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). 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. 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]. Dual process accounts of addictive behaviors [56,57] are likely to be useful for generating hypotheses about dynamic relapse processes and explaining variance in relapse, including episodes of sudden divergence from abstinence to relapse. Implicit cognitive processes are also being examined as an intervention target, with some potentially promising results [62].

Mechanisms of treatment effects

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]. 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. While a abstinence violation effect lapse might prompt a full-blown relapse, another possible outcome is that the problem behavior is corrected and the desired behavior re-instantiated–an event referred to as prolapse. A critical implication is that rather than signaling a failure in the behavior change process, lapses can be considered temporary setbacks that present opportunities for new learning to occur.

Planning a cognitive behavioural programme

Recognize that cravings are inevitable and do not mean that a person is doing something wrong. • Build a support network of friends and family to call on when struggling and who are invested in recovery. Considering the numerous developments related to RP over the last decade, empirical and clinical extensions of the RP model will undoubtedly continue to evolve. In addition to the recent advances outlined above, we highlight selected areas that are especially likely to see growth over the next several years. Rajiv’s unsuccessful attempts at abstinence lead to a low sense of self-confidence and a belief that he would not be able help himself (low perceived self- efficacy) setting up a vicious cycle.

Models of nonabstinence psychosocial treatment for SUD

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The longer someone neglects self-care, the more that inner tension builds to the point of discomfort and discontent. This stage is characterized by a tug of war between past habits and the desire to change. Thinking about and romanticizing past drug use, hanging out with old friends, lying, and thoughts about relapse are danger signs.

abstinence violation effect psychology

2. Relationship between goal choice and treatment outcomes

High-risk situations are determined by an analysis of previous lapses and by reports of situations in which the client feels or felt “tempted.” Appropriate responses are those behaviours that lead to avoidance of high-risk situations, or behaviours that foster adaptive responses. Seemingly irrelevant decisions (SIDs) are those behaviours that are early in the path of decisions that place the client in a high-risk situation. For example, if the client understands that using alcohol in the day time triggers a binge, agreeing for a meeting in the afternoon in a restaurant that serves alcohol would be a SID5. A more recent development in the area of managing addictive behaviours is the application of the construct of mindfulness to managing experiences related to craving, negative affect and other emotional states that are believed to impact the process of relapse34. It is now believed that relapse prevention strategies must be taught to the individual during the course of therapy, and various strategies to enhance patient involvement and adherence such as increasing patient responsibility, promoting internal attributions to events are to be introduced in therapy. Working with a variety of targets helps in generalization of gains, patients are helped in anticipating high risk situations33.

  • Relapse is most likely in the first 90 days after embarking on recovery, but in general it typically happens within the first year.
  • Therapeutic strategies such as contingency management, differential reinforcement of incompatible and alternate behaviours and rearrangement of environmental cues that set the occasion for addictive behaviour, including emotional triggers are used in this approach.
  • AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse.

Mindfulness training, for example, can modify the neural mechanisms of craving and open pathways for executive control over them. Good treatment programs recognize the relapse process and teach people workable exit strategies from such experiences. They are particularly prone to relapse because they spent their formative years engaged with substances rather than developing a strong social support network, learning basic life skills, or gaining academic achievement—all positive predictors of success. Learning what one’s triggers are and acquiring an array of techniques for dealing with them should be essential components of any recovery program. Another factor that may occur is the Problem of Immediate Gratification where the client settles for shorter positive outcomes and does not consider larger long term adverse consequences when they lapse. This can be worked on by creating a decisional matrix where the pros and cons of continuing the behaviour versus abstaining are written down within both shorter and longer time frames and the therapist helps the client to identify unrealistic outcome expectancies5.

  • Furthermore, the use of FDA-approved medications (which not all clients will view as “abstinence”) has been shown to produce the best health and recovery outcomes for people with opioid use disorders.
  • Nevertheless, these studies were useful in identifying limitations and qualifications of the RP taxonomy and generated valuable suggestions [121].
  • Among the most important coping skills needed are strategies of distraction that can be quickly engaged when cravings occur.
  • Given data demonstrating a clear link between abstinence goals and treatment engagement in a primarily abstinence-based SUD treatment system, it is reasonable to hypothesize that offering nonabstinence treatment would increase overall engagement by appealing to those with nonabstinence goals.
  • Thus, examining withdrawal in relation to relapse may only prove useful to the extent that negative affect is assessed adequately [64].
  • However, broadly speaking, there are clear features of 12-step programs that can contribute to the AVE.

However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD. That view contrasts with the evidence that addiction itself changes the brain—and stopping use changes it back. Use of a substance delivers such an intense and pleasurable “high that it motivates people to repeat the behavior, and the repeated use rewires the brain circuitry in ways that make it difficult to stop. Evidence shows that eventually, in the months after stopping substance use, the brain rewires itself so that craving diminishes and the ability to control behavior increases. The brain is remarkably plastic—it shapes and reshapes itself, adapts itself in response to experience and environment.

  • 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.
  • Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment.
  • As summarized below, preliminary empirical support exists for each of these possibilities.
  • Approach oriented participants may see themselves as more responsible for their actions, including lapse, while avoidance-based coping may focus more on their environment than on their own actions14.
  • In our era of heightened overdose risk, the AVE is more likely than ever to have tragic effects.

These results suggest that researchers should strive to consider alternative mechanisms, improve assessment methods and/or revise theories about how CBT-based interventions work [77,130]. Findings concerning possible genetic moderators of response to acamprosate have been reported [99], but are preliminary. Additionally, other findings suggest the influence of a DRD4 variable number of tandem repeats (VNTR) polymorphism on response to olanzapine, a dopamine antagonist that has been studied as an experimental treatment for alcohol problems. Olanzapine was found to reduce alcohol-related craving those with the long-repeat VNTR (DRD4 L), but not individuals with the short-repeat version (DRD4 S; [100,101]).