Individuals who experience an intense AVE go through a motivation crisis that affects their commitment to abstinence goals30,31. Additionally, this model acknowledges the contributions of social cognitive constructs to the maintenance of substance use or addictive behaviour and relapse1. Future research with a data set that includes multiple measures of risk factors over multiple days can help in validating the dynamic model of relapse. Elucidating the “active ingredients” of CBT treatments remains an important and challenging goal, Also, integration of neurocognitive parameters in relapse models as well as neural (such as functional circuitry involved in relapse) and genetic markers of relapse will be major challenges moving ahead19.
- We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches.
- The rationale and methods of the COMBINE study have been described in detail elsewhere (aCOMBINE Study Research Group, 2003a, COMBINE Study Research Group, 2003b).
- Social skills training (SST) incorporates a wide variety of interpersonal dimensions15.
- Marlatt, based on clinical data, describes categories of relapse determinants which help in developing a detailed taxonomy of high-risk situations.
- Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence.
Here the assessment and management of both the intrapersonal and interpersonal determinants of relapse are undertaken. This article discusses the concepts of relapse prevention, relapse determinants and the specific interventional strategies. The revised dynamic model of relapse also takes into account the timing and interrelatedness of risk factors, as well as provides for feedback between lower- and higher-level components of the model. For example, based on the dynamic model it is hypothesized that changes in one risk factor (e.g. negative affect) influences changes in drinking behavior and that changes in drinking also influences changes in the risk factors.
Cognitive Behavioral Treatments for Substance Use Disorders
Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021).
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”). Despite the empirical support for many components of the cognitive-behavioral model, there have also been many criticisms of the model for being too static and abstinence violation effect definition hierarchical. In response to these criticisms, Witkiewitz and Marlatt proposed a revision of the cognitive-behavioral model of relapse that incorporated both static and dynamic factors that are believed to be influential in the relapse process. The “dynamic model of relapse” builds on several previous studies of relapse risk factors by incorporating the characterization of distal and proximal risk factors.
III.D. Abstinence Violation Effect
” I refer to this as a case of the “screw-it’s” (although harsher language is not uncommon!); a sense of giving up. Several behavioural strategies are reported to be effective in the management of factors leading to addiction or substance use, such as anxiety, craving, skill deficits2,7. The first step in planning a cognitive behavioural treatment program is to carry out a functional analysis to identify maintaining antecedents and set treatments targets, select interventions. There is a large literature on self-efficacy and its predictive relation to relapse or the maintenance of abstinence. When someone abuses a substance for a long time, they will have a higher tolerance for its effects.
Problem solving therapy (PST) is a cognitive behavioural program that addresses interpersonal problems and other problem situations that may trigger stress and thereby increase probability of the addictive behaviour. The four key elements of PST are problem identification, generating alternatives, decision making, implementing solutions, reviewing outcomes and revising steps where needed. 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. The Trans theoretical model (TTM), describes stages of behavioral change, processes of change and the decisional balance and self-efficacy which are believed to be intertwined to determine an individual’s behaviour11. Shiffman and colleagues describe stress coping where substance use is viewed as a coping response to life stress that can function to reduce negative affect or increase positive affect. They assume a distinction between stress coping skills, which are responses intended to deal with general life stress, and temptation coping skills, which are coping responses specific to situations in which there are temptations for substance which could contribute to relapse13.
Cognitive behaviour therapy is a structured, time limited, psychological intervention that has is empirically supported across a wide variety of psychological disorders. CBT for addictive behaviours can be traced back to the application of learning theories in understanding addiction and subsequently to social cognitive theories. The focus of CBT is manifold and the focus is on targeting maintaining factors of addictive behaviours and preventing relapse. Relapse prevention programmes are based on social cognitive and cognitive behavioural principles. More recent developments in the area of managing addictions include third wave behaviour therapies.
This approach would be applicable to recovered depressed patients and would serve as a means of preventing relapse. Teasdale and colleagues provide a description of this training which teaches generic psychological, self-control skills and can be used on a continuing basis to maintain skills after initial training. While no data on the effectiveness of this approach in preventing relapse exist to date, this appears to be a useful and stimulating conceptualization of relapse and relapse prevention that deserves further attention.
The second, Combined Behavioral Intervention (CBI), consisted of up to twenty, 50-minute sessions which integrated aspects of cognitive behavioral therapy, 12-step facilitation, motivational interviewing, and involvement of support systems. A more recent development in the area of managing addictive behaviours is the application of the construct of mindfulness to managing experiences related to craving, negative affect and other emotional states that are believed to impact the process of relapse34. In CBT for addictive behaviours cognitive strategies are supported by several behavioural strategies such as coping skills. Relapse is a process in which a newly abstinent patient experiences a sense of perceived control over his/her behaviour up to a point at which there is a high risk situation and for which the person may not have adequate skills or a sense of self-efficacy. Self- efficacy increases and the probability of relapsing decreases when one is able to cope with this situation31. Training in assertiveness involves two steps, a minimal effective response and escalation.
Lapses are, however, a major risk factor for relapse as well as overdose and other potential social, personal, and legal consequences of drug or alcohol abuse. The abstinence violation effect (AVE) describes the tendency of people recovering from addiction to spiral out of control when they experience even a minor relapse. Instead of continuing with recovery, AVE refers to relapsing heavily after a single violation. Social skills training (SST) incorporates a wide variety of interpersonal dimensions15.