1. History of prevention of relapse

Editors: Spanagel, Rainer; Mann, Karl F.

Title: Drugs for Relapse Prevention of Alcoholism, 1st Edition

Copyright 2005 Springer

> Table of Contents > History of prevention of relapse

History of prevention of relapse

Griffith Edwards

National Addiction Centre, Institute of Psychiatry, 4 Windsor Walk, London SE5 8AF, UK

Why history?

A salient feature of the problem people encounter with alcohol is that a habit of excessive drinking, once acquired, does not easily and permanently go away. More often it is behaviour that comes and goes and comes again, within any of a myriad patterns of intermittency. That is the destructive fact with which the drinker lives, the serial frustration that their family endures, and what the man or woman in the street recognizes as the face of alcoholism. The attempt to deal with this fact suffuses clinical practice.

Relapse is thus at the heart of the problem with drink, and relapse prevention the essence of the related therapeutic endeavour. And so it has been with this drug for a long time. The phrase relapse prevention as today applied in this field [1] has been in wide currency for only about a quarter of a century, but it is the phrase that is new rather than the issue.

The purpose of this chapter is to identify key issues relating to relapse and how to deal with it, which can be seen as running perseveratively across time. It will look firstly at the history of the state's efforts to prevent relapse by punitive measures. Secondly, it will describe the attempt to deal with relapse through moral persuasion. Under those two headings we will be exploring the deep past of relapse prevention. We will then examine the complex history of relapse as behaviour to be prevented by treatment. The intention is to use history to throw light on present dilemmas rather than any attempt being made at in-depth historical analysis. The focus will be on the English language literature with ready acknowledgement that many other European countries have over the centuries made important contributions to ideas on the prevention of relapse.

Punishment as the earliest form of relapse prevention

Long before relapse prevention became the business of the clinic, the state, or at parish level the local community, had to deal with the public order problem set by drunkenness and the unfortunate repetitiveness of that habit among some citizens. Over the centuries and across different cultures one can find

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ordinances, which decreed more or less dire punishment for the person who got publicly drunk, and repeated offences often met with an escalating scale of consequences. Lewin [2] provided an example of that kind of formula: -

In France, in the reign of Fran ois I, an edict of the year 1536 stipulated that anyone who appeared in public in a state of intoxication should on the first occasion be imprisoned on bread and water, on the second chastised with birch and whip, and on the third publicly flogged. Should further relapses occur the delinquent was to have an ear cut off and suffer banishment.

The idea of punishment as the appropriate way of dealing with and deterring drunken recidivism is thus ancient. But with the growth in drunkenness that accompanied the industrial revolution, it was a policy instituted on a grand scale. David Pitman, an American sociologist who made important contributions to researching the penal response to public drunkenness in America [3], many years after Fran ois I wrote on this topic as follows [4]: -

Historically in the United States, public intoxication has been viewed as a crime in almost every legal jurisdiction. Some individuals have been arrested 100-200 times and have served 10-20 years in jail on short-term sentences. The recidivism rates clearly indicate the futility of the present system in dealing with the underlying sociomedical problems involved.

Pitman estimated that there were at that time more than two million arrests for drunkenness annually in the USA. The response to drunken recidivism favoured by many countries was still punishment. Although the penalties had become less draconian, the underlying assumption was identical: relapse prevention was best to be accomplished by negative reinforcement. Faith in the punitive formula was, however, in the 1960s beginning rather generally to wane, with detoxification centres and diversion to treatment increasingly coming to be viewed as the benign alternatives to court handling.

On the face of it, the assumption that drunken relapse can be deterred by punishment is not unreasonable. Yet it is a postulate that sees little confirmation from experience. Excessive drinking is generally not a behaviour easily extinguished by negative reinforcement of a crude sort, although the impact on drinking of a total field of environmental reinforcers cannot be doubted. The sector of the drink problem where punishment is still widely seen as appropriate and escalating punishment appropriate for recidivism, is drink driving [5]. There is research, which demonstrates the efficacy of drink-driving countermeasures based on a statutory blood alcohol concentration, effective enforcement of the law, and licence revocation. Many drink drivers are not alcohol-dependent, and drink-driving legislation is effective in shaping the behaviour of the population and in setting social norms.

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The community reinforcement model of treatment enshrines a postulate, which is the obverse of ear trimming, and its efficacy does receive some research confirmation [6]. Reward for avoidance of drinking can seemingly make a more effective contribution to prevention of relapse than can punishment for recidivism.

Looking at the parallel public responses to illicit drugs, faith in the contribution which punishment can supposedly make to relapse prevention is not, however, dead. Recently some American states have enacted legislation for withdrawal of welfare rights as punishment for relapse into illicit drug taking. Diversion of the arrestee into treatment may be coupled with return to penal handling if there is relapse [7]. Whether or not these kinds of punitive responses are effective in preventing return to use of cocaine or opiates is uncertain, but one may suspect that punishment of the drinker or the drug taker has always been as much determined by moral fervour and political expediency as by concern with the operational evidence.

Salvation as prevention of drunken relapse

The clergy can be found preaching against the sin of drunkenness from early times [8]. However, with the emergence in the 19^th century of the Temperance Movement, salvation of the drunkard became hands-on and a mass endeavour. The movement had as its prime concern the prevention of drunkenness by persuading the population to give up drink, but the attempt to save the individual drunkard from their sin was always part of the programme, especially so for the Washingtonians [9]. The relation between the Church and Temperance was complex and varied over time, but was generally close.

The Temperance literature demonstrates an acute awareness that drunkenness tends to be a relapsing condition. Relapse was to be prevented by bringing the inebriate to God. Here is a case history of that kind of preventive programme operating out in the streets [10].

One day he was proceeding up one of the principal streets in Newark, in the crooked way peculiar to drunken men. At some distance before him, he saw a lady who was slowly coming toward him. When the lady got quite near the drunken man turned out to the best of his ability to allow her to pass by; but the lady, instead of passing him, put her hand on his shoulder and asked, in a calm voice, Where are you going my man? The man was thunderstruck, so to speak, for those were the very words which policemen were accustomed to use when arresting him Finally, however, he managed to say Dear lady, as near as I can reckon I am going as fast as possible to his satanic majesty. And I replied the lady producing a New Testament, and laying one of her hands on it, am going, as near as I can reckon, to the Lord Jesus Christ. Don't you want to go along with me Brother? She led her companion to a temperance

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meeting. The man was conducted to a seat, and then was prayed for by some of the ladies present. The prayers which were so earnestly uttered that night by these women undoubtedly greatly impressed the man A few days after he was converted to Christ.

Such a story will probably seem somewhat mawkish to the objectively minded modern professional, and today's drunk will not be prayed over in the A and E Department. And yet salvation was a well-articulated model of relapse prevention. It saw the tendency to relapse as residing in the person, and the remedy was only a holistic approach that brought about total change in that person's sense of being. Only that kind of life change could be expected to extirpate the problem. Relapses could be dealt with by more prayer, but true conversion was expected to result not in a transient amelioration of the drinking behaviour but in permanent cure. The Temperance group, the church circle and new and sober friendships, were on hand to provide the long-term after-care.

Temperance workers knew that reform could easily be followed by relapse, and they were not unrealistic in their expectations. But there were plenty of life-long reformed drunkards to give their testimony from the platform. A great Temperance orator, John B. Gough, who was known in his time as The Temperance Apostle , had a harrowing personal history of alcoholic debauchery to give him credibility as a speaker [11].

The Temperance Movement thus created as a recognisable and popular image the person who is likely today to be designated the recovering alcoholic . The movement faded but reference to the importance of spirituality in recovery lives on [12]. Whatever the researcher's or professional's personal stance on formal religion, it can hardly be doubted that what the religious approach can contribute to relapse prevention sets good questions. Getting really saved is what P.E. Turner [13] deemed to be the heart of therapy, but the kind of personal change-experience identified here is not limited to religious experience alone [14].

Treatment makes its entry as means to prevent the drunken relapse

Treatment when it arrived on this scene did not supplant punishment or salvation as methods for curing relapse. It coexisted with these older remedies and at times absorbed elements from them. But in the 18^th and early 19^th century, doctors began to appear who claimed that drunkenness was a treatable medical condition [15]. That was revolutionary thinking. These doctors defined the target condition as drunkenness and the differentiation between drunkenness and dependence was at that time unknown.

Within the armamentarium of treatment there developed over time two main elements. One was the psychological, culminating in the psychologically based relapse prevention approaches as epitomised today in the formulations offered by Marlatt and his colleagues [1]. The other was physical, with its

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fruition seen in the sorts of drug treatment that are the subject of this book. We will consider each of these developments in turn. To an extent they mesh with the contrasting underlying formulations as to the nature of the disorder as learnt habit, or alternatively as disease of the brain.

Relapse prevention as a psychological undertaking

It was the concept of excessive drinking as learnt habit that, at the turn of the 18^th-19^th centuries, legitimised the presence of the medical doctor in this treatment arena. A potent background influence was the ferment of ideas resulting from the European enlightenment, with its emphasis on rationality [16]. Benjamin Rush [17] and Thomas Trotter [18] contributed to emerging views on the nature of drunkenness and its appropriate treatment. Trotter's thinking on these matters was particularly well worked out and we will here concentrate on the ideas elaborated in his 1804 Essay on Drunkenness [18].

Trotter asserted that intoxication was an event that lay within the mental sphere, or as he put it the habit of drunkenness is a disease of the mind : the word disease has to be understood as carrying a meaning close to disorder rather than anything more specific. He said that it would be useless to treat the physical complications of excessive drinking until the evil genius of the habit has been subdued . Craving was a manifestation of the habit: -

The cravings of appetite for the poisonous draft are to the intemperate drinker as much the inclinations of nature for the time, as a draft of cold water to a traveller panting of thirst in the desert.

The duty of treatment was to break the chain of habit and the follow-through from theoretical exposition to therapy was close, with the need to identify relapse precipitants explicit. The case analysis should lead to identification of the particular cause, time and place of his love of the bottle and something proposed that will effectually wean his affection from it . The word relapse was in Trotter's vocabulary.

Trotter probably derived his theoretical ideas from David Hume, the Edinburgh philosopher who was a powerful enlightenment thinker. There is in Trotter's writing a feeling of the radical break with all that had gone before. The invitation was to understand the behaviour rather than bluntly punish or preach against it. At or around that enlightened time the psychological treatment of drinking problems, as we today know it, was born.

In the 19^th century many writers showed the persistence of interest in development of a psychological approach to treatment of the drinking habit [19], although few if any of these authors matched Trotter's clarity of vision. The application in the 1950s of Pavlovian conditioning to the treatment of alcohol dependence [20] represented a formal attempt to apply psychological theory to treatment of the drink habit, but the theoretical analysis was not highly developed.

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But in the 1950s and against a background of the strong general emergence of behaviour therapy as a theory-based treatment for psychological disorders, reports began to be published on the application of learning theory to the treatment of drinking problems [21, 22 and 23].

Important further contributions to this field of thought were made by Litman [24]. A book published in 1985 by Marlatt and Gordon [1], then brought together work of a scope and quality to give relapse prevention both a firm theoretical underpinning and an important place in the repertoire of relevant treatments. Indeed, the phrase relapse prevention from 1985 onwards for many people became synonymous with the ideas developed by Marlatt and his colleagues. Several reviews have reached positive conclusions on the effectiveness of this approach [25] although one review has reached more guarded conclusions [26]. Relapse prevention as conceived by Marlatt today constitutes a broad array of psychological treatments, but pharmacological approaches are not in the listing [25].

Relapse prevention as physical treatment

The view became general among 19^th century physicians that inebriety led to exhaustion of the nerve cells, with this brain disorder then perpetuating the problem [27]. The exhaustion could be relieved by abstinence, rest, and the general provisions of a sanatorium regime. A number of physical treatments could, however, be added to the interventions and were, by implication, agents of relapse prevention.

Norman Kerr's influential textbook on the treatment of Inebriety or Narcomania was first published in 1888 [27]. He was in 1884 the inaugural president of the society that later evolved into the present-day Society for the Study of Addiction, and he was a founding editor of the journal which is today published as Addiction [28].

Kerr provided a detailed critique of the then current physical treatments for alcohol dependence. He insisted that inebriety was a complex disease , and although not dismissive of the psychological components in treatment, he put more emphasis on the physical treatments than Trotter had done. His was the era of disease theories, and disease required somatic treatments. He warned against nostrums and was dismissive of vegetarianism as a cure for inebriety. Various tonics might however be beneficial, including Gentian and dilute nitro-hydrochloric acid with cardamoms , and orange and quinine had a place. Strychnine might cautiously be prescribed. There was a place for cod liver oil as a specific nerve food . Kerr was dismissive of the then fashionable Turkish bath as a 7-day cure - Alas for the inebriate this is but an oriental dream .

Kerr's faith in drug treatments to restore the health of his patients' exhausted brain cells was in accord with the therapeutic beliefs of the period. Over the following decades and with no availability of controlled trials, unbridled therapeutic

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enthusiasm led in this sector of practice to a variety of physical remedies such as to constitute an era of anything goes [2].

The availability in the 1940s of disulfiram (antabuse) for the first time put on offer a pharmacotherapy specifically directed at preventing alcoholic relapse [29]. It is difficult to imagine a drug technology more sharply intended to sever Trotter's chain : If the patient drank, after taking this drug, rather than their experiencing the intended pleasure, they would sustain an unpleasant toxic reaction. After 60 or so years of clinical experience, disulfiram as relapse prevention technology does not, however, appear to have won widespread acceptance. Toxic reactions can occur and compliance will be poor unless dosing is supervised and some doctors will be uneasy about the ethicality of risking, in the name of treatment, a potentially dangerous alcohol disulfiram reaction [30].

In 1980 Robin Murray published in the lineal descendant of Kerr's journal a prescient editorial entitled Why Are The Drug Companies so Disinterested in Alcoholism? [31]. Murray at the time argued,

there is no available drug which acts in a fundamental way to hinder the development and progression of the alcohol dependence syndrome Surely the time is now right for one or more of the pharmaceutical companies to mount a major research programme aimed at developing drugs which interfere with the biochemical mechanisms involving tolerance and dependence on alcohol.

That editorial stimulated the convening in 1983 of an international conference at the Institute of Psychiatry, London, under the title Pharmaceutical treatments for alcoholism . The Proceedings volume was published in 1984 [32].

The 1983 meeting and the publication that followed, represented an intentional attempt by the academic community to provoke drug firm interest in the treatment of drinking problems. Whether those moves had any tangible impact is an open question. The first controlled report on the use of Acamprosate in the treatment of alcoholic dependence appeared in 1985 [33], while the first major reports on the use of Naltrexone for this purpose came in 1992 [34, 35]. The present volume speaks to the burgeoning of interest, which has since occurred in alcohol-related pharmacotherapies, and in the study of underlying brain mechanisms.

Alcoholics anonymous as agent of relapse prevention

Alcoholics Anonymous is a self-help group that traces its origin to an event in 1933 [36, 37]. A precariously sober stockbroker, Bill W , called on a recently relapsed surgeon, Dr. Bob , and helped him to pull out of a relapse and find sobriety. It could be argued that AA from its inception has been an organisation dedicated to relapse prevention.

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How AA participation may achieve the relapse prevention aim was described thus by Edwards [38]: -

Many aspects of AA actively seem designed to teach the necessary cognitive and coping skills for achievement and maintenance of the drinkfree life. Indeed, an AA meeting can sometimes seem almost to take on the guise of a cognitive-behavioural workshop. Don't get tired, don't get angry, learn to laugh at yourself, see the other person's point of view. Look out for the tricks your thinking can play on you, the planned relapse, the planned excuses, the self-justifying resentment. Have something else to do, don't get bored. Carry some chocolate. Count your blessings. Don't go to that party if you are going to find the temptation to drink too great.

AA defines abstinence as the cure. It is an organisation that not only seeks to prevent relapse but has a capacity to deal with relapse and invites its members to learn from the relapse experience. The programme contains within it a spiritual element but the extent to which the individual member aligns with that perspective is optional.

A recent monograph [39] gives an account of AA and other self-help or mutual help groups operating internationally in the alcohol problems field. AA and similar organisations point to the fact that relapse prevention is not a concept which should be limited to what professionals do for or to their patients. It is a concept which should also embrace what people do for themselves to prevent relapse.

Conclusions and directions for the future

On the basis of this brief survey of the past, let us now identify some messages for the future of the relapse prevention endeavour.

Relapse prevention is a useful concept. From the material laid out in this chapter, it is clear that relapse prevention has been the intention of many types of actor and activity, long before the phrase passed into present usage. To an extent the modern phrasing is no more than a restatement of the old and evident truth - the business of treatment is to prevent and deal with relapse. The phrase contains within it an invitation both to the laboratory scientist and the research psychologist better to understand the mechanisms of relapse, and better and more intelligently to interdict those mechanisms. Relapse prevention is a phrase usefully to invite the focusing of minds even if it is really only treatment in new wrappings.

Relapse prevention is a multidisciplinary endeavour. Powerful animal models can now assist the laboratory scientist who wishes to investigate pharmacological approaches to relapse prevention, and the new anti-craving drugs are likely to have a significant impact on clinical practice. Psychological methods

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of relapse prevention have become increasingly sophisticated and broad-based over recent years. In terms of effect size, maintenance of intended impact, cost-effectiveness, treatment compliance, and ability to reach a satisfactory percentage of the population in need, there are still many important unanswered research questions relating to the value of either pharmacological or psychological approaches to relapse prevention. Rather than viewing these two types of intervention as rivals, what should increasingly be built into theory, research and practice, should be concepts that integrate brain science and psychology.

Learning from other substances. Treatment of the use of illicit drugs and of tobacco raises many of the same questions as occur with alcohol. There are, for instance, similar histories to be traced out on competing models of understanding and the competition between physical and psychological approaches to treatment. For present purposes let us note the potential fruitfulness of a comparative historical analysis of the relapse prevention concept across substances, but we will not enter that territory. In both instances the same questions on how most effectively to combine drug and psychological treatments to prevent relapse are being debated as in the alcohol sector.

Is the aim of relapse prevention inevitably total abstinence? Over much of history, and whether punishment, preaching or treatment was the vogue, the prescribed interventions have had abstinence as their goal. With the development of modern psychological ideas on drinking as learnt habit, more flexible approaches have developed with the therapy often aimed perhaps at the unlearning of excess, rather than the learning of life-long abstinence [15]. There is no reason why pharmacotherapy should not similarly embrace this more flexible goal. The appropriateness of different goals becomes here an empirical research question.

One size is unlikely to fit all. History seems often to show the response to the drinker as having been a matter of one size fits all. Every drunkard should be beaten, every drunken sinner prayed over, every inebriate put into a Turkish bath, all alcoholics given antabuse, all presenting clients enrolled in a psychological relapse prevention program. A lesson must surely be that the help given to troubled drinkers has to be differentiated by personal need and circumstance. That awareness becomes increasingly important with the mounting evidence on the clinical importance of co-morbidity [15].

Not forgetting the whole person. Much of the relevant history is a chronicle of well-intentioned authorities doing things to people with drinking problems, with the recipients conceived as passive objects. Punishment, preaching, drugs and psychological treatments, they are sequential scenes in the one long play. The lesson from history is that at the end of the day relapse prevention is, in fact, about the individual's personal choice made within a unique personal, social and cultural context, and it is the outcome of what George Vaillant has termed the natural healing process [40].

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