The term “predictive validity” refers to the ability of a test or method to predict a certain outcome abstinence violation effect (e.g., relapse risk) accurately. Gillian Steckler is a research assistant for Dr Katie Witkiewitz at Washington State University Vancouver where she also attended and received a bachelor of science degree in psychology. Rather than labeling oneself as a failure, weak, or a loser, recognizing the effort and progress made before the lapse can provide a more balanced perspective.
Cognitive Behavioral Therapy for Substance use Disorders
- Consistent with the philosophy of harm reduction as described by Marlatt et al. (2001), harm reduction psychotherapy is accepting of a wide range of client goals, including risk reduction, moderation, and abstinence (of note, abstinence is conceptualized as consistent with harm reduction when it is a goal chosen by the client).
- 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.
- Rather than focusing on binary and distal relapse outcomes, our analyses aimed to advance understanding of factors that influence the dynamic process of recurrent lapse episodes recorded as participants attempted to maintain abstinence from smoking.
- Practitioners indicated change in daily structure, stress, maladaptive coping skills, habitual behavior, and lack of self-efficacy regarding weight loss maintenance as most important recurrent (mentioned in all groups) predictors.
- For example, in this study self-value and resilience received high importance ratings, but these are not reflected in current models.
Research among college students has shown that those who drink the most tend to have higher expectations regarding the positive effects of alcohol (i.e., outcome expectancies) and may anticipate only the immediate positive effects while ignoring or discounting the potential negative consequences of excessive drinking (Carey 1995). Such positive outcome expectancies may become particularly salient in high-risk situations, when the person expects alcohol use to help him or her cope with negative emotions or conflict (i.e., when drinking serves as “self-medication”). In these situations, the drinker focuses primarily on the anticipation of immediate gratification, such as stress reduction, neglecting possible delayed negative consequences.
Relapse crises and coping among dieters
To the extent that the AVE is bound to a series of recurrent lapses, the timing, frequency and severity of each lapse should also synergistically influence AVE dynamics and lapse progression. During smoking cessation some quitters tend to experience rapidly occurring lapses, while others experience more isolated lapses spread over extended periods of time (e.g., Conklin et al., 2005; Hoeppner et al., 2008; Wileyto et al., 2005). The way pre-lapse abstinence duration and amount smoked might modulate recurrent AVEs and subsequent progression remains unclear. One possibility is that lapses occurring after longer periods of abstinence taint successful progress accumulated to that point, call the lapser’s ability to maintain abstinence into question, increase attributions of blame, as well as feelings of guilt. Alternatively, longer pre-lapse abstinence time may actually increase perceptions of control over cessation, and may therefore protect against the AVE, mitigating the detrimental impact of lapses.
Relapse Prevention And Ongoing Treatment At Bedrock
A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013). Additionally, no studies identified in this review compared reasons for not completing treatment between abstinence-focused and nonabstinence treatment. Specific intervention strategies include helping the person identify and cope with high-risk situations, eliminating myths regarding a drug’s effects, managing lapses, and addressing misperceptions about the relapse process.
Ongoing cravings, in turn, may erode the client’s commitment to maintaining abstinence as his or her desire for immediate gratification increases. This process may lead to a relapse setup or increase the client’s vulnerability to unanticipated high-risk situations. Given the abstinence focus of many SUD treatment centers, studies may need to recruit using community outreach, which can yield fewer participants compared to recruiting from treatment (Jaffee et al., 2009). However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to treatment. 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 sum, research suggests that achieving and sustaining moderate substance use after treatment is feasible for between one-quarter to one-half of individuals with AUD when defining moderation as nonhazardous drinking.
Immediate Determinants of Relapse
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). Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005). In the multifaceted journey of overcoming addiction and living a healthier life, individuals often encounter a psychological phenomenon known as the abstinence violation effect (AVE). It sheds light on the challenges individuals face when attempting to maintain abstinence and how a single lapse can trigger a surge of negative emotions, potentially leading to a full relapse or a return to unhealthy living (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999). The AVE describes the negative emotional response that often accompanies a failure to maintain abstinence from drugs or alcohol. Gordon as part of their cognitive-behavioral model of relapse prevention, and it is used particularly in the context of substance use disorders.
- Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008).
- The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004).
- In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010).
- This suggests that smokers should be encouraged to remain on treatment even after they have lapsed, at least through the first 8–10 lapses, while persisting in efforts to recover abstinence as soon as possible.
- If the reason for the violation is attributed to internal, stable, and/or global factors, such as lack of willpower or possession of an underlying disease, then the individual is more likely to have a full-blown relapse after the initial violation occurs.
In contrast, several models of relapse that are based on social-cognitive or behavioral theories emphasize relapse as a transitional process, a series of events that unfold over time (Annis 1986; Litman et al. 1979; Marlatt and Gordon 1985). According to these models, the relapse process begins prior to the first posttreatment alcohol use and continues after the initial use. This conceptualization provides a broader conceptual framework for intervening in the relapse process to prevent or reduce relapse episodes and thereby improve treatment outcome. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. 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).
- This imagery technique is known as “urge surfing” and refers to conceptualizing the urge or craving as a wave that crests and then washes onto a beach.
- Alan Marlatt is a professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington.
- 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.
- Any smoking after initial cessation, ranging from a single puff to multiple cigarettes, can be considered a lapse (Brownell et al., 1986; Shiffman et al., 1986).
- In one clinical intervention based on this approach, the client is taught to visualize the urge or craving as a wave, watching it rise and fall as an observer and not to be “wiped out” by it.
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. 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). Conversely, people with low self-efficacy perceive themselves as lacking the motivation or ability to resist drinking in high-risk situations. 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). 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).
Cognitive neuroscience of self-regulation failure
- Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders.
- To do so, the mean importance of each perceived predictor was calculated based on the overall mean importance ratings of the underlying statements.
- A focus of relapse-prevention treatment has been on helping those who lapse manage the AVE and maintain or reestablish abstinence from the undesired behavior.
- 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.
Practitioners indicated change in daily structure, stress, maladaptive coping skills, habitual behavior, and lack of self-efficacy regarding weight loss maintenance as most important recurrent (mentioned in all groups) predictors. Persons who regained weight indicated lifestyle imbalance or experiencing a life event, lack of perseverance, negative emotional state, abstinence violation effect, decrease in motivation and indulgence as most important recurrent predictors. Covert antecedents and immediate determinants of relapse and intervention strategies for identifying and preventing or avoiding those determinants. If stressors 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.
Subsequently, the research team named all clusters, thereby keeping the names given by the participants in consideration. Within the groups, each cluster represented multiple perceived predictors; this made it impossible to do a group comparison on cluster level. We therefore analyzed our results on predictor level instead of cluster level, which is in accordance with former concept mapping literature (Hidding, Chinapaw, & Altenburg, 2018). To do so, the mean importance of each perceived predictor was calculated based on the overall mean importance ratings of the underlying statements. It is essential to understand what individuals with SUD are rejecting when they say they do not need treatment.