Abstinence Violation Effect AVE What It Is & Relapse Prevention Strategies

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. Most notably, we provide a recent update of the RP literature by focusing primarily on studies conducted within the last decade. We also provide updated reviews of research areas that have seen notable growth in the last abstinence violation effect few years; in particular, the application of advanced statistical modeling techniques to large treatment outcome datasets and the development of mindfulness-based relapse prevention. Additionally, we review the nascent but rapidly growing literature on genetic predictors of relapse following substance use interventions. Despite various treatment programmes for substance use disorders, helping individuals remain abstinent remains a clinical challenge.

4. Consequences of abstinence-only treatment

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]. The dynamic model of relapse assumes that relapse can take the form of sudden and unexpected returns to the target behavior. 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 [32]. While maintaining its footing in cognitive-behavioral theory, the revised model also draws from nonlinear dynamical systems theory (NDST) and catastrophe theory, both approaches for understanding the operation of complex systems [10,33]. Detailed discussions of relapse in relation to NDST and catastrophe theory are available elsewhere [10,31,34].

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• 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).
• In general, the longer a person has not used a substance, the lower their desire to use.
• Whereas most theories presume linear relationships among constructs, the reformulated model (Figure ​(Figure2)2) views relapse as a complex, nonlinear process in which various factors act jointly and interactively to affect relapse timing and severity.
• Those who drink the most tend to have higher expectations regarding the positive effects of alcohol9.

It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment. To date there has been limited research on retention rates in nonabstinence treatment. This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention. 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. They found that their controlled drinking intervention produced significantly better outcomes compared to usual treatment, and that about a quarter of the individuals in this condition maintained controlled drinking for one year post treatment (Sobell & Sobell, 1973).

Systematic reviews and large-scale treatment outcome studies

In our era of heightened overdose risk, the AVE is more likely than ever to have tragic effects. In RP client and therapist are equal partners and the client is encouraged to actively contribute solutions for the problem. Client is taught that overcoming the problem behaviour is not about will power rather it has to do with skills acquisition. Another technique is that the road to abstinence is broken down to smaller achievable targets so that client can easily master the task enhancing self-efficacy. Also, therapists can provide positive feedback of achievements that the client has been able to make in other facets of life6. Interpersonal relationships and support systems are highly influenced by intrapersonal processes such as emotion, coping, and expectancies18.

Continued empirical evaluation of the RP model

• Most studies of relapse rely on statistical methods that assume continuous linear relationships, but these methods may be inadequate for studying a behavior characterized by discontinuity and abrupt changes [33].
• 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 [32].
• About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b).
• For instance, twelve-month relapse rates following alcohol or tobacco cessation attempts generally range from 80-95% [1,4] and evidence suggests comparable relapse trajectories across various classes of substance use [1,5,6].
• Such feelings sabotage recovery in other ways as well—negative feelings are disquieting and are often what drive people to seek relief or escape in substances to begin with.
• For example, one could imagine a situation whereby a client who is relatively committed to abstinence from alcohol encounters a neighbor who invites the client into his home for a drink.
• These are presented repeatedly without the previously learned pattern of drinking so as to lead to extinction.

However, when Ss made more intense internal, global, and uncontrollable causal attributions for a binge, a subsequent binge followed significantly sooner. Within-subject variations in AVEs across binges prospectively predicted within-subject variations in the speed with which another binge followed. Analyses suggested that cognitive states (e.g., AVE and guilt) evoked by particular events were better predictors of how quickly binging repeats than were stable differences in attributional style. 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.

AVE in the Context of the Relapse Process

Emerging topics in relapse and relapse prevention

• In another study examining the behavioral intervention arm of the COMBINE study [128], individuals who received a skills training module focused on coping with craving and urges had significantly better drinking outcomes via decreases in negative mood and craving that occurred after receiving the module.
• However, many of the treatments ranked in the top 10 (including brief interventions, social skills training, community reinforcement, behavior contracting, behavioral marital therapy, and self-monitoring) incorporate RP components.
• Cognitive restructuring techniques are employed to modifying beliefs related to perceived self-efficacy and substance related outcome expectancies (“such as drinking makes me more assertive”, “there is no point in trying to be abstinent I can’t do it”).
• It reflects the difficulty of resisting a return to substance use in response to what may be intense cravings but before new coping strategies have been learned and new routines have been established.
• Gradually he began to drink before meetings or interactions (maladaptive coping and negative reinforcement).

Planning a cognitive behavioural programme