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Running Head: Alcohol Relapse after Treatment: The Influence of Marital Status and Gender
Alcohol Relapse after Treatment: The Influence of Marital Status and Gender
Stephanie L. Hood
J. Scott Tonigan, PhD
The Center on Alcoholism, Substance Abuse, and Addictions
University of New Mexico
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Abstract:
Background: To date, studies have not investigated the effects of gender, marital status, and
interaction in spite of its clear importance to understanding the mechanisms accounting for
alcohol relapse. Such an investigation, using Project MATCH is a prerequisite to understanding
how, if at all, coping is important in Marlatt’s Relapse Prevention model.
Methods: Using Reasons for Relapse Questionnaire from Project MATCH, the 1,726
participants self reported influential factors of alcohol relapse. Using SPSS 18.0, all general
linear models (GLM) models included gender, marital status, and the interaction between gender
and marital status. All inferential tests were evaluated at p < .05.
Results: At three months, spousal support played a greater significant role for females than
males (p <.019) and amongst married individuals (p<.026). Conversely non-married individuals
and the relationship between gender and marital status played a significant role for “people
outside the family” (both at p<.000). Females also reported greater significance than males for
“feeling down or blue.” (p<.026). At nine months, males reported greater significance than
females about “feeling good” (p<.001), females reported greater significance about feeling
“uptight or anxious” (p<.016), and for married individuals reported having greater significance
than non-married individuals for “letting down your guard about alcohol”. Lastly at 15 months,
married individuals reported a greater significance for spousal or spousal equivalent (p<.034),
and females continually reporting significance for “feeling uptight or anxious” (p<.002).
Conclusion: This study compared the retrospective reasons men and women provided for a
relapse, with attention given to how these reasons may be influenced by patient marital status.
Key Words: Marlatt’s Relapse Prevention Model, Alcoholism, Gender, Marital Status, Project
MATCH
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Alcohol is the most frequently abused substance in the country, with nearly 85,000 deaths
yearly. Unknown to many, alcohol is the only drug known to result in death from withdrawals
(Mokdad et al., 2004; Schneider et. al., 2003). In spite of effective and evidence-base treatments
relapse is common. Approximately 93% of all problem drinkers, for example, resume alcohol
use in the time-span of 5 years (Emrick and Hansen, 1983). One of the prominent models of
relapse (Marlatt and Gordon, 1985) argues that patients are poorly equipped to identify relapse
prone situations and therefore patients must learn to identify relapse situations and appropriate
responses to prevent relapse. In this light, Marlatt’s approach includes environmental and
emotional considerations. They categorize these into two groups; one is immediate determinants
(ex. high risk situations, coping skills, and outcome expectancies) and, the second, covert
antecedents which include lifestyle imbalance (stress, sadness, etc.) and urges and cravings for
alcohol. Further, their relapse prevention (RP) model includes therapist-patient interactions
intended to identify high risk situations and the conditions under which they may or may not
drink. Central to avoiding relapse is abstinence self-efficacy or the confidence one has in
avoiding the use of alcohol. Marlatt and Gordon’s model therefore seeks to provide the patient
with the “big picture” in trying to control these situations (Larimer, et al., 1999). Within this
model therapists seek to elicit patient responsibility for their drinking, and to encourage patients
to take a more immediate view of relapse triggers. Marlatt also describes that therapists must
have their patients examine the myths, placebos, and misperceptions they hold about the positive
effects of alcohol. This allows therapists to interpret patient’s alcohol expectancies before they
drink which are often based on these myths and placebos (ex. how they will feel, the high, etc.)
versus what the real side effects are, which a majority of them are negative side effects
(sleepiness, emotional instability, etc.). The RP suggest that one can manage lapse or relapse by
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identifying triggers or high-risk situations and using cognitive restructuring techniques learned in
therapy to avoid drinking.
Although the RP model has gained widespread acceptance and its use of empirical
support has been mixed about its’ validity. To illustrate, the Relapse Replication & Extension
Project (RREP), which was funded by the National Institute on Alcohol Abuse and Alcoholism
(Larimer, et al., 1999), studied predictors of relapse every two months for a year. At each
assessment, they measured five different domains: (1) the occurrence of negative life events; (2)
cognitive appraisal variables including self-efficacy, alcohol expectancies, and motivation for
change; (3) client coping resources; (4) craving experiences; and (5) affective/mood status. This
study’s impact is important because as a multi-site trial with a large sample substantial
confidence can be placed in study findings. Surprisingly, high-risk situations did not predict later
relapse as suggested by Marlatt, suggesting that individuals are especially good at identifying
high risk situations. In contrast, coping skills were predictive of relapse as proposed in the
model, with positive approach and negative avoidance coping, predicting 85% of the cases that
had relapsed at six-months.
An important question is, do men and women differ in their relapse rates? Based upon a
large meta-analytic study (Vannicelli & Nash, 1984) this deceptively simple question appears to
have an elusive answer. First, according to these authors women were underrepresented in
alcohol research. To illustrate, women comprise about 20-25% of alcohol dependent adults in
treatment but in reviewing 259 studies only 7.8% of the study participants were female. Jarvis
(1992) meta-analytically analyzed Vanicelli & Nash’s study to determine if women have poorer
prognoses than men. Jarvis found no support for the claim that gender moderated outcome.
Similar conclusions were drawn by Annis and Liban (1980) in their review of 23 studies. Here,
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men and women had relatively similar treatment outcomes although these authors highlighted
that predisposing factors predicting relapse (men vs. women) have not been explored. With
Jarvis’ meta-analysis of qualitative and quantitative research she looked at relapse from 3-6
months, 7-12 months, and 12+ months. Jarvis concluded from her review that: (1) men have had
better inpatient results then women, (2) men and women have better outcomes with different
treatments, (3) women have a lower alcohol intake than men, which might result in
successful/non successful treatment outcomes, and (4) women respond better to one-on-one
therapy due to high stigma linked to the “role” of women with alcoholism and that they can
discuss more issues in confidence rather than in a group. Unlike with men, Jarvis notes that men
like to discuss their problems amongst other men who are going through the same thing and
would rather do this in a group setting. This is also discussed in Pemberton’s article which 50
females were admitted to the hospital and evaluated by different factors about their drinking
onset. Their findings supported Jarvis conclusions; men feel more comfortable discussing their
alcohol issues amongst others, while women remained secretive about their alcoholism. Jarvis
found that gender difference was very small and that women have better outcomes in the first
year, while men do better past 12+ months. Regarding treatment, Krentzman, et. al’s study
discovered no gender difference in one year sobriety for their study (who identified themselves
as AA members). These women’s demographic information were statistically different than
males which were more likely to be White, more educated, and were more employed. This goes
against Rubin and colleague’s study who found gender differences that women drink to
intoxication more than men, while men experienced more positive mood states during relapse
than women. Walton, et al., 2003 reports that men have higher self-efficacy, which predicts
lower alcohol use, and women report greater resource needs, which predicted more drug use.
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Furthermore, in Timko, et al.’s results found that there are gender differences in baseline status
and help-seeking at their 8 year follow up.
Evidence suggests a complex relationship between relapse and gender; one that may be
moderated by patient marital status. To begin, Walton, et al., (2003) followed 180 participants
after treatment, and interviewed them at 1-month and two years. It should be noted that Walton,
et al., 2003 studied alcohol as well as general substance abuse. He divided results into two
graphs (alcohol and drugs). Within this sample, 25.4% were never married, 1.3% was widowed,
and 40.8% separated or divorced. They found that alcohol relapse correlated with income,
marital status, cravings, leisure activities, self-efficacy (previously mentioned with RP), and
resource needs. Marital status which is our main concern, was significantly directed both in
interpersonal assets (.45) and also social/environmental (.46). Adding to that, Pemberton’s
research found that females find it more difficult to establish a satisfying role amongst their
family due to a demanding husband, another illness they might be suffering from, or failure to
adapt to the loss of their husband. Self-efficacy significantly mediated indirect effects of income,
gender, marital status, and problem severity in Walton’s study. Markers of low self-efficacy
included lower income, being female, greater problem severity, and being unmarried. Walton, et
al. (2003) found that coping in this study did not predict post treatment alcohol as suggested by
Marlatt and Gordon. Previous work (Cronkite & Moos, 1984) has found that being married is
associated with more positive treatment outcome for male substance abusers, but the impact of
being married on women’s relapse is not consistent and needs further research. Schneider et al,
(1995), states that results indicated being married is consistently related to less drinking for men,
while for women, being married contributes to relapse in the short term.
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Central in the RP model is how people identify and cope with stressful situation.
According to Noone et al., (1999) the lack of coping resources, poor social support, low efficacy,
loss of control, and negative coping can all lead to relapse. A moderator of stress that has not
been tested is cognitive hardiness, which is the motivation and high efficacy personality needed
to reduce stress which could decrease the rate of relapse. The health belief model also helps
reduce drinking behavior by describing in depth to patients that drinking deteriorates health and
resorting to sobriety can improve these health implications like liver disease, alcoholic hepatitis,
and severe abnormalities to the brain. In this study, stress was assessed by their health, work,
financial stability, family, environmental, and social hassles. The only demographic variable
which showed a significant multivariate effect was level of education. Of course, high efficacy
and high social support decreased drinking according to Noone et al., (1999) and also Brown, et.
al., 1995. Noone’s findings were that 26% remained abstinent and 28% drank at harmful levels
of 6+ drinks a day. Stressors in the patients’ lives were measured a month prior before their
follow-up date and was said to be a significant predictor. Social support is very important to help
recovering alcoholics and concludes that treatments should include stress management
techniques, encouragement for patients to utilize ongoing social support, and positive coping
strategies to increase self-efficacy.
The scope of this study is to investigate the attributions people make about why they
relapse. To date, studies have not investigated this topic in spite of its clear importance to
understanding the mechanisms accounting for alcohol relapse. Specifically, this study will
compare the retrospective reasons men and women provided for a relapse, with attention given to
how these reasons may be influenced by patient marital status. Such an investigation is a
prerequisite to understanding how, if at all, coping is important in the RP model. The context for
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this investigation is a large multi-site clinical trial (PMRG, 1998; 2002) studying the
effectiveness of cognitive behavioral, motivational enhancement and 12-step outpatient
treatment. In examine reasons for relapse we will adopt the practice of grouping reasons
according to whether they are situation or emotional in nature. Given that relapse typically
occurs rapidly after treatment, our study will focus on the first 12 months after the outpatient
experience or 15 months after the initiation of treatment.
METHOD
Project MATCH aftercare (N = 774) and outpatient (N = 952) samples were used in this
retrospective study. Briefly, Project MATCH was a multi-site clinical trial investigating client-
treatment matching, and findings have been reported elsewhere (e.g., PMRG, 1997; 1998).
Following recruitment into the study, clients were randomly assigned to one of three
psychosocial treatments: Cognitive Behavioral Therapy (CBT; Kadden et al., 1992),
Motivational Enhancement Therapy (MET; Miller et al., 1992) or Twelve Step Facilitation (TSF;
Nowinski et al., 1992). Therapy lasted twelve weeks, and therapists were nested within therapy
conditions. Follow-up assessments were conducted in three month intervals from randomization
which corresponded to an end of treatment assessment and follow-up interviews 3, 6, 9, and 12
months after treatment.
A noteworthy contribution of the Project MATCH research group was the aggressive
attention paid to the training of therapists and research assistants, documentation of treatment
fidelity, high follow-up rate (exceeding 90% at all follow-ups), and use of an exhaustive number
of instruments, nearly all of which had published psychometric data. Full descriptions of these
aspects of Project MATCH have been provided elsewhere (Connors et al., 1994; Zweben et al.,
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1998). In addition, a test-retest exercise was conducted (N = 82) to evaluate the reliability of
instruments that were developed specifically for Project MATCH, instruments which form the
core assessments for this study (Tonigan et al., 1997)
Quick Screen Interview. This interview was conducted to make a final determination
about eligibility and to collect basic demographic information. Information critical for this study
collected measure included participant gender and marital status.
The Form 90 family of instruments was developed for Project MATCH as the central
measure of client drinking (Miller, 1996). The Form 90 is a semi-structured interview that
combines grid (Miller & Marlatt, 1984) and calendar-based approaches to reconstruct day-by-
day drinking and health-related activities over a 90-day period. Measures of percent days
abstinent (by month) and drinks per drinking day (by month) have good reliability (Tonigan et
al., 1997), as do measures of the frequency of health-related experiences, e.g., emergency room
visits for medical care.
Reasons for Relapse Questionnaire. This was a self-report survey that included a total of
45 items that asked about two domains, reasons for relapse and methods for staying sober. This
study examined response to section 1, which was divided into situational influences (6 items),
personal influences (8 items), and (11 items) general influences. Of these, we focused on
situational and personal influences (14 items) because they corresponded most closely to
Marlatt's RP model.
(Reasons For Relapse and Methods For Staying Sober questionnaire about here)
Statistical Analyses. In addition to descriptive statistics, e.g., means and standard
deviation (SD), used to describe the sample we used SPSS version 18.0 to conduct General
Linear Model (GLM) tests. The dependent measures in these analyses included the 14 items in
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the Reasons for Relapse Questionnaire, all which straddled the fence between ordinal and
interval scaled data (1 through 5, Likert scale with anchors of small to great influence). Our two
independent variables were marital status (married versus not married), and gender. In the
analysis, these factors were considered fixed. All GLM models included the marital, gender, and
marital times gender interaction. All inferential tests were evaluated at p< .05 (1 in 20 chances of
being wrong). However, we planned to conduct 14 tests which inflated Type I error.
RESULTS
Displayed in Table 1 are the samples’ characteristics. The total sample of this study was
1,726 participants; 1,305 males and 421 females. Amongst this sample the average age amongst
both men and women was 40 and nearly the same level of education of 13 years. The alcohol
severity was recorded for males at 52.81 and 48.12 for women which is extremely severe.
Anyone over 20 is considered alcohol dependent. This study had many categories of the patient’s
status (married, divorced, separated, widowed, etc.), but with sole concern on the patients marital
status, males had a percentage of 34.8% being married and women were at a lower rate of
26.84%. A majority of the study was Caucasian, with a variety of Hispanic background. An
estimated 22% of this study was unemployed amongst males and females.
(Insert table 1 about here)
Table 2 summarizes the hypothesis of the situational and personal influences on reasons
for relapse. There was over 108 tests ran; 12 influences were measured at 3 months, 6 months,
and 15 months, and for gender, marital status, and the interaction. Only the significant tests are
reported as the others were not sensitive measures of relapse.
(Insert table 2 about here)
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Examining at three months after assessment, spousal support played a greater significant
role for females p <.019 and also a significant finding amongst married individuals at p<.026.
People outside the family had an influence at three months for non married individuals
and the relationship between gender and marital status played a significant
role (both at p<.000). Females also reported “feeling down or blue” as more
significant than males at p<.026. At nine months, there was a significant increase in
situational levels with patients feeling good, specifically with males (p<.001), feeling uptight or
anxious for females (p<.016) and patients having difficulty with married individuals letting their
guard down (p<.034). Very little change was reported later in treatment at 15 months, with the
only significant variable for spousal support for married individuals (p<.034) and feeling uptight
or anxious for females (p<.002).
Discussion
This study examined the effects of gender, marital status, and their interaction on alcohol
relapse. We found, for example, specifically, the first three months after treatment female and
married participants showed significance for spousal support, while non-married individuals
showed significance for support outside of the family. Females also reported if they felt “down
or blue” was significance. Nine months following treatment, males reported “feeling good” was
highly significant more than females, which might have correlation with Walton et al.’s (2003)
study concluding men having higher self efficacy and if they feel positive might result into
relapse. While females, feel more negative affect (“uptight or anxious”), and married individuals
having difficulty letting their guard down about alcohol which might be related to Pemberton’s
findings of women having a demanding family. At 15 months, spousal support and the emotions
of feeling “uptight or anxious” continually reported as significant. Even though, previous studies
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reported no gender difference, both men and women did not report significance for the same
items resulting that both men and women different in their reasons for relapse. Marital status has
difference showing that married individuals demonstrated higher significance from their spouse
and letting down their guard. The only interaction amongst gender and marital status was
“people outside of the family” at three months after treatment. Several implications should be
noted, females showed significance in social settings, specifically through spousal support. This
may allow females to seek out treatment (ex. 12-step facilitation) that is social, yet is an
abstinence environment to allow sobriety to occur. Females also reported repeatedly negative
affect to result into relapse. In our study, they reported “feeling down or blue” at three months,
and “feeling uptight or anxious” both at nine months and 15 months. This allowing females to
become vulnerable when these emotions arise, making females seek out alternative activities to
remain sober. Study findings partially support Marlatt’s model. The RP model includes negative
affect for relapse to occur. If someone is feeling angry or down or blue the RP model states that
relapse will occur. If you examine item 12 of our study “feeling angry” was not reported at all
significant at 3, 9, or 15 months. Gender examined closer, females did report “feeling down or
blue” as significant, but not for males. Marlatt’s RP model did not necessarily include family and
people relationships, rather environmental cues. Clear utility of the RP model is in clinical
settings; yet our findings suggest that specific elements are poorly understood.
Some study limitations should be noted. One is the retrospective time frame of the
assessment procedure. Specifically, MATCH participants answered this questionnaire after they
had relapsed, potentially biasing recall of the factors precipitating the relapse. Another limitation
is our definition of gender. Participants reported what gender they considered themselves. This
can go much more in depth if they are females, but have high masculinity or male and having
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high femininity. Likewise, sexual orientation was not countered for. Another limitation focuses
on how “relapse” is to be defined. In this study relapse was considered to have occurred when
any alcohol was consumed. This definition, however, did not discriminate between lapse and
relapse, and it should be noted that such distinctions may produce different findings. Another
limitation involves the cross-sectional nature of the data analyses. At one extreme, different
people could have relapsed at each follow-up interview. This possibility would make it
problematic to know whether reasons for relapse change over time or if different people have
different reasons for relapse. Our analyses indicated that relapse group membership was
relatively unstable at early follow-up, but stabilized in later follow-up. Some may argue with our
decision to define marital status as only a legally binding relationship, thus not including
cohabitating relationships. While a valid concern, and an alternative which should be explored,
our choice was based upon the assumption that termination of a legally binding relationship was
qualitatively different than for cohabitating couples thus deepening the influence of a
relationship partner (positive and negative). Finally, our exploratory study conducted 108
inferential tests and therefore had a significant Type I error rate. Our pattern of findings,
however, suggests that many of the results were not spurious. Future investigations may elect to
narrow the number of inferential tests based upon our findings. Concluding this study, rare
views of gender and marital status have been explored to explain alcohol relapse. Through
Project MATCH and the personal and situational influences reported throughout this study the
effects of gender and marital status on alcohol relapse can help further the addiction field in
correspondence to Marlatt’s Relapse Prevention model.
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References
Annis, H. M. & Liban, C. B. (1980). Alcoholism in women: treatment modalities and outcomes, in: KALANT, O. J. (Ed.) Alcohol and Drug Problems in Women: Research Advances in Alcohol and Drug Problems Vol 5, pp. 384-422 (New York, Plenum).
Brown, S. A., Vik, P. W., Patterson, T. L., Grant, I., & Schuckit, M. A. (1995). Stress, vulnerability, and adult alcohol relapse. Journal of Studies on Alcohol, 56, 538–545.
Cronkite, R., & Moos, R. (1984). The role of predisposing and moderating factors in the stress–illness relationship. Journal of Health and Social Behavior, 25, 372–393.
Jarvis, T. J. (1992). Implications of gender for alcohol treatment research: a quantitative and qualitative review. British Journal of Addiction, 87, 1249–1261.
Krentzman, A., Brower, K., Cranford J., Bradley J.C., Robinson, E. (2012). Gender and Extroversion as Moderators of the Association between Alcoholics Anonymous and Sobriety. J. Stud. Alcohol Drugs, 73, 44-52.
Larimer, M. E., Palmer R., and Marlatt A., (1999). Relapse Prevention. An Overview of Marlatt’s Cognitive-Behavioral Mode. Alcohol Research & Health, Vol. 23, No. 2. 151-160.
Miller, W.R., Westerberg, V.S., Harris, R.J., Tonigan, J.S., (1996). Extensions of Relapse Predictors beyond High-Risk Situations. What predicts relapse? Prospective testing of antecedent models, 91 (Supplement):S155-S171.
Mokdad A, Marks, J., Stroup D., Gerberding J. (2000). Actual Causes of Death in the United States. JAMA. 2004; 291(10):1238-1245. doi:10.1001/jama.291.10.1238.
Noone, M., Dua, J., Markham, R., (1999). Stress, Cognitive Factors, and Coping Resources as Predictors of Relapse in Alcoholics. Addictive Behaviors, Vol. 24, No. 5, pp. 687–693.
Pemberton, D.A. (1967) A comparison of the outcome of treatment in female and male alcoholics, British Journal of Psychiatry, 113, pp. 367-373.
Rubin, A., Stout, R.T., Longabaugh R., (1996). Gender Differences in Relapse Situations. Addiction, 91 Suppl: S111-20
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Schneider, U., Kroemer-Olbrisch, T., Wedegartner, F., Cimander K. F., and Wetterling T., (2004). Wishes and Expectancies of Alcoholic Patients Concerning their Therapy. Alcohol & Alcoholism Vol. 39, No. 2, pp. 141–145, 2004. doi:10.1093/alcalc/agh029.
Timko, C., Moos, R., Finney, J., Connell E. (2011). Gender differences in help-utilization and the 8-year course of alcohol abuse. Addiction 97, 877-889.
Vannicelli, M. & Nash, L. (1984) Effect of sex bias on women's studies on alcoholism, Alcoholism: Clinical and Experimental Research, 8, pp. 334-336.
Walton M., Blow F., Bingham R., Chermack S. (2003). Individual and social/environmental predictors of alcohol and drug use 2 years following substance abuse treatment. Addictive Behaviors 28 (2003) 627–642.
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Reasons for Relapse and Methods for Staying Sober questionnaire
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Table 1:Sample Characteristics
Male (N=1305) Female (N=421)
Years of Education 13.22 (2.11%) 13.40 (2.12%)
Age 40.28 (10.81%) 40.08 (11.58%)
Alcohol Severity 52.81 (23.34%) 48.12 (22.80%)
% Married 454 (34.80%) 113 (26.84%)
% Caucasian 1046 (80.15%) 336 (79.81%)
% Hispanic 70 (5.36%) 30 (7.13%)
% Unemployed 129 (9.89%) 49 (11.64%)
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Table 2:
Gender by Marital Responses to the Reasons for Relapse and Methods for Staying Sober:Summary of GLM Analyses
Item Stem 3 months 9 months 15 months
Situational Influences
Spouse influence (5) Gender, p< .019 ------------ Marital, p<.034
Marital, p<.026
Family members (6) ------------ ------------ ------------People outside the family(7) Marital, p < .001
Marital*Gender, p <.001------------ ------------
Someone offering a drink (8) ------------ ------------ ------------Alcohol readily available (9) ------------ ------------ ------------
Personal Influences
Feeling good (11) ------------ Gender, p <.001 ------------Feeling angry (12) ------------ ------------ ------------Feeling down or blue (13) Gender, p <.026 ------------ ------------Feeling uptight or anxious (14) ----------- Gender, p <.016 Gender, p.<.002Desire to drink or get high (15) ------------ ------------ ------------Letting down your guard (16) ------------ Marital, p<.034------------
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Feeling in control (17) ------------ ------------ ------------