Abstinence Violation Effect: How Does Relapse Impact Recovery?

The RP model has been studied among individuals with both AUD and DUD (especially Cocaine Use Disorder, e.g., Carroll, Rounsaville, & Gawin, 1991); with the largest effect sizes identified in the treatment of AUD (Irvin, Bowers, Dunn, & Wang, 1999). As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014). Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010).

• Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020).
• Therefore, one global self-management strategy involves encouraging clients to pursue again those previously satisfying, non-drinking recreational activities.
• But to provide such clients with consistent, high-quality care, counselors need a common foundation of knowledge and skills.450 The consensus panel identified the following competencies for working with individuals who have problematic substance use or who are in recovery.
• These covert antecedents include lifestyle factors, such as overall stress level, as well as cognitive factors that may serve to “set up” a relapse, such as rationalization, denial, and a desire for immediate gratification (i.e., urges and cravings) (see figure 2).
• In order to understand AVE, it is important to realize the difference between a lapse and relapse.
• Relative to the TAU group, the VM group reported significantly lower levels of substance use and alcohol-related consequences and improved psychosocial functioning at follow-up 116.

1. Nonabstinence psychosocial treatment models

An essential part of this process involves developing self-awareness and understanding what triggers certain thoughts, emotions, or behaviors. While this can affect anyone making behavioral changes, it’s particularly impactful for those recovering from mental health challenges and substance use disorders. Upon breaking the self-imposed rule, individuals often experience negative emotions such as guilt, shame, disappointment, and a sense of failure. These emotional and cognitive reactions intensify the Abstinence Violation Effect, which may lead to a further loss of control and increased vulnerability to subsequent relapses or deviations from the established rule. Being able to understand how your thoughts, emotions, and behaviors play off of each other can help you to better control and respond to them in a positive way. Acknowledging your triggers and developing the appropriate coping skills should be a part of a solid relapse prevention program.

• Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991).
• Experiencing a setback in mental health recovery can feel disappointing, frightening, or devastating.
• We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied.
• For example, maybe your short-term goal is to eat healthy and build muscle so that you can perform better in your sport, and your long-term goal is to care for your body in order to avoid preventable diseases later in life.
• Many treatment centers already provide RP as a routine component of aftercare programs.

G Alan Marlatt

Depending on the setting, counselors providing or thinking of providing recovery-oriented counseling may need to consider the ways that payment systems can affect delivery of care. Recurrence of substance use happens, but recovery-oriented counseling can help clients avoid it or confidently return to recovery when it does occur. However, there are some common early psychological signs that a relapse may be on the way. If you are worried that you might be headed for a relapse, you don’t have to wait until it happens to reach out for help. It is inevitable that everyone will experience negative emotions at one point or another. It is not necessarily these natural emotions that cause emotional relapse, but how you cope with them, that does.

What Is The Difference Between A Lapse And Relapse?

In these situations, the drinker focuses primarily on the anticipation of immediate gratification, such as stress reduction, neglecting possible delayed negative consequences. Expectancy research has recently started examining the influences of implicit cognitive processes, generally defined as those operating automatically or outside conscious awareness 54,55. Recent reviews provide a convincing rationale for the putative role of implicit processes in addictive behaviors and relapse 54,56,57. Implicit measures of alcohol-related cognitions can discriminate among light and heavy drinkers 58 and predict drinking above Twelve-step program and beyond explicit measures 59. One study found that smokers’ attentional bias to tobacco cues predicted early lapses during a quit attempt, but this relationship was not evident among people receiving nicotine replacement therapy, who showed reduced attention to cues 60. Counselors should then use this self-awareness to address their biases and provide inclusive care.

Counselor Responses to Warning Signs of a Recurrence

This cue leads to a cognitive conflict, as the individual struggles between their desire to maintain abstinence and the urge to engage in the prohibited behavior. If the person succumbs to the urge and violates their self-imposed rule, the Abstinence Violation Effect is activated. If you’re worried you might be heading towards a lapse or full-blown relapse, don’t struggle with this alone. If you’re currently lost within the confusion of the abstinence violation effect, we can help. This model notes that those who have the latter mindset are proactive and strive to learn from their mistakes. To do so, they adapt their coping strategies to better deal with future triggers should they arise.

NEARBY TERMS

This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. Although the RP model considers the high-risk situation the immediate relapse trigger, it is actually the person’s response to the situation that determines whether he or she will experience a lapse (i.e., begin using alcohol). A person’s coping behavior in a high-risk situation is a particularly critical determinant of the likely outcome.

• The therapist also can use examples from the client’s own experience to dispel myths and encourage the client to consider both the immediate and the delayed consequences of drinking.
• 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.
• In the 1970s, the pioneering work of a small number of alcohol researchers began to challenge the existing abstinence-based paradigm in AUD treatment research.
• Overall, many basic tenets of the RP model have received support and findings regarding its clinical effectiveness have generally been supportive.

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. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.

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. Currently, the dynamic model can be viewed as a hypothetical, theory-driven framework that awaits empirical evaluation. Testing the model’s components will require that researchers avail themselves of innovative assessment techniques (such as EMA) and pursue cross-disciplinary collaboration in order to integrate appropriate statistical methods.

Overall, many basic tenets of the RP model have received support and findings regarding its clinical effectiveness have generally been supportive. RP modules are standard to virtually all psychosocial interventions for substance use 17 and an increasing number of self-help manuals are available to assist both therapists and clients. RP strategies can now be disseminated using simple but effective methods; for instance, mail-delivered RP booklets are shown to reduce smoking relapse 135,136. As noted earlier, the broad influence of RP is also evidenced by the current clinical vernacular, as “relapse prevention” has evolved into an umbrella term synonymous with most cognitive-behavioral skills-based interventions addressing high-risk situations and coping responses. While attesting to the influence and durability of the RP model, the tendency to subsume RP within various treatment modalities can also complicate efforts to systematically evaluate intervention effects across studies (e.g., 21). Elucidating the “active ingredients” of CBT treatments remains an important and challenging goal.

• Although many developments over the last decade encourage confidence in the RP model, additional research is needed to test its predictions, limitations and applicability.
• This protects their sobriety and enhances their ability to protect themselves from future threats of relapse.
• CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript.
• Based on the classification of relapse determinants and high-risk situations proposed in the RP model, numerous treatment components have been developed that are aimed at helping the recovering alcoholic cope with high-risk situations.
• Using a person-centered, strengths-based approach and unconditional positive regard, counselors should affirm clients’ efforts to continue in recovery and encourage them to reflect on their goals and how the recurrence could be an opportunity to gain greater insight and adjust their action plan.
• Although specific intervention strategies can address the immediate determinants of relapse, it is also important to modify individual lifestyle factors and covert antecedents that can increase exposure or reduce resistance to high-risk situations.

Seek Support

When you’ve experienced some success in your recovery, you may think that you can return to drug or alcohol use and control it. You may think that this time will be different, but if your drinking and drug use has gotten out of control in the past, it’s unlikely to be different this time. However, it can sometimes lead to the thought that you have earned a drink or a night of using drugs. It sounds counterintuitive, and it is, but it is a common thought that many people have to recognize to avoid relapse. Celebrating victories is a good thing, but it’s important to find constructive ways to appreciate your sobriety.

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). 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. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity). Some researchers propose that the self-control required to maintain behavior change strains motivational resources, and that this “fatigue” can undermine subsequent self-control efforts 78. 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 79.