The Family Afterward…factors in relapse!

The majority of relapses I have witnessed have been due to interpersonal factors, e.g. arguments at home with family and loved ones, not being able to cope with relationship breakdowns, perceived rejection by loved ones.

Research itself shows that the majority of relapses are caused by an inability to deal with distress (negative emotions) especially in the context of interpersonal relationship.

In this two part blog we have considered evidence that shows intrapersonal traits (e.g. rejection sensitivity and low self esteem) and interpersonal environments (e.g. the family environment) can interact to increase an addict’s risk of relapse.

This study (1) concludes by proposing that substance-dependent individuals with high trait rejection sensitivity and a critical interpersonal environment are particularly vulnerable to relapse.

In the first part of this blog we looked mainly at intrapersonal (i.e. within the self) traits now we consider how these factors interact with interpersonal (relationships between individuals ) factors to often prompt relapse situations.

“Interpersonal Vulnerabilities to Addiction and Relapse

Perceived criticism (PC) and expressed emotion (EE) are related constructs that are used to measure criticism by family members directed toward the patient (36,37). EE—measured with a semi-structured interview—reflects the degree to which relatives refer to the patient in critical, hostile or over-involved ways (36).

O’Farrell et al. (36) found that alcoholic patients with high EE spouses are also more likely to relapse than their low EE counterparts. They proposed the development of a vicious cycle in which increased criticism leads to increased drinking, which leads to escalating criticism. They also found that behavioral marital therapy that aims to improve communication and decrease criticism reduced relapse in patients with high EE spouses (36).

The perceived criticism (PC) measure is operationalized using the single question “How critical is your spouse of you?” Similar to high EE, high PC—a far simpler measure that is less expensive to obtain than EE—significantly predicted relapse to substance use in a sample of alcohol dependent individuals (37).

Marital distress and spousal criticism are frequently associated with worse outcomes in treatment-seeking addicts (40,41). Family cohesion has been shown to significantly predict the severity of a person’s dysfunction resulting from drug use (42), and one study reported that spousal conflict was most frequently identified by male alcoholics as the cause of their relapse (43).

Booth et al. (40) showed that support from family and friends, specifically “reassurance of worth,” significantly predicted improved treatment outcomes even in patients with high rates of prior recidivism.

They argued that enhancing an alcoholic’s sense of self-worth would increase the individual’s likelihood of recovery and called for treatment interventions that focus on enhancing social support (40). Consistent with this approach, numerous studies have shown a positive association between supportive family and friends and improved drug and alcohol treatment outcomes and enhanced psychological functioning (44,45,46,47).

Individuals who are unable effectively to regulate the negative affective states elicited by interpersonal conflict are at greater risk of becoming substance dependent and to persist in their use of alcohol and drugs despite adverse consequences (48,49). For instance, fMRI studies have repeatedly shown that threatening social cues elicit increased amygdala reactivity. Sripada et al. (48) showed that alcohol attenuates this reactivity and hypothesized that alcohol’s ability to reduce stress and anxiety is mediated by its attenuation of threat processing in the amygdala (48).

Negative reinforcement of social rejection is not the only mechanism increasing high-rejection-sensitivity individuals’ risk for addiction and relapse. Because rejection activates the defensive motivational system, these individuals frequently respond with automatic aggressive behaviors, sometimes assuming a passive form of “going out and getting wasted” to “punish” the person who rejected them. Social rejection also impairs self-regulation, further diminishing the high- rejection-sensitivity individual’s ability to employ the strategies and cognitions necessary to avoid relapse.”

As the Big Book suggests “All members of the family should meet upon the common ground of tolerance, understanding and love…Cessation of drinking is but the first step away from a highly strained, abnormal condition…”Years of living with an alcoholic is almost sure to make any wife or child neurotic. The entire family is, to some extent, ill.” Let families realize, as they start their journey, that all will not be fair weather….”


Indeed, the family needs to recover not just the obvious candidate of the alcoholic/addict. This is a family illness and everyone in the family needs to support each other in their recovery.  This hard earned wisdom often seems the profound and most profitable to all.

The NCADD  state the notion of family disease clearly …

“Alcoholism and drug addiction affects the whole family – young, teenage, or grown-up children; wives or husbands; brothers or sisters; parents or other relatives and friends.  One family member addicted to alcohol and drugs means the whole family suffers.  Addiction is a family disease that stresses the family to the breaking point, impacts the stability of the home, the family’s unity, mental health, physical health, finances, and overall family dynamics.

Without help, active addiction can totally disrupt family life and cause harmful effects that can last a lifetime.

Regrettably, no family is born with the knowledge of how to deal effectively with addiction.  It is a skill that must be learned and practiced daily.

But, with the proper help and support, family recovery has become a reality for millions!”



1. Leach, David, and Henry R. Kranzler. “An Interpersonal Model of Addiction Relapse.” Addictive disorders & their treatment 12.4 (2013): 183–192. PMC. Web. 30 Jan. 2015.

2.   Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Services.






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