Countering The Abstinence Violation Effect: Supporting Recovery Through Relapse

Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985). In 1973, alcohol researchers Sobell and Sobell published the first of several studies examining behavioral treatment for inpatients with AUD aimed at “controlled” drinking (defined as days during which 6 oz. or less of 86-proof liquor or its equivalent were consumed, or any isolated 1- or 2-day sequence when between 7 and 9 oz. were consumed). Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research. Thus, while there is a clear need to engage people earlier in SUD progression to reduce the harms caused by problematic substance use, this goal is incompatible with the predominant model of abstinence-based SUD treatment. In this model, treatment success is defined as achieving and sustaining total abstinence from alcohol and drugs, and readiness for treatment is conflated with commitment to abstinence (e.g., Harrell, Trenz, Scherer, Martins, & Latimer, 2013). Many therapies (both behavioral and pharmacological) have been developed to help individuals cease or reduce addictive behaviors and it is critical to refine strategies for helping individuals maintain treatment goals.

In addition to shaping mainstream addiction treatment, the abstinence-only 12-Step model also had an indelible effect on the field of SUD treatment research. This standard persisted in SUD treatment even as strong evidence emerged that a minority of individuals who receive 12-Step treatment achieve and maintain long-term abstinence (e.g., Project MATCH Research Group, 1998). This model both accelerated the spread of AA and NA and helped establish the abstinence-focused 12-Step program at the core of mainstream addiction treatment. The Minnesota Model involved inpatient SUD treatment incorporating principles of AA, with a mix of professional and peer support staff (many of whom were members of AA), and a requirement that patients attend AA or NA meetings as part of their treatment (Anderson, McGovern, & DuPont, 1999; McElrath, 1997).

Historical context of nonabstinence approaches

For example, if arguments with a former spouse are a high-risk situation, the therapist can help the client map out several possible scenarios for interacting with the ex-spouse, including the likelihood of precipitating an argument in each scenario.
In this study incarcerated individuals were offered the chance to participate in an intensive 10-day course in Vipassana meditation (VM).
This concurs not only with clinical observations, but also with contemporary learning models stipulating that recently modified behavior is inherently unstable and easily swayed by context .
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.

A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002). In sum, there is a strong theoretical and empirical rationale for offering treatment options aligned with client goals. A wide range of empirical research also supports the importance of goal alignment between clients and providers, both for psychotherapy broadly and for SUD treatment specifically. Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches.

Evidence further suggests that negative affect can promote positive outcome expectancies or undermine situational self-efficacy , outcomes which could in turn promote a lapse.
Learning to spot and challenge these automatic negative thoughts is a cornerstone of effective therapy.
One bupropion trial found that DRD2 variations predicted withdrawal symptoms, medication response and time to relapse .
The desire for immediate gratification can take many forms, and some people may experience it as a craving or urge to use alcohol.
Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal).

In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985). Overall, the literature suggests that nonabstinence treatment for AUD can significantly reduce alcohol consumption and related problems, even for individuals with high-risk drinking and alcohol dependence (Charlet & Heinz, 2017; Marlatt & Witkiewitz, 2010). Additionally, individuals are most likely to achieve the outcomes that are consistent with their goals (i.e., moderation vs. abstinence), based on studies of both controlled drinking and drug use (Adamson, Heather, Morton, & Raistrick, 2010; Booth, Dale, & Ansari, 1984; Lozano et al., 2006; Schippers & Nelissen, 2006). The authors concluded that, given the centrality of SE to most cognitive-behavioral models of relapse, the association of SE with cessation was weaker than would be expected (i.e., SE accounted for roughly 2% of the variance in treatment outcome following initial abstinence).

Thus, specific cognitive and behavioral strategies are often necessary to maintain initial treatment gains and minimize relapse likelihood following initial behavior change. Notable advances in RP in the last decade include the introduction of a reformulated cognitive-behavioral model of relapse, the application of advanced statistical methods to model relapse in large randomized trials, and the development of mindfulness-based relapse prevention. Furthermore, in that study the majority of relapse episodes after treatment occurred during situations involving negative emotional states, a finding that has been replicated in other studies (Cooney et al. 1997; McKay 1999; Shiffman 1992). 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. Thus, a person who can execute effective coping strategies (e.g., a behavioral strategy, such as leaving the situation, or a cognitive strategy, such as positive self-talk) is less likely to relapse compared with a person lacking those skills. Based on research on precipitants of relapse in alcoholics who had received inpatient treatment, Marlatt (1996) categorized the emotional, environmental, and interpersonal characteristics of relapse-inducing situations described by study participants.

The Hidden Psychology Driving AVE

Lapses may also evoke physiological (e.g., alleviation of withdrawal) and/or cognitive (e.g., the AVE) responses that in turn determine whether use escalates or desists. Substance use and its immediate consequences (e.g., impaired decision-making, the AVE) are additional phasic processes that are set into motion once a lapse occurs. Phasic responses include cognitive and affective processes that can fluctuate across time and contexts--such as urges/cravings, mood, or transient what is holistic addiction treatment changes in outcome expectancies, self-efficacy, or motivation.

Building Resilience Against the AVE in Massachusetts

This reaction focuses on the drinker’s emotional response to an initial lapse and on the causes to which he or she attributes the lapse. They can help by learning about AVE themselves, offering encouragement without judgment, and reminding you that a lapse is not a failure. Your family can be a crucial part of your support system.

He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998). The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research. In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001). A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982). Most scientists who studied SUD treatment believed that abstinence was the only acceptable treatment goal until at least the 1980s (Des Jarlais, 2017). As such, even the Big Book of AA notes that controlled drinking may be possible for some who are not “alcoholics,” and acknowledges that “moderate drinkers” are able to control their drinking.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

The terms "relapse" and "relapse prevention" have seen evolving definitions, complicating efforts to review and evaluate the relevant literature. We begin with a concise overview of the historical and theoretical foundations of the RP model and a brief summary of clinical intervention strategies. Relapse prevention (RP) is a tertiary intervention strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviors. Preventing relapse or minimizing its extent is therefore a prerequisite for any attempt to facilitate successful, long-term changes in addictive behaviors. Relapse poses a fundamental barrier to the treatment of addictive behaviors by representing the modal outcome of behavior change efforts 1-3.

The last decade has seen numerous developments in the RP literature, including the publication of Relapse Prevention, Second Edition and its companion text, Assessment of Addictive Behaviors, Second Edition . The client's appraisal of lapses also serves as a pivotal intervention point in that these reactions can determine whether a lapse escalates or desists. Other important assessment targets include the client's self-efficacy, outcome expectancies, readiness to change, and concomitant factors that could complicate treatment (e.g., comorbid disorders, neuropsychological deficits). Viewing a lapse as a personal failure may lead to feelings of guilt and abandonment of the behavior change goal . 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.

Definitions of relapse and relapse prevention

Using high-risk situations as a starting point, the clinician works backward to identify immediate precipitants and distal lifestyle factors related to relapse, and forward to evaluate coping responses 16,24. An essential starting point in treatment is a thorough assessment of the client's substance use patterns, high-risk situations and coping skills. Whether a high-risk situation culminates in a lapse depends largely on the individual's capacity to enact an effective coping response--defined as any cognitive or behavioral compensatory strategy that reduces the likelihood of lapsing. Based on the cognitive-behavioral model of relapse, RP was initially conceived as an outgrowth and augmentation of traditional behavioral approaches to studying and treating addictions. The RP model developed by Marlatt 7,16 provides both a conceptual framework for understanding relapse and a set of treatment strategies designed to limit relapse likelihood and severity. Thus, RP has in many ways evolved into an umbrella term encompassing most skills-based treatments that emphasize cognitive-behavioral skills building and coping responses.

Mindfulness-based relapse prevention

The results of recent research, particularly the RREP study, likely will lead to modifications of the original RP model, particularly with regard to the assessment of high-risk situations as well as the conceptualization of covert and immediate antecedents of relapse. The RP model of relapse is centered around a detailed taxonomy of emotions, events, and situations that can precipitate both lapses and relapses to drinking. Several recent review articles and meta-analyses have examined the effectiveness of treatments based on the RP model in preventing relapse (Dimeff and Marlatt 1998; Rawson et al. 1993; Carroll 1996; Irvin et al. 1999). In a recent review of the literature on relapse precipitants, Dimeff and Marlatt (1998) also concluded that considerable support exists for the notion that an abstinence violation effect can precipitate a relapse.

Many clients report that activities they once found pleasurable (e.g., hobbies and social interactions with family and friends) have gradually been replaced by drinking as a source of entertainment and gratification. Many clients may never need to use their lapse-management plan, but adequate preparation can greatly lessen the harm if a lapse does occur. Lapse management includes contracting with the client to limit the extent of use, to contact the therapist as soon as possible after the lapse, and to evaluate the situation for clues to the factors that triggered the lapse. With such a matrix, the client can juxtapose his or her own list of the delayed negative consequences with the expected positive effects. Asking clients questions designed to assess expectancies for both immediate and delayed consequences of drinking versus not drinking (i.e., using a decision matrix) (see table, p. 157) often can be useful in both eliciting and modifying expectancies.

Systematic reviews and large-scale treatment outcome studies

Though the phrase "relapse prevention" was initially coined to denote a specific clinical intervention program 7,16, RP strategies are now integral to most psychosocial treatments for substance use , including many of the most widely disseminated interventions (e.g., 18-20). For present purposes we define relapse as a setback that occurs during the behavior change process, such that progress toward the initiation or maintenance of a behavior change goal (e.g., abstinence from drug use) is interrupted by a reversion to the target behavior. We also provide updated reviews of research areas that have seen notable growth in the last few years; in particular, the application of advanced statistical modeling techniques to large treatment outcome datasets and the development of mindfulness-based relapse prevention. Specific emphasis is placed on the reformulated cognitive-behavioral model of relapse as a basis for hypothesizing and studying dynamic aspects of the relapse process.

Secondary analyses showed that compared to TAU, MBRP participants evinced a decreased relation between depressive symptoms and craving following treatment. Compared to TAU, MBRP participants reported significantly reduced craving, and increased acceptance and mindful awareness over the 4-month follow-up period, consistent with the core goals of MBRP. In this study incarcerated individuals were offered the chance to participate in an intensive 10-day course in Vipassana meditation (VM). In terms of clinical applications of RP, the most notable development in the last decade has been the emergence and increasing application of Mindfulness-Based Relapse Prevention (MBRP) for addictive behaviors 112,113.

In the present review we emphasize Marlatt's RP model 7,16 and its more recent iteration when discussing the theoretical basis of RP. Definitions of RP have also evolved considerably, due largely to the increasingly broad adoption of RP approaches in various treatment contexts. Most notably, we provide a recent update of the RP literature by focusing primarily on studies conducted within the last decade. Preparation of this manuscript was supported by National Institute on Alcohol Abuse and Alcoholism grants R3A–AA–05591 to G. Classical or Pavlovian conditioning occurs when an originally neutral stimulus (e.g., the sight of a beer bottle) is repeatedly paired with a stimulus (e.g., alcohol consumption) that induces a certain physiological response.