Even when alcohol’s perceived positive effects are based on actual drug effects, often only the immediate effects are positive (e.g., euphoria), whereas the delayed effects are negative (e.g., sleepiness), particularly at higher alcohol doses. To increase the likelihood that a client can and will utilize his or her skills when the need arises, the therapist can use approaches such as role plays and the development and modeling of specific coping plans for managing potential high-risk situations. Questionnaires such as the situational confidence test (Annis 1982b) can assess the amount of self-efficacy a person has in coping with drinking-risk situations. For example, the therapist can interview the client about past lapses or relapse episodes and relapse dreams or fantasies in order to identify situations in which the client has or might have difficulty coping.
Relapse Road Maps
If you’re in the Massachusetts area, a personalized outpatient plan can give you the structure and support you need to build a recovery that lasts. It’s about building the resilience to get back up after a stumble, armed with new insight and unwavering support. A solid plan is your emergency guide for those first critical moments after a lapse. A lapse often unleashes a storm of intense emotions—shame, panic, guilt.
- Project MATCH evaluated the efficacy of three interventions–Motivational Enhancement Therapy (MET), Twelve-Step Facilitation (TSF), and Cognitive Behavioral Therapy (CBT)–for treating alcohol dependence.
- Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013).
- The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse.
- It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019).
Actionable Strategies to Overcome the Abstinence Violation Effect
- Taking decisive action reinforces your commitment and stops the abstinence violation effect dead in its tracks.
- For example, Miller and colleagues (1996) found that although mere exposure to specific high-risk situations did not predict relapse, the manner in which people coped with those situations strongly predicted subsequent relapse or continued abstinence.
- Relapse can affect the brain in a variety of ways, depending on the situation and the substance used.
Practicing abstinence can be an important strategy for people experiencing challenges with addiction. That’s why adopting a more realistic, compassionate view of the recovery journey can be helpful, in addition to seeking the appropriate mental health support as needed. It has also been shown to promote a decrease in symptoms of anxiety, depression, and specific phobias, all which have a comorbid relationship with substance use disorders. If you prefer receiving this type of support from the comfort of your own home, you might consider working with a therapist virtually. Some people feel more comfortable or supported by meeting with this type of professional in person. Life situations, relationships, and commitments all have to be parsed through carefully and continually evaluated for balance and harmony.
Empirical findings relevant to the RP model
While AUD treatment studies commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use. Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019). Alternatively, researchers who conduct trials in community-based treatment centers will need to obtain buy-in to test nonabstinence approaches, which may necessitate waiving facility policies regarding drug use during treatment – a significant hurdle. Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness). Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD).
From this standpoint, an initial return to the target behavior after a period of volitional abstinence (a lapse) is seen not as a dead end, but as a fork in the road. Because detailed accounts of the model’s historical background and theoretical underpinnings have been published elsewhere (e.g., 16,22,23), we limit the current discussion to a concise review of the model’s history, core concepts and clinical applications. By necessity, our literature review also includes studies that do not explicitly espouse the RP model, but that are relevant nonetheless to its predictions. We also take the perspective that relapse is best conceptualized as a dynamic, ongoing process rather than a discrete or terminal event (e.g., 1,8,10).
Evidence of the abstinence violation effect can be seen in any individual who attributes a lapse and subsequent relapse to entirely uncontrollable conditions, such as a perceived character flaw or adherence to the constraints of addiction. AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse. Given this notable gap in research, empirical attention to nonabstinence treatment is a logical next step for the field of SUD treatment research. As policy-makers, community members, and treatment providers continue to reject scientific evidence supporting harm reduction, research examining more effective strategies for shifting public perception may be key to moving the field forward.
A small body of research has identified patterns of controlled and occasional drug use among subsets of individuals who use illicit drugs, but there are significant gaps in this research regarding treatment implications. Rooted in the disease model of addiction, this assumption stems from an understanding of addiction as a chronic, incurable disease characterized by total loss of control over substance use, and thus manageable only by abstinence (Marlatt et al., 2001; Van Amsterdam & Van Den Brink, 2013; Wilbanks, 1989). This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention. Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success.
G Alan Marlatt, Ph.D.
Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. One critical goal will be to integrate empirically supported substance use interventions in the context of continuing care models of treatment delivery, which in many cases requires adapting existing treatments to facilitate sustained delivery . Relapse prevention is a cognitive-behavioral approach designed to help individuals anticipate and cope with setbacks during the behavior change process. While the overall number of studies examining neural correlates of relapse remains small at present, the coming years will undoubtedly see a significant escalation in the number of studies using fMRI to predict response to psychosocial and pharmacological treatments.
Most studies of relapse rely on statistical methods that assume continuous linear relationships, but these methods may be inadequate for studying a behavior characterized by discontinuity and abrupt changes . A key contribution of the reformulated relapse model is to highlight the need for non-traditional assessment and analytic approaches to better understand relapse. Consistent with this idea, EMA studies have shown that social drinkers report greater alcohol consumption and violations of self-imposed drinking limits on days when self-control demands are high . However, despite findings that coping can prevent lapses there is scant evidence to show that skills-based interventions in fact lead to improved coping . Some studies find that the number of what is salvia for parents coping responses is more predictive of lapses than the specific type of coping used 76,77. Moreover, Baker and colleagues propose that high levels of negative affect can interfere with controlled cognitive processes, such that adaptive coping and decision-making may be undermined as negative affect peaks .
According to this metaphor, learning to anticipate and plan for high-risk situations during recovery from alcoholism is equivalent to having a good road map, a well-equipped tool box, a full tank of gas, and a spare tire in good condition for the journey. The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process. These approaches include specific intervention strategies that focus on the immediate determinants of relapse as well as global self-management strategies that focus on the covert antecedents of relapse. A person whose life is full of demands may experience a constant sense of stress, which not only can generate negative emotional states, thereby creating high-risk situations, but also enhances the person’s desire for pleasure and his or her rationalization that indulgence is justified (“I owe myself a drink”). Marlatt and Gordon (1985) have proposed that the covert antecedent most strongly related to relapse risk involves the degree of balance in the person’s life between perceived external demands (i.e., “shoulds”) and internally fulfilling or enjoyable activities (i.e., “wants”). In many cases, initial lapses occur in high-risk situations that are completely unexpected and for which the drinker is often unprepared.
The Abstinence Violation Effect and Overcoming It
There is less research examining the extent to which moderation/controlled use goals are feasible for individuals with DUDs. Returning to use under this framework might be understood as indicating a need for further skill development or a change in treatment goals or motivation – natural parts of the treatment process – rather than as a treatment failure (Marlatt et al., 2001). In contrast, the harm reduction framework views substance use on a spectrum, framing any positive change (e.g., steps toward safer or more controlled use) as a marker of treatment success. This suggests that returns to use are the norm rather than the exception, and that an expectation of sustained, continuous abstinence during and after treatment is unrealistic for most people with SUD. Indeed, those who engage in SUD treatment require an average of three to four treatment episodes over about nine years to achieve long-term abstinence (Dennis, Scott, Funk, & Foss, 2005). A majority of individuals who complete SUD treatment return to use within one year post-treatment (Brandon, Vidrine, & Litvin, 2007).
Global Lifestyle Self-Control Strategies
Marlatt explicitly described RP as a model that could be used to maintain abstinence or harm reduction treatment goals (Marlatt & Donovan, 2005), and MBRP has been described as a harm reduction treatment approach due to its emphasis on normalizing and accepting lapses as a natural part of the recovery process (Bayles, 2014). Thus, while there is some evidence to support MI as a nonabstinence DUD intervention, evidence most strongly supports its use as an adjunct to abstinence-based treatment. For example, at a large outpatient SUD treatment center in Amsterdam, goal-aligned treatment for drug and alcohol use involves a version of harm reduction psychotherapy that integrates MI and CBT approaches, and focuses on motivational enhancement, self-control training, and relapse prevention (Schippers & Nelissen, 2006). While models of nonabstinence treatment in the U.S. have been described primarily in harm reduction-specific settings (e.g., private practice settings and nonprofit organizations such as the Harm Reduction Therapy Center; Little & Franskoviak, 2010), there are also examples from Europe in which harm reduction has been integrated into community-based SUD treatment. These models generally use motivational and cognitive-behavioral strategies to increase motivation to change, provide AUD psychoeducation, and teach skills for regulating drinking. These include cognitive-behavioral and skills-focused drinking interventions (e.g., Behavioral Self-Control Training), brief interventions for primary care settings, and alcohol risk reduction interventions for college students (e. g., Alcohol Skills Training Program and Brief Alcohol Screening and Intervention for College Students).
For example, in AUD treatment, individuals with both goal choices demonstrate significant improvements in drinking-related outcomes (e.g., lower percent drinking days, fewer heavy drinking days), alcohol-related problems, and psychosocial functioning (Dunn & Strain, 2013). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness.
Outcome Expectancies
Major treatment outcome studies and meta-analyses are summarized, as are selected empirical findings relevant to the tenets of the RP model. The Relapse Prevention (RP) model has been a mainstay of addictions theory and treatment since its introduction three decades ago. The term “predictive validity” refers to the ability of a test or method to predict a certain outcome (e.g., relapse risk) accurately. The RP-based treatments included in those analyses were delivered both as stand-alone treatments for initiating abstinence and as adjuncts to other treatment programs. The researchers then coded key, or baseline, relapse episodes3 described by study participants entering treatment at the study sites.
Multiple such models have strong empirical support and have been described in previous reviews (Marlatt & Witkiewitz, 2002; Witkiewitz & Alan Marlatt, 2006). Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review. Thus, while AUD treatment research can inform research directions for the treatment of other SUDs, it is also important to test the effectiveness of treatments across substance types. However, there may be differences in the effectiveness of specific treatments for AUD vs. DUD, and many AUD treatment effectiveness studies exclude patients with DUD (Rounsaville et al., 2003).
The reformulated cognitive-behavioral model of relapse
A lapse is a single instance of using a substance after you’ve been sober. The abstinence violation effect gets its power from how you react to the slip, not the slip itself. That said, the effectiveness of abstinence can depend on the person’s own self-efficacy, their reason for abstaining, their support system, and various other factors. That said, abstinence can also come from a desire to avoid a potential high-risk situation later on.
