This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment. 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. Most scientists who studied SUD treatment believed that abstinence was the only acceptable treatment goal until at least the 1980s (Des Jarlais, 2017). Abstinence rates became the primary outcome for determining SUD treatment effectiveness (Finney, Moyer, & Swearingen, 2003; Kiluk, Fitzmaurice, Strain, & Weiss, 2019; Miller, 1994; Volkow, 2020), a standard which persisted well into the 1990s (Finney et al., 2003).
- Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002).
- Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge.
- 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.
- Before any substance use even occurs, clinicians can talk to clients about the AVE and the cognitive distortions that can accompany it.
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. Traditional alcoholism treatment approaches often conceptualize relapse as an end-state, a negative outcome equivalent to treatment failure. Thus, this perspective considers only a dichotomous treatment outcome—that is, a person is either abstinent or relapsed.
Integrating implicit cognition and neurocognition in relapse models
Sometimes, it begins from the very moment we even consider the notion of using again. If AVE sets in pre-emptively, it may actually lead us to the relapse we so desperately fear. Those who wish to become sober—and stay that way—must therefore learn to identify abstinence violation effect and the dangerous ways in which it might impact our recovery. One helpful cognitive strategy in the initial phase of CBT includes using the Advantage/disadvantage technique with the patient29. The therapist and patient collaboratively review the advantages/disadvantages of engaging in substance use or addictive behaviour. Social skills training (SST) incorporates a wide variety of interpersonal dimensions15.
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. Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies. The assumption of RP is that it is problematic to expect that the effects of a treatment that is designed to moderate or eliminate an undesirable behaviour will endure beyond the termination of that treatment. Further, there are reasons to presume a problem will re-emerge on returning to the old environment that elicited and maintained the problem behaviour; for instance, forgetting the skills, techniques, and information taught during therapy; and decreased motivation5. Miller and Hester reviewed more than 500 alcoholism outcome studies and reported that more than 75% of subjects relapsed within 1 year of treatment1.
1. Review aims
Problem orientation must also be addressed in addition to these steps, and the efficacy of PST increases when problem orientation is addressed in addition to the other steps25,26. Early learning theories and later social cognitive and cognitive theories have had a significant influence on the formulation CBT for addictive behaviours. https://ecosoberhouse.com/ Theoretical constructs such as self-efficacy, appraisal, outcome expectancies related to addictions arising out these models have impacted treatment models considerably. Although withdrawal is usually viewed as a physiological process, recent theory emphasizes the importance of behavioral withdrawal processes [66].
SST is particularly useful when patients return to drinking due to social pressures. Patients may also require communication skills to deal with interpersonal conflicts. Cue exposure is another behavioural technique based on the classical conditioning theory and theories of cue reactivity and extinction12,13. The technique involves abstinence violation effect exposure to a hierarchy of cues, which signal craving and subsequently substance use. These are presented repeatedly without the previously learned pattern of drinking so as to lead to extinction. Despite work on cue reactivity, there is limited empirical support for the efficacy of cue exposure in recent literature14.
‘This Time Will Be Different’
The result of this lackluster planning is that we recognize future disturbances, yet do nothing to truly resolve them. If we feel stress, anger or depression, we do not find healthy ways of confronting these feelings. We instead view these emotions as justifications of the negative cognition experienced under AVE. Our hopelessness and our instinctive desire to give up were spot-on, or else we would be happy all the time. Giving up on sobriety should never feel like a justified response to vulnerability. As seen in Rajiv’s case illustration, internal (social anxiety, craving) and external cues (drinking partner, a favourite brand of drink) were identified as triggers for his craving.
- Conversely, people with ineffective coping responses will experience decreased self-efficacy, which, together with the expectation that alcohol use will have a positive effect (i.e., positive outcome expectancies), can result in an initial lapse.
- Each of the five stages that a person passes through are characterized as having specific behaviours and beliefs.
- A major development in this respect was the reformulation of Marlatt’s cognitive-behavioral relapse model to place greater emphasis on dynamic relapse processes [8].
- This stage is characterized by a tug of war between past habits and the desire to change.
- It was initially not favored by the medical community because it had side effects such as dizziness, fainting, irregular heartbeat, and priapism…
This type of policy is increasingly recognized as scientifically un-sound, given that continued substance use despite consequences is a hallmark symptom of the disease of addiction. Although it may be helpful for treatment centers to incorporate small penalties or rewards for specific client behaviors (for example, as part of a contingency management program), enforcing harsh consequences when clients do not maintain total abstinence will only exacerbate the AVE. The results reported in the RREP study indicate that the original relapse taxonomy of the RP model has only moderate inter-rater reliability at the highest level of specificity, although reliability of the more general categories (e.g., negative affect and social pressure) was better.
