse prevention by involvingboth the patients and their family members.

It must also be stressed that the high concord-ance between the patients and their relatives was

not a spurious aftermath of their joint interpret-ation of events at the time of testing. There wasno common discussion with the therapist prior tocompletion of the RPI by the patients and therelatives who, furthermore, completed the inven-tory separately with no possibility of mutualconsultation and hence common interpretation.

The `actor± observer difference’ (Jones & Nis-bett7) alluded to in previous studies3,4 may notapply in our clinic. All the family members inter-viewed in this study had actually lived with thepatients through their relapses, cared for themand shared the burden together. The `actor±observer’ difference may have become blurredover time. This is in contrast to previous studies,where:

most wives did not actually see their husband’srelapses. Therefore their relapse attributionswere primarily generated by their knowledgeof the husband’ s personalities and pasthistories of alcoholism.4

It is interesting to note that, even in the latterstudy, concordance of relapse attribution withincouples increased over time.4

Although from a small sample, the ® ndings ofthe current study suggest that the family mem-ber’ s understanding of the patient’ s problem ofpost-treatment alcoholic relapse is mainlyadequate in an Indian setting. This may be uti-lized by involving the family members moreactively in the treatment programmes aimed atrelapse prevention.

References1. MCCRADY, B.S. (1982) Conjoint behavioural

treatment of an alcoholic and his spouse, in: HAY,W.M. & NALTHAN, P.E. (Eds) Clinical Case Studiesin the Behavioural Treatment of Alcoholism (NewYork, Plenum).

2. O’FARRELL, T.J. (1986a) Marital and familytherapy for alcohol problems, in: COX, W.M. (Ed.)

Patients vs. family perspectives on alcohol relapse 713

Treatment and Prevention of Alcohol Problems: aresource manual, pp. 205± 233 (New York,Academic Press).

3. MAISTO, S.A., O’FARRELL, T.J., MCKAY, J.R.,CONNORS, G.J. & PELCOVITS, M. (1988) Alcoholicand spouse concordance on attributions aboutrelpase to drinking, Journal of Substance Abuse andTreatment, 5, 179± 181.

4. MCKAY, J.R., O’FARRELL, T.J., MAISTO, S.A.,CONNORS, G.J. & FUNDER, D.C. (1989) Biases inrelapse attributions made by alcoholics and theirwives, Addictive Behaviors, 14, 513± 522.

5. WORLD HEALTH ORGANIZATION (WHO) (1993)The ICD-10 Classi® cation of Mental and Behavioural

Disorders: diagnostic criteria for research (Geneva,WHO).

6. LITMAN, G.K., STAPLETON, J., OPPENHEIM, A.N.,PELEG, M. & JACKSON, P. (1983) Situationsrelated to alcoholism relapse, British Journal ofAddiction , 78, 381± 389.

7. JONES, E.E. & NISBETT, R.E. (1972) The actorand the observer: divergent perceptions of thecauses of behavior, in: JONES, E.E., KANOUSE, D.,KELLEY, H.H. et al. (Eds) Attributions: perceivingthe causes of behavior, pp. 79± 94 (New York,General Learning Press).