Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process. Marlatt and Gordon (1980, 1985) have described a type of reaction by the drinker to a lapse called the abstinence violation effect, which may influence whether a lapse leads to relapse. A critical difference exists between the first violation of the abstinence goal (i.e., an initial lapse) and a return to uncontrolled drinking or abandonment of the abstinence goal (i.e., a full-blown relapse). The abstinence violation effect, along with positive outcome expectancies, can increase the probability of a relapse. A central aspect of the model is the detailed classification (i.e., taxonomy) of factors or situations that can precipitate or contribute to relapse episodes.
Expanding the continuum of substance use disorder treatment: Nonabstinence approaches
Nonabstinence goals have become more widely accepted in SUD treatment in much of Europe, and evidence suggests that acceptance of controlled drinking has increased among U.S. treatment providers since the 1980s and 1990s (Rosenberg, Grant, & Davis, 2020). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995). The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985).
Efforts to develop, test and refine theoretical models are critical to enhancing the understanding and prevention of relapse 1,2,14. A basic assumption is that relapse events are immediately preceded by a high-risk situation, broadly defined as any context that confers vulnerability for engaging in the target behavior. Rather than being viewed as a state or endpoint signaling treatment failure, relapse is considered a fluctuating process that begins prior to and extends beyond the return to the target behavior 8,24.
1.3. Harm reduction integrated in SUD treatment
We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms. This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD.
Self-control and coping responses
For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009).
RP Intervention Strategies
- In contrast to the former group of people, the latter group realizes that one needs to “learn from one’s mistakes” and, thus, they may develop more effective ways to cope with similar trigger situations in the future.
- The abstinence violation effect isn’t just a term used by therapists; it’s a powerful psychological trap that can turn a small slip-up into a full-blown crisis.
- These factors can lead to initial alcohol use (i.e., a lapse), which can induce an abstinence violation effect that, in turn, influences the risk of progressing to a full relapse.
- In sum, research suggests that SUD treatment is beneficial to individuals with both abstinence and nonabstinence goals.
According to these models, the relative balance between controlled (explicit) and automatic (implicit) cognitive networks is influential in guiding drug-related decision making 54,55. In the last several years increasing emphasis has been placed on “dual process” models of addiction, which hypothesize that distinct (but related) cognitive networks, each reflective of specific neural pathways, act to influence substance use behavior. As the foregoing review suggests, validation of the reformulated RP model will likely progress slowly at first because researchers are only beginning to evaluate dynamic relapse processes.
These choices have been termed “apparently irrelevant decisions” (AIDs), because they may not be overtly recognized as related to relapse but nevertheless help move the person closer to the brink of relapse. People who lack adequate coping skills for handling these situations experience reduced confidence in their ability to cope (i.e., decreased self-efficacy). If stressors what is powdered alcohol and is it dangerous are not balanced by sufficient stress management strategies, the client is more likely to use alcohol in an attempt to gain some relief or escape from stress. In these situations, the drinker focuses primarily on the anticipation of immediate gratification, such as stress reduction, neglecting possible delayed negative consequences. Moreover, people who have coped successfully with high-risk situations are assumed to experience a heightened sense of self-efficacy (i.e., a personal perception of mastery over the specific risky situation) (Bandura 1977; Marlatt et al. 1995, 1999; Marlatt and Gordon 1985).
This article presents one influential model of the antecedents of relapse and the treatment measures that can be taken to prevent or limit relapse after treatment completion. Relapse, or the return to heavy alcohol use following a period of abstinence or moderate use, occurs in many drinkers who have undergone alcoholism treatment. You can find more abstinence violation effect relapse statistics that highlight this connection. In many cases, relapse can also affect the brain by causing the abstinence violation effect discussed in this article. The abstinence violation effect (AVE) describes a common response among people practicing abstinence when relapse occurs. Having healthy and effective coping strategies in place to anticipate a lapse or relapse can be pivotal, because the likelihood of never again lapsing into an addictive behavior is often quite low.
4. Current status of nonabstinence SUD treatment
Similarly, a second study found that individuals in the outpatient arm of Project MATCH with low motivation to change at baseline who were assigned to MET had better outcomes than those assigned to CBT. Two additional recent analyses of the MATCH dataset showed that nonlinear approaches can detect processes that may go unobserved in the context of linear models. Limit violations were predictive of responses consistent with the AVE the following day, and greater distress about violations in turn predicted greater drinking . In one study, individuals who were unable to sustain a smoking cessation attempt for more than 24 hours (compared to those with a sustained quit attempt) reported greater depressive symptoms and NA in response to stress and displayed less perseverance during experimental stress inductions . A large literature attests to the role of negative affect (NA) in the etiology and maintenance of addictive behaviors.
Outcome Expectancies
One bupropion trial found that DRD2 variations predicted withdrawal symptoms, medication response and time to relapse . The catechol-O-methyltransferase (COMT) Val158Met polymorphism, established as predicting variability in prefrontal dopamine levels, has been evaluated in relation to smoking cessation in several studies. Several candidate polymorphisms have been examined in response to smoking cessation treatments, especially nicotine replacement therapy (NRT) and bupropion . First, in the context of pharmacotherapy interventions, relevant genetic variations can impact drug pharmacokinetics or pharmacodynamics, thereby moderating treatment response (pharmacogenetics).
Specific Intervention Strategies
This process may lead to a relapse setup or increase the client’s vulnerability to unanticipated high-risk situations. In relapse “set ups,” however, it may be possible to identify a series of covert decisions or choices, each of them seemingly inconsequential, which in combination set the person up for situations with overwhelmingly high risk. White boxes indicate steps in the relapse process and intervention strategies that are related to the client’s general lifestyle and coping skills. Shaded boxes indicate steps in the relapse process and intervention measures that are specific to each client and his or her ability to cope with alcohol-related situations. Self-monitoring, behavior assessment, analyses of relapse fantasies, and descriptions of past relapses can help identify a person’s high-risk situations.
Previous reviews have recommended that treatment should be tailored to patient goals with consideration of SUD severity (Van Amsterdam & Van Den Brink, 2013; Witkiewitz & Alan Marlatt, 2006); however, some still argue that abstinence is favorable if patients are receptive (Mann, Aubin, & Witkiewitz, 2017). Individuals with lower problem severity and fewer years of problematic use sometimes benefit more from nonabstinence treatment. This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment. Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation. In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008). In a study of cannabis users participating in abstinence-oriented treatment, those with moderation goals were more likely to have non-moderate use outcomes (i.e., to use more than outlined in goals) than the abstinence goal group (Lozano et al., 2006).
Most individuals entering SUD treatment prefer having a goal choice rather than having goals determined by their provider (Sobell et al., 1992), and research on SUD treatment highlights multiple benefits of including nonabstinence goals in treatment. Thus, while individuals who lack commitment to abstinence are often seen as “unmotivated” for treatment, Miller’s theory of treatment motivation would suggest these individuals may simply be motivated to different goals (e.g., reducing substance-related harms), and that identifying and aligning treatment to these goals is key for successful treatment. In sum, research suggests that SUD treatment is beneficial to individuals with both abstinence and nonabstinence goals.
2. Established treatment models compatible with nonabstinence goals
Catastrophe models accounted for more than double the amount of variance in drinking than that predicted by linear models. Compared to a control group, those who practiced self-control showed significantly longer time until relapse in the following month. Evidence further suggests that practicing routine acts of self-control can reduce short-term incidence of relapse.
Countering The Abstinence Violation Effect: Supporting Recovery Through Relapse
- A central concept of the RP model postulates that high-risk situations frequently serve as the immediate precipitators of initial alcohol use after abstinence (see figure 1).
- Recently, Magill and Ray conducted a meta-analysis of 53 controlled trials of CBT for substance use disorders.
- Whereas tonic processes may dictate initial susceptibility to relapse, its occurrence is determined largely by phasic responses–proximal or transient factors that serve to actuate (or prevent) a lapse.
- Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful.
Expectancy research has recently started examining the influences of implicit cognitive processes, generally defined as those operating automatically or outside conscious awareness 54,55. During a smoking cessation attempt, participants reported on SE, negative affect and urges at random intervals. Although SE is proposed as a fluctuating and dynamic construct , most studies rely on static measures of SE, preventing evaluation of within-person changes over time or contexts .
Research supports that expectancies could partly mediate influences such as personality factors , genetic variations 51,52, and negative affect on drinking. In the first study to examine relapse in relation to phasic changes in SE , researchers reported results that appear consistent with the dynamic model of relapse. Findings from these studies suggested that participants’ SE was lower on the day before a lapse, and that lower SE in the days following a lapse in turn predicted progression to relapse 43,45.
Thus, this perspective considers only a dichotomous treatment outcome—that is, a person is either abstinent or relapsed. Global strategies comprise balancing the client’s lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urge-management techniques, and developing relapse road maps. Their role is to support you in activating your relapse prevention plan and getting back on track, not to shame you for a mistake. Getting past the abstinence violation effect isn’t just a matter of “trying harder.” It takes a solid support network and a new set of skills designed for the real world of recovery. This is where we move from theory to practice, building a toolkit of proven strategies to manage a lapse and stop a full-blown relapse in its tracks.
Further, there was strong support that increases in self-efficacy following drink-refusal skills training was the primary mechanism of change. Considering the numerous developments related to RP over the last decade, empirical and clinical extensions of the RP model will undoubtedly continue to evolve. Rather than signaling weaknesses of the model, these issues could simply reflect methodological challenges that researchers must overcome in order to better understand dynamic aspects of behavior . Additionally, the revised model has generated enthusiasm among researchers and clinicians who have observed these processes in their data and their clients 122,123. Nevertheless, these studies were useful in identifying limitations and qualifications of the RP taxonomy and generated valuable suggestions . Following the initial introduction of the RP model in the 1980s, its widespread application largely outpaced efforts to systematically validate the model and test its underlying assumptions.
Leave a Comment