Introduction
Assessing and addressing the risks of relapse is a crucial part of substance abuse treatment. According to Javed et al. (2020), relapse prevention is the main therapy challenge since 70-90% of addicts are reported to return to substance use within one year after their discharge from a rehabilitation center. There are multiple risks that may result in a relapse, which include emotional instability, pessimism, impaired family communication, a lack of coping skills, and various environmental factors (Javed et al., 2020). This paper aims to assess the key risks that may undermine the treatment effectiveness in Riley Stanton, a 39-year-old man who has made several unsuccessful attempts to quit cannabis use. Mr. Stanton began using marijuana when he was ten years old, and he has consumed it daily for the last 28 years, smoking an average of 20-25 joints per day. The client is willing to discontinue cannabis use, so he has not been smoking for the past month, but abstinence has been difficult for him. This paper will identify Mr. Stanton’s risks of relapse, explore relevant cultural factors exposing the client to these risks, and propose an intervention plan.
Key Risk Factors
Many external and internal factors may lead individuals to resume substance use after treatment. They include mental illness, social pressure, interpersonal conflicts, unemployment, a lack of leisure activities, and others (Ramsewak et al., 2020). Many of these risks stem from individuals’ choice of maladaptive strategies for addressing various life situations, such as stress, social interactions, or boredom. In the given case, the key factors are unstable employment history, high distress, insufficient social support, and a lack of coping skills.
Unstable Employment History
Employment is an important area of life since it directly influences individuals’ socioeconomic status and may have an impact on self-esteem and self-actualization. Studies show that unemployment can increase the risk of substance abuse relapse for two main reasons. First, unemployed individuals have much time to indulge in substance use (Ramsewak et al., 2020). Second, a lack of a job often results in low incomes and poor quality of life, which increases people’s distress and forces them to resume substance use (Ramsewak et al., 2020). A recent study conducted by Ramsewak et al. (2020), who aimed to investigate the risk factors of substance abuse disorder, found that low socioeconomic status was strongly linked to addiction, as almost half of 180 addicted participants lived below the poverty line.
In the given case, low socioeconomic status is a risk because Mr. Stanton has unstable employment resulting from his drug use. The client is employed part-time and has worked 15 of the past 30 days. It means that he has sufficient time to indulge in cannabis use, which may eventually lead to relapse. Because of his unstable employment and reliance on his wife’s income, he may also experience distress and use drugs to alleviate the negative feelings.
High Distress
Distress and negative emotions are other warning signs of relapse. According to Ramsewak et al. (2020), psychological distress may lead addicted individuals to resume using drugs as a means of recovering from painful situations. In the presented case, Mr. Stanton appears to be depressed because of his struggle with abstinence and concerns about the consequences of prolonged cannabis use. Such a mental state can undermine the effectiveness of substance abuse treatment unless the client is taught to cope with stress in adaptive ways.
Insufficient Social Support
Studies have shown that social support is crucial for the success of the treatment. For example, in research conducted by Javed et al. (2020), 41% of respondents revealed that a lack of support from the family caused them to lose motivation to abstain from using drugs. In contrast, positive family support increased individuals’ confidence, developed an optimistic approach to treatment, and led to emotional stability (Javed et al., 2020). Another study conducted by Sari et al. (2018) obtained similar findings, showing that the risk of relapse was several times higher in individuals lacking social support than in those who had strong social support. Sari et al. (2018) also distinguished between three types of support: informational, appraisal, instrumental, and emotional. Appraisal support appeared to be the most important since individuals need to be encouraged to pursue their abstinence efforts and reassured of their success. Although the sample size of the study was small (39 respondents), it provided useful insights into the significance of social support in substance abuse treatment.
In the given case, Mr. Stanton experiences a lack of support, which is evidenced by his relationships with the family. The client has conflicts with his wife because his addiction has negatively affected different aspects of their marital life. The client’s relationships with his mother and children are also strained because these family members disapprove of his substance use. Finally, Mr. Stanton mentions that he often spends time alone rather than with his family because it enables him to smoke. Under such circumstances, the client may lack the support necessary for him to maintain his abstinence.
Ineffective Coping Strategies
A lack of coping skills often contributes to the development of substance use disorder (SUD) and may lead to relapse. The study conducted by Marquez-Arrico et al. (2019) showed that individuals with SUD dealt with problems using self-blaming and self-criticism. Problem avoidance was also common among this population since such individuals tended to avoid problem-related behaviors and thoughts. Finally, substance users were found to involve in social withdrawal from friends and family (Marquez-Arrico et al., 2019). Such behaviors indicate a lack of effective coping skills and may lead to relapse because, not knowing how to handle aggravating problems, individuals are likely to indulge in substance use to alleviate stress.
In the given case, the client’s lack of coping skills is evidenced by his regular alcohol use, in addition to smoking cannabis, withdrawing from spending time with the family, and the inability to secure employment. Mr. Stanton drinks 3-4 times a week and can consume 8-12 beers per sitting. Although he does not see it as a problem, such regular alcohol consumption may indicate a lack of skills for coping with boredom effectively. The client’s choice of spending much time alone rather than with his family may mean that he does not have effective strategies to manage interpersonal conflicts. Finally, his inability to secure employment may suggest a lack of skills for coping with stress, which is an essential part of the employment.
Cultural Factors Affecting the Exposure to Risk
Cultural factors that may increase the client’s exposure to risk are related to his social background and environment. First of all, the client may be influenced by a culture in which cannabis use is accepted as a proper way of relaxation. According to Ndasauka et al. (2017), cultural values can significantly increase individuals’ excessive involvement in particular behaviors. For example, in cultures with ambivalent attitudes toward alcohol or in countries where alcohol was introduced only recently, alcoholism is more prevalent than in those cultures that have established patterns of alcohol consumption (Ndasauka et al., 2017). This finding can be used to explain cannabis use. In the US, there are ambivalent attitudes toward cannabis: in some states, marijuana is prohibited, while in others, medical or even recreational cannabis use is legal. This uncertainty may contribute to individuals’ involvement in cannabis use because this substance is not considered totally illegal, and its consumption is acceptable for stress relief and relaxation in certain parts of society.
The client’s family can also be regarded as a cultural factor that may influence the client’s exposure to the risk of relapse. As Ndasauka et al. (2017) note, “Cultural norms, practices and conceptions are transmitted from one generation to another through families” (p. 10). It means that culture can be viewed not only as a macro-level concept but also as a micro-level construct because people are influenced by norms established in both their families and the larger society. In the given case, Mr. Stanton’s addiction can be related to his family history since his father had problems with alcohol, and all of his brothers and brothers-in-law smoke cannabis. The client has already noted that such a family history of marijuana use has made it difficult for him to quit smoking, and it can present a risk of relapse.
An Intervention Plan for Addressing Risks
The intervention plan for this client should include identifying triggers, managing cravings, and analyzing possible lapses to prevent them from transforming into a relapse. One evidence-based intervention to address the specified areas and reduce the client’s risks of relapse is mindfulness-based relapse prevention (MBRP). This is an eight-session program in which individuals are taught to stay in the present moment and avoid acting in an automatic way (Morin et al., 2017). The studies assessing the effectiveness of mindfulness-based interventions for substance abuse disorder found that they reduced the participants’ use of different substances (cannabis, cocaine, alcohol) and decreased cravings as compared to the control groups (Morin et al., 2017). Therefore, MBRP is an evidence-based intervention that can help the client cope with cravings and prevent a relapse.
MBRP can address the key client’s risks of ineffective coping strategies and high distress. In particular, this program includes an intervention during which individuals are exposed to triggers and high-risk situations and learn to resist them (Morin et al., 2017). In this way, the counselor emphasizes that individuals are not obliged to act on their thoughts and cravings; instead, they have the choice not to indulge in their addiction. Mindfulness-based interventions also teach clients to cope with and tolerate strong emotional responses, which provides them with an effective alternative to using substances for stress relief and relaxation. Thus, Mr. Stanton can benefit from MBRP because it is an evidence-based practice that may provide him with proper coping skills and reduce his levels of distress.
Other interventions suggested for the given client include marital and family-based interventions. According to Glasner and Drazdowski (2019), the most extensively researched evidence-based intervention in this field is Behavioral Couples Therapy (BCT). The goal of this therapy is to maintain abstinence and improve marital relationships. This program consists of 12-20 weekly sessions that can be conducted over a period of 3-6 months (Glasner & Drazdowski, 2019). Although BCT is intended for couples, it can sometimes include other relatives such as parents or siblings. A significant part of this intervention is a “Recovery Contract,” which is signed every day and in which the client states his or her intentions to abstain from substance use while the partner expresses his or her support (Glasner & Drazdowski, 2019). The other part of the program is focused on improving relationships by teaching the couple to use effective communication skills such as listening, expressing feelings, and negotiating (Glasner & Drazdowski, 2019). Studies show that BCT results in reduced substance use and increased relationship satisfaction, as well as decreased divorces and improved medication adherence (Glasner & Drazdowski, 2019). This program is not appropriate for those with active restraining orders or couples with severe domestic violence, but this is not the case for Mr. Stanton.
BCT can be helpful for the client because, as noted in the case, he has strained relationships with his wife, mother, and children and, thus, experiences a lack of social support. Without enlisting family support, the client is likely to relapse because he will still be influenced by cultural factors such as ambivalent societal attitudes toward cannabis use and the family history of smoking marijuana. Involving the client’s family in the process of recovery may help address the risk of high distress because social support has been shown to decrease the negative effect of stress (Sari et al., 2018). BCT can be particularly helpful in increasing the amount of emotional and appraisal support obtained by the client. According to Sari et al. (2018), emotional support enables the client to feel cared for and understood, while appraisal support allows the individual to feel appreciated and motivated on their path toward abstinence. Since BCT teaches spouses to communicate effectively with each other, Mr. Stanton’s wife can learn to listen to her husband and provide him with the support necessary to maintain his sobriety. Finally, BCT can help the client address the risk of unstable employment if the “Recovery Contract” contains a clause about this issue.
Conclusion
The client from the given case is subject to the risks of unstable employment history, high distress, insufficient social support, and ineffective coping strategies, which may lead him to relapse. In addition, he is influenced by the culture in which cannabis use is partially acceptable for stress relief and relaxation, and several members of his family are involved in smoking marijuana. In order to address these risks, mindfulness-based interventions and BCT are recommended. MBRP may help the client resist triggers and cravings and tolerate intense emotional responses, thus providing him with effective coping strategies to replace his substance use. BCT is intended to increase the amount of social support available to the client, which is necessary to keep him motivated and avoid relapses. Despite these measures, relapse is possible, so the suggested treatment programs should also include education about relapses and encourage the client to analyze any slips to prevent them from transforming into a relapse.
References
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