FACTORS RELATED TO ALCOHOL RELAPSE IN PERSONS WITH ALCOHOL
DEPENDENCE IN THAI NGUYEN HOSPITALS, VIETNAM
Mr. Trieu Van Nhat
A Thesis Submitted in Partial Fulfillment of the Requirements
for the Degree of Master of Nursing Science Program in Nursing Science
Faculty of Nursing
Chulalongkorn University
Academic Year 2018
Copyright of Chulalongkorn University
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ACKNOWLEDGEMENTS
I would like to take this opportunity to express my heartfelt gratitude to people
who have helped me to complete this study. I would first like to express my very great
appreciation to my major advisor, Assist. Prof. Penpaktr Uthis for her guidance and
support during the planning and development of this study, for her patience, motivation,
and immense knowledge. The door to her office has always opened whenever I had a
trouble or question about my research. I am very grateful to have the opportunity to
study under her guidance. I would also like to express my high regard and sincere
gratitude to my co-advisor, Dr. Sunisa Suktrakul for her continuous support, academical
and emotional assistance, and constructive advice and suggestions. I have been so lucky
to have a supervisor who cared so much about my work.
I would like to extend my sincere appreciation to other committee members,
Assoc. Prof. Jintana Yunibhand and Assist. Prof. Natkamol Chansatitporn for their
insightful comments and suggestions, but also the hard question which helped me
broaden my horizon and made my thesis much better.
I am grateful to Chulalongkorn University and Dean of Faculty of Nursing,
Chulalongkorn University for providing academic assistance to pursue my master
course in Thailand. My sincere thanks also goes to all lectures and staffs in Faculty of
Nursing, Chulalongkorn University for their teaching, guidance, and encouragement.
I am particularly grateful for the assistance given by the Directors, doctors,
nurses, and other staffs of Thai Nguyen National Hospital, Thai Nguyen Psychiatry
Hospital, Thai Nguyen A Hospital, Thai Nguyen C Hospital, and Thai Nguyen Gang
Thep Hospital in Thai Nguyen city, Vietnam for their unconditional support. Also, I am
grateful to the participants and their families for their beliefs and enthusiasm.
I wish to acknowledge the help provided by my classmates and friends in the
master and Ph.D. program for friendship, enthusiasm, and assistance. I would also like
to thank all my friends in Vietnam and Thailand who have always given me support
when needed. Last but not means least, I would like to thank my family: my
grandparents, my parents, and my brothers for their unconditional and unlimited
support, encouragement and love, and without which I would not have come this far.
TABLES OF CONTENTS
ABSTRACT (THAI) ................................................................................................... iv
ABSTRACT (ENGLISH) ............................................................................................. v
ACKNOWLEDGEMENTS ........................................................................................... v
TABLES OF CONTENTS ..........................................................................................vii
LIST OF TABLES ......................................................................................................... x
LIST OF FIGURES ...................................................................................................... xi
CHAPTER I INTRODUCTION .................................................................................... 1
Background and Significance of the study ................................................................ 1
Objectives of the study............................................................................................... 6
Research questions ..................................................................................................... 6
Rationale and Hypotheses .......................................................................................... 6
Scope of the study .................................................................................................... 10
Operational definitions............................................................................................. 10
Expected benefits ..................................................................................................... 12
CHAPTER II LITERATURE REVIEW ..................................................................... 13
2.1 Overview of persons with alcohol dependence ................................................. 14
2.1.1 Description of alcohol dependence ............................................................. 14
2.1.2 Alcohol dependence and brain system ........................................................ 15
2.1.3 Characteristic of persons with alcohol dependence .................................... 17
2.1.4 Prevalence and incidence of alcohol dependence ....................................... 18
2.1.5 The consequence of alcohol consumption .................................................. 18
2.2 Overview of alcohol relapse .............................................................................. 20
2.2.1 Definition of alcohol relapse ....................................................................... 20
2.2.2 Prevalence and incidence of alcohol relapse .............................................. 22
2.2.3 The measuring of alcohol relapse ............................................................... 22
2.3 Overview of alcohol use and treatment and care for alcohol dependence in
Vietnam .................................................................................................................... 23
2.3.1 Overview of alcohol use in Vietnam .......................................................... 23
2.3.2 The burden of alcohol drinking behavior in Vietnam ................................. 25
2.3.3 Treatment and care for alcohol dependence in Vietnam ............................ 26
2.4 The Relapse Prevention Model .......................................................................... 29
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2.5 Factors related to alcohol relapse among persons with alcohol dependence ..... 30
2.5.1 Overview of factors related to alcohol relapse ........................................... 30
2.5.2 Relationship between selected factors in this study and alcohol relapse .... 32
2.6 The conceptual framework in this study ............................................................ 46
2.7 Nursing intervention for persons with alcohol relapse ...................................... 47
CHAPTER III METHODOLOGY .............................................................................. 51
3.1 Research Design................................................................................................. 51
3.2 Settings ............................................................................................................... 51
3.3 Population and sample ....................................................................................... 52
3.4 Research instruments ......................................................................................... 55
3.4.1 Instrument for the screening of participants ............................................... 55
3.4.2 Instruments for data collection.................................................................... 56
3.5 Instrument Translation Process .......................................................................... 62
3.6 Instrument validity ............................................................................................. 63
3.7 Protection of human subjects ............................................................................. 65
3.8 Data Collection .................................................................................................. 66
3.9 Data analysis ...................................................................................................... 67
CHAPTER IV RESULTS ............................................................................................ 68
4.1 Demographic characteristics of the participants ................................................ 68
4.2 Description of the dependent variable and independent variables ..................... 71
4.2.1 Description of dependent variable .............................................................. 71
4.2.2 Description of independent variables.......................................................... 71
4.3 The relationship between independent variables and alcohol relapse ............... 90
CHAPTER V CONCLUSION AND DISSCUSSION ................................................ 93
5.1 Conclusion ......................................................................................................... 93
5.2 Discussion .......................................................................................................... 94
5.2.1 Demographic characteristics of the participants ......................................... 95
5.2.2 The situation of alcohol relapse .................................................................. 98
5.2.3 Factors related to alcohol relapse in persons with alcohol dependence in Thai
Nguyen hospitals, Vietnam ................................................................................ 100
5.3 Recommendations ............................................................................................ 116
5.3.1 Recommendations for nursing practice .................................................... 116
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5.3.2 Recommendations for further studies ....................................................... 118
5.3.3 Recommendations for the health care system in Thai Nguyen, Vietnam . 119
REFERENCES .......................................................................................................... 113
APPENDICES ........................................................................................................... 135
Appendix A Approval of thesis proposal.............................................................. 136
Appendix B IRB approval ..................................................................................... 137
Appendix C Permission for data collection ........................................................... 138
Appendix D Permission for using instruments ...................................................... 142
Appendix E List of instrument translators ............................................................. 148
Appendix F List of experts for content validity ..................................................... 149
Appendix G Research instruments......................................................................... 150
Appendix H Participant Information sheet ............................................................ 167
Appendix I Consent form....................................................................................... 170
VITA .......................................................................................................................... 171
LIST OF TABLES
Table 1 Sample size of participants ............................................................................. 54
Table 2 The validity and reliability testing of all instruments ..................................... 65
Table 3 Demographic characteristics of participants (n=110) ..................................... 68
Table 4 Frequency, percentage, range, mean, and standard deviation of number of
alcohol relapse (n=110) ............................................................................................... 71
Table 5 Frequency, percentage, range, mean, and standard deviation of drinking
refusal self-efficacy (n=110) ........................................................................................ 72
Table 6 Mean and standard deviation of drinking refusal self-efficacy (n=110) ........ 73
Table 7 Range, mean, and standard deviation of outcome expectancies (n=110) ....... 74
Table 8 Mean and standard deviation of outcome expectancies (n=110) .................... 75
Table 9 Frequency, range, mean, and standard deviation of craving (n=110)............. 77
Table 10 Frequency, percentage, mean and standard deviation of craving (n=100) ... 78
Table 11 Range, mean, and standard deviation of motivation (n=110) ....................... 80
Table 12 Mean and standard deviation of motivation (n=110).................................... 81
Table 13 Range, mean, and standard deviation of coping (n=110) ............................. 83
Table 14 Mean and standard deviation of coping (n=110) .......................................... 84
Table 15 Range, mean, and standard deviation of emotional states (n=110) .............. 86
Table 16 Mean and standard deviation of emotional states (n=110) ........................... 87
Table 17 Frequency, percentage, range, mean, and standard deviation of social
support (n=110)............................................................................................................ 88
Table 18 Mean and standard deviation of social support (n=110)............................... 89
Table 19 Correlation coefficients of independent variable and alcohol relapse (n=110)
...................................................................................................................................... 91
LIST OF FIGURES
Figure 1 Hospitals providing treatment for persons with alcohol dependence in Thai
Nguyen province, Vietnam .......................................................................................... 28
Figure 2 The original Relapse Prevention model (Marlatt & Gordon, 1985) .............. 30
Figure 3 The conceptual framework of this study ....................................................... 47
Figure 4 Diagram of sampling process ........................................................................ 55
CHAPTER I
INTRODUCTION
Background and Significance of the study
Alcohol dependence is one of the major health and social problems seen in
nearly all countries. Globally, number of people with alcohol use disorders including
alcohol dependence and alcohol abuse were estimated at 107 million in 2017, measured
across both sexes and all ages (Ritchie & Roser, 2018). In the United States, this
corresponding rate was 15.1 million of the adult population (NIAAA, 2016). Regarding
European countries, the prevalence of alcohol dependence was reported at 6-8% of the
total population (Parkash, Sharma, & Sharma, 2017). In Asia, the high rate of alcohol
dependence was found in South Korea (4.7%), Kazakhstan (3.3%), and Uzbekistan
(3.3%) (Monzavi, Afshari, & Rehman, 2015). In Vietnam, 2.9% of the Vietnamese
were diagnosed with alcohol dependence (Monzavi et al., 2015).
Alcohol dependence is defined as “a group of physiological, behavioral, and
cognitive phenomena in which the use of alcohol is a much higher priority for a person
than other behaviors” (WHO, 1992). It is also accepted as a psychiatric disorder with
harmful physical, mental and social consequences. For example, alcohol dependence
was the cause of 3 million deaths in 2016 (WHO, 2018). Besides, it has various effects
on both health and economic status of alcoholics such as physical illness (Rehm, Taylor,
et al., 2010); unemployment, loss of earning, and family conflicts (WHO, 2010).
Additionally, there is a negative impact of alcohol dependence on other people who are
spouses, children, relatives, friends, and even strangers (APA, 2018).
Despite preventive efforts, many people fall into relapses after a period of
abstinence. According to the National Institute of Alcohol Abuse and Alcoholism
(NIAAA), evidence shows that in the Unite Stated, 90% of alcohol-dependent patients
have experienced at least one relapse within 4 years after the treatment completion
(NIAAA, 1989). Similarly, other researchers reported the high rate of alcohol relapse
among people with alcohol use disorder ranging from about 37.6% to 60.5% by the 16year follow-up (Moos & Moos, 2006). In Asian countries, alcohol relapse is also a
common problem. For example, a study in China showed that nearly 80% of patients
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with alcohol dependence had experienced relapse after completing treatment (Xie &
Liu, 2015).
Relapse is a term used to display the return to previous levels of symptomatic
behavior and considered as a complex multidimensional phenomenon (Dawson et al.,
2005). Historically, it was seen as an ominous sign and had a negative meaning (Marlatt
& George, 1984). While modern researchers considers relapse to alcohol as a
transitional process from the abstinence period to the addiction to alcohol (Hartney &
Gans, 2017). In recent years, for mostly acceptable, alcohol relapse is defined as reemergence of alcohol dependence syndrome as per International Classification of
Disease Tenth Version (ICD-10) diagnostic criteria after a period of abstinence for at
least one month (Kaundal, Sharma, & Jha, 2016; Parkash et al., 2017)
Alcohol relapse is significant for nursing practice. For a long time, substance
and alcohol abuse was addressed as an important nursing problem and nursing has
become more involved in the spectrum of substance use disorders (Nies & McEwen,
2011). It is noteworthy that preventing relapse is one of the favorable nursing outcomes
during treatment of alcohol dependence. The goal is to help people with alcohol
dependence to identify trigger situations of relapse so that the period of abstinence can
be lengthen over time (Varcarolis, 2013). In addition, understanding relapse as normal
process can help nurses feel less pressured to get patient into treatment and easily
maintaining an accepting, nonjudgment-mental attitude (Nies & McEwen, 2011).
Exploring factors that contribute to relapse is a crucial part of relapse prevention
strategies (Witkiewitz & Marlatt, 2007). In the literature, many theories have been
developed to explain the occurrence of relapse (Simonelli, 2005). Among which, the
Relapse Prevention (RP) model is widely used (Marlatt & Gordon, 1985). Based on this
model, factors related to relapse are divided into two broad categories: intrapersonal
determinants which refer to emotional states, self-efficacy, coping, motivation,
outcome expectancies, craving, and abstinence violation effects and interpersonal
determinants including relationship conflicts, peer pressure, social pressure, and social
support (Marlatt & Witkiewitz, 2005).
Based on the RP model, many studies have been conducted to identify factors
which might contribute to develop relapse or create a high-risk situation for relapse
(Adamson, Sellman, & Frampton, 2009; Charney, Zikos, & Gill, 2010; Evren et al.,
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2010; McKay, 2011). From the literature, many factors were found to be correlated to
relapse such as self-efficacy (Ibrahim, Kumar, & Samah, 2011; Nikmanesh, Baluchi,
& Motlagh, 2017), outcome expectancies (Anthenien, Lembo, & Neighbors, 2017;
Nicolai, Moshagen, & Demmel, 2017), coping strategies (Metzger et al., 2017; Opalach
et al., 2016), emotional states (Bravo, Pearson, Stevens, & Henson, 2016; Oliva et al.,
2018; Sureshkumar, Kailash, Dalal, Reddy, & Sinha, 2017), motivation (D’Souza &
Mathai, 2017; Gaume, Bertholet, & Daeppen, 2017), cravings (Kharb, Shekhawat,
Beniwal, Bhatia, & Deshpande, 2018; Sinha et al., 2011; Stohs, Schneekloth, Geske,
Biernacka, & Karpyak, 2019), and social support (Atadokht, Hajloo, Karimi, &
Narimani, 2015; Githae, 2016; Yang, Xia, Han, & Liang, 2018).
This is worrisome as relapse after treatment of alcohol dependence causes
various problems. For example, it might cause such negative consequences as
impairment of cognitive, medication non-adherence, personal distress, and
hospitalizations (Pigott et al., 2003). Relapse is also the main reason of increasing the
cost of treatment, excessing of health care services utilization, and losing of
productivity (Nancy, Pacula, Kilmer, Lundberg, & Chiesa, 2009). According to the
Center for Substance Abuse Treatment (CSAT), relapse is the cause of negative effects
on the relationship between family members such as role modeling, trust, and concept
of normative behavior (CSAT, 2004). In addition, it might contribute to numbers of
social and economic problems, for example, unemployment, poor job performance, and
increase in crime rates (Parrott, Morinan, Moss, & Scholey, 2004).
In Vietnam, alcohol is commonly used in society. It has been observed in many
events from casual gathering, celebrations to important ceremonies (Lincoln, 2016).
There are many acceptable standard of drinking alcohol such as a quoting “a hundred
percent” - requires the drinkers to down shots of liquor in tandem or “not drunk not
going home” - a pressure for the drinkers to consume more alcohol, even drink to
intoxication (Craig, 2002). As a consequence, alcohol consumption is one of the main
causes of medical and social burden. In the country, 7.3% of all-cause deaths were
estimated as related to alcohol consumption for 2016 (WHO, 2016). For the same year,
nearly 10% of Vietnamese’s men aged 50 to 69 years old died of alcohol-related liver
cancer (Vietcetera, 2018).
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Unfortunately, in Vietnam, treatment for people with alcohol dependence is
heavily biased toward medication (Cuong, 2017). The psychiatric nurses provide
interventions for patients with alcohol dependence mostly focus on medical technique
such as injection and infusion. While the psycho-education or psychosocial treatments
are rarely provided. (Niemi, Thanh, Tuan, & Falkenberg, 2010). It is might due to the
lack of the guidance and evidence-based nursing intervention that can guild the nurse
to provide effective intervention for their clients.
Besides, there is a lack of social support system and follow-up services provided
to alcohol-dependent patients when they discharge (Hoa, 2014). Although, health care
services are available at the community, it limited to case-management of schizophrenia
and epilepsy (Giang, Dzung, Kullgren, & Allebeck, 2010). Therefore, alcohol relapse
has become a common problem. A study conducted in Hanoi, Vietnam reported that
62.8% of patients with alcohol dependence had relapsed more than once after one year
of discharge (Mai & Viet, 2014).
There is no doubt that relapse prevention is an essential part of treatment for
alcohol dependence (Witkiewitz & Marlatt, 2007). Understanding factors relating to
relapse allows the clinicians to develop effective relapse prevention strategies
(Hendershot, Witkiewitz, George, & Marlatt, 2011). However, in Vietnam, to the best
of our knowledge, only one study mentioned above was conducted to explore alcohol
relapse - it did not evaluate the association between alcohol relapse and its related
factors. Therefore, few evidence-based interventions were available. For this reason,
this study was designed to fill the gap of exploring alcohol relapse by describing the
relapse situation and investigating the relationship between alcohol relapse and several
psychological factors in individuals with alcohol dependence.
In Vietnam, Thai Nguyen is a province with high prevalence of alcohol
consumption (Go et al., 2013; Hang, 2010). In this province, alcohol is easy to buy at
markets and restaurants. Local residents highly believe that drinking is an indispensable
part of society and refuse to drink may be noticed as rude or worse (Hershow et al.,
2018). In 2010, 61.3% of male respondents in Thai Nguyen city were harmful drinkers.
Among them, 19.7% reported likely to display alcohol dependence (Hang, 2010). This
number is far higher when compared to other provinces. For example, among the
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current drinkers in Son La, Thanh Hoa, and Ba Ria-Vung Tau provinces, the prevalence
of alcohol dependence was 6.9%, 5.4%, and 8.9%, respectively (Phuong, 2009).
Due to the high rate of alcohol consumption, Thai Nguyen Psychiatry Hospital
which provides treatment for people with Severity Mental Illness (SMI) including
schizophrenia, depression, and alcohol dependence reported that the number of patients
hospitalized because of alcohol use disorder occupied nearly 42.6% of total patients
(Phuong, 2017). Unfortunately, the treatment of alcohol dependence in Thai Nguyen is
limited (Hershow et al., 2018). Most of the services have focused on managing alcohol
withdrawal syndromes and physical problems due to alcohol consumption. There is no
education about preventing alcohol relapse provided to clients with alcohol
dependence. Besides, there is no follow-up service provided to the clients after they
discharge from hospital. Therefore, most of patients (70%) return to drink alcohol after
discharge (Phuong, 2017).
In addition to the high prevalence of alcohol dependence, the researchers
decided to conduct this study in Thai Nguyen because of the diverse characteristics of
the population in this province. Thai Nguyen has one Ministry of Health hospital which
is considered as a tertiary referral hospital in the Northern region. Besides, there are
eight provincial hospitals with higher-tech medical equipment and higher quality of
care compare to nearby provinces. Therefore, these hospitals provide services for not
only local clients but for clients from other provinces such as Bac Can, Cao Bang, and
Lang Son province (Anh, 2016).
Through the decade of study, it can be said that relapse is a common event of
the recovery process (Witkiewitz & Marlatt, 2007). Although many studies were
conducted the reasons for alcohol relapse and factors correlating to relapse were varied
and different among different group of people and culture (Korlakunta, Chary, &
Reddy, 2012; Kuria, 2013; Sureshkumar et al., 2017). Conducting a context-specific
study could provide information on the local relapse situation and related factors among
Vietnamese people with alcohol dependence in hospitals.
Besides, people with alcohol dependence in the community did not choose to
participate in this study. It is because, in Thai Nguyen, there is no follow-up service for
people with alcohol dependence after they complete treatment in hospitals. Therefore,
it is difficult to identify and approach these persons when they live in their community.
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The finding of this study is beneficial for the health care system, clinicians, nurses,
psychologist and other healthcare providers in Thai Nguyen and other regions in
Vietnam.
Objectives of the study
1. To study alcohol relapse in persons with alcohol dependence in Thai Nguyen
hospitals, Vietnam.
2. To investigate the relationship between self-efficacy, outcome expectancies,
craving, motivation, coping, emotional states, social support and alcohol relapse in
persons with alcohol dependence in Thai Nguyen hospitals, Vietnam.
Research questions
1. What is the situation of alcohol relapse in persons with alcohol dependence
in Thai Nguyen hospitals, Vietnam?
2. What is the relationship between self-efficacy, outcome expectancies,
craving, motivation, coping, emotional states, social support and alcohol relapse in
persons with alcohol dependence in Thai Nguyen hospitals, Vietnam?
Rationale and Hypotheses
From the literature review, it is not unusual for alcoholics to relapse during the
recovery process of alcohol dependence (Witkiewitz & Marlatt, 2007). It is noted that
although relapse is common occurrence, it is preventable (Hartney & Gans, 2017).
Therefore, it is imperative that relapse should be examined carefully. Further,
understanding factors related to relapse allows the clinicians to provide betterindividualized treatment (Hendershot et al., 2011). Because of these reasons, this study
aimed to explore alcohol relapse situation and its related factors among people with
alcohol dependence in Thai Nguyen hospitals, Vietnam.
In this study, the Relapse Prevention (RP) model which was developed by
Marlatt and Gordon in 1985 was used as a guidance to study alcohol relapse. Based on
this model, the researchers reviewed and identified factors relating to alcohol relapse
from numbers of previous studies. Therefore, the independent variables in this study
were derived from both RP model and the literature review. In particular, many studies
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reported that there was a strong relationship between self-efficacy, outcome
expectancies, craving, motivation, coping, emotional states, social support and alcohol
relapse. Besides, some variables such as the withdrawal symptom and the abstinence
violation effects were suggested to use to study alcohol relapse with a caution. The
detail was presented below.
Self-efficacy is considered as the perceived of individuals in their abilities to
control alcohol consumption (Witkiewitz & Marlatt, 2007). Many studies indicated that
levels of self-efficacy were related to the rate of relapse, particularly, higher score of
self-efficacy might predict more non-use of substance, in turn, reduce the probability
of relapse. While the lower score of self-efficacy was related to the poorer rate of
abstinence and increase relapse rates (Chavarria, Stevens, Jason, & Ferrari, 2012;
Hendershot et al., 2011; Nikmanesh et al., 2017).
Outcome expectancies refer to the anticipation of outcomes of a specific
behavior. Regarding alcohol consumption, they are defined as an individual’s
subjective perception of the effects related to alcohol consumption (Jones, Corbin, &
Fromme, 2001). It is noteworthy that, in Vietnam, there is a high expectation toward
drinking alcohol. Many people believe that drinking is an indispensable pleasure in
their life, a way to relieve their boredom, and facilitate personal and business
relationships (Vietcetera, 2018).
In this study, outcome expectancies were categorized into two groups: positive
outcome expectancies referring to the individual’s expectation as drinking might bring
good effects and negative outcome expectancies reflecting the beliefs that drinking
might lead to adverse consequences (Anthenien et al., 2017). Literature supported that
positive alcohol outcome expectancies were risk factors increasing the motivation to
continue to use alcohol that, in turn, increased the rate of relapse (Anthenien et al.,
2017; Ham, Zamboanga, Bridges, Casner, & Bacon, 2013; Nicolai et al., 2017). In
contrast, negative expectancies were viewed as factors that decreased the motivation
for substance and alcohol use and reduced the probability of relapse (Hendianti & Uthis,
2018; Morean, Corbin, & Treat, 2012).
Craving is generally defined as the strong desire of an individual to drink
alcohol (Marlatt & Donovan, 2005). Many researchers reported that an increase in the
levels of craving for alcohol might increase in the rate of relapse and vice versa, a lower
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percentage of relapse was seen if a lower level of craving was reported (Glockner-Rist,
Lemenager, & Mann, 2013; Hendianti & Uthis, 2018; Higley et al., 2011; Holt, Litt, &
Cooney, 2012; Sinha et al., 2011).
Motivation is defined as the willingness of an individual to change a particular
behavior (Miller & Rollnick, 2002). The Transtheoretical Model of Change (TTM) with
five stages (pre-contemplation, contemplation, preparation, action, and maintenance)
was commonly used to explain the motivation to change the drinking behavior
(Prochaska & Diclemente, 1982).
In this study, the motivation to change drinking were classified into three
groups: recognition (a combination of contemplation and preparation), taking steps
(action versus maintenance), and ambivalence (interpreting as the extent to which
individuals open the possibility to change their behavior) (Miller, 1999). From the
literature, people with high motivation to change their drinking behavior reported more
engaged to treatment and healthy behaviors, in turn, reduce the probability of alcohol
relapse (Fiabane, Ottonello, Zavan, Pistarini, & Giorgi, 2017; Gaume et al., 2017).
Coping is defined as an individual’s responses to a situation in order to reduce
danger, correct harm or achieve a satisfaction (Litman, Stapleton, Oppenheim, & Peleg,
1983). In the RP model, the response of an individual to the risk situations of drinking
might determine if he/she might experience a relapse or not (Larimer, Palmer, &
Marlatt, 1999). In this study, coping was divided into adaptive coping which helps
patients to control their drinking and maladaptive coping that might increase the
likelihood to alcohol use and relapse (Litman, Stapleton, Oppenheim, Peleg, & Jackson,
1983).
Many studies indicated a positive relationship between maladaptive coping and
harmful drinking that increase the probability of relapse (Metzger et al., 2017; Opalach
et al., 2016). Besides, individuals who remained abstinence to alcohol tended to use
more numbers of effective coping than those who have relapsed (Kaundal, Sharma, &
Jha, 2016; Nagaich, Radha, Neeraj, Sandeep, & Subhash, 2016; Parkash et al., 2017;
Rohit, Shwetha, & Bhat, 2017).
Emotional states are defined as the state of an individual’s emotions which
usually refer to a list of anger, disgust, fear, joy, sadness, and surprise (Cabanac, 2002).
In this study, the researchers evaluate the influence of the state of emotions on drinking
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alcohol. Through the decade of study, emotional states were classified into two groups
including positive and negative emotional states (Larimer et al., 1999).
From the literature review, negative emotional states such as anger, depression,
anxiety, and frustrated were reported most frequently as the main cause of alcohol
relapse (Armeli, Sullivan, & Tennen, 2015; Bravo et al., 2016; Oliva et al., 2018).
While, positive emotional states, for example, joy, interest, and love were reported as
the protective factors that reduce alcohol relapse rates (Schlauch, Gwynn-Shapiro,
Stasiewicz, Molnar, & Lang, 2013).
Social support can be defined as “the assistance and protection are given to
others, especially to an individual. In this study, social support refers to the support that
a person received from their family, friends, and significant others in order to help them
to maintain abstinence from alcohol. Broadly, positive social support is highly
predictive of the treatment maintenance and, in general, reduce the probability of
relapse; while negative social support has been reported as a factor that increases the
severity of alcohol and drug abuse, in turn, increase the probability of relapse (Dixit,
Chauhan, & Azad, 2015; Githae, 2016; Hafez, Kazemeini, & Shayan, 2015).
In addition, the two variables, alcohol withdrawal syndrome (AWS) and
abstinence violation effects (AVE) were suggested to used based on the phenomena of
each study. In this study, the population was in-patients diagnosed with alcohol
dependence. They were treated by the standard medication to reduce and prevent
withdrawal symptoms. As a consequence, there might be a bias in measuring the
influences of AWS on alcohol relapse. Therefore, the researchers did not use the AWS
as an independent variable.
Regarding AVE, many researchers suggested that this variable should be
measured immediately after the first violation of an abstinent rule (Cormier, 2000;
Fletcher, 2007). However, in this study, patients were having treatment in the hospitals
and the use of alcohol was not allowed. Besides, most patients might not come to seek
treatment after their first drink but a long period of alcohol consumption. There might
be a bias of recalling the cognitive and affective reactions of patients to their first drink
of alcohol. Thus, the AVE did not use as an independent variable in this study.
To conclude, self-efficacy, outcome expectancies, craving, motivation,
emotional states, and social support were selected as the independent variables to study
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