Self-monitoring, behavior assessment, analyses of relapse fantasies, and descriptions of past relapses can help identify a person’s high-risk situations. Specific intervention strategies (e.g., skills training, relapse rehearsal, education, and cognitive restructuring) and general strategies (e.g., relaxation training, stress management, efficacy-enhancing imagery, contracts to limit the extent of alcohol use, and reminder cards) can help reduce the impact of relapse determinants. Shaded boxes indicate steps in the relapse process and intervention measures that are specific to each client and his or her ability to cope with alcohol-related situations. White boxes indicate steps in the relapse process and intervention strategies that are related to the client’s general lifestyle and coping skills. High-risk situations are related to both the client’s general and specific coping abilities. Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically.
- In relapse “set ups,” however, it may be possible to identify a series of covert decisions or choices, each of them seemingly inconsequential, which in combination set the person up for situations with overwhelmingly high risk.
- During early recovery, clients need to develop coping and avoidance skills to reduce risk of recurrence to use.590 Clients should determine which coping and avoidance skills work best for them.
- Support for her work has been provided by the National Institute on Alcohol Abuse and Alcoholism and the University of Washington’s Alcohol and Drug Abuse Institute.
- Variations in insurance plans and reimbursement rates and limitations on certain services can potentially act as barriers to receiving payment or make the payment process labor intensive and difficult, affecting the delivery of care.
- This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future.
Relapse to smoking
A critical difference exists between the first violation of the abstinence goal (i.e., an initial lapse) and a return to uncontrolled drinking or abandonment of the abstinence goal (i.e., a full-blown relapse). Although research with various addictive behaviors has indicated that a lapse greatly increases the risk of eventual relapse, the progression from lapse to relapse is not inevitable. Lindsey Rodriguez is a third-year doctoral student in the Social Psychology Program at the University of Houston, USA. Her long-term research interests include the development of a comprehensive understanding of how problematic alcohol use and interpersonal relationship processes interact to influence various physical, emotional, and relational outcomes for individuals and their relationship partners. The Abstinence Violation Effect is a concept originally introduced by psychologist Alan Marlatt in the context of treating substance abuse. It stems from the belief that individuals who establish strict rules of abstinence may be more vulnerable to relapse when faced with a violation of those rules.
2. Controlled drinking
- Regarding SUD treatment, there has been a significant increase in availability of medication for opioid use disorder, especially buprenorphine, over the past two decades (opioid agonist therapies including buprenorphine are often placed under the “umbrella” of harm reduction treatments; Alderks, 2013).
- 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.
- Overall, the Abstinence Violation Effect is a complex phenomenon influenced by a combination of cognitive, emotional, and biological factors.
- As a result, the AVE can trigger a cycle of further relapse and continued substance use, since people may turn to substances as a way to cope with the emotional distress.
- Even when alcohol’s perceived positive effects are based on actual drug effects, often only the immediate effects are positive (e.g., euphoria), whereas the delayed effects are negative (e.g., sleepiness), particularly at higher alcohol doses.
- 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.
The goal of the specific intervention strategies—identifying and coping with high-risk situations, enhancing self-efficacy, eliminating myths and placebo effects, lapse management, and cognitive restructuring—is to teach clients to anticipate the possibility of relapse and to recognize and cope with high-risk situations. These strategies also focus on enhancing the client’s awareness of cognitive, emotional, and behavioral reactions in order to prevent a lapse from escalating into a relapse. The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process. For example, the therapist can use the metaphor of behavior change as a journey that includes both easy and difficult stretches of highway and for which various “road signs” (e.g., “warning signals”) are available to provide guidance. According to this metaphor, learning to anticipate and plan for high-risk situations during recovery from alcoholism is equivalent to having a good road map, a well-equipped tool box, a full tank of gas, and a spare tire in good condition for the journey.
An introduction to behavioral addictions
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). Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001). 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). Upon breaking the self-imposed rule, individuals often experience negative emotions such as guilt, shame, disappointment, and a sense of failure. Cognitive processes may include self-blame, rumination, and heightened self-awareness.
- Chapters 3 and 4 further discuss how to incorporate the concepts in this chapter into practice.
- Listing the outcome expectancies for the substance use and resolved behavior (e.g., reduced use of substances).
Some tools may be more appropriate for use in certain settings or with specific populations. Below is a description of several of these tools, including information about how to access them and limitations. The chapter also looks at ways that payment systems can affect the delivery of care for counselors in healthcare and behavioral health service systems. Introducing an approach to promoting a healthy life for clients who are beyond early recovery.
- Connections to other services and supports for clients in recovery, such as housing resources and child care.
- Unfortunately, there has been little empirical research evaluating this approach among individuals with DUD; evidence of effectiveness comes primarily from observational research.
- The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process.
This false sense of control can often lead us to put ourselves in highly tempting situations, such as going to our favorite bar, mistakenly thinking the urge to drink is now behind us. However, the temptation from a familiar setting, coupled with the thought “one drink won’t hurt,” makes resisting the drink extra hard. Find valued directions for your life – Developing a balanced life with healthy indulgences and activities that can substitute for unhealthy and undesirable addictive behaviors is a good start. But in the long run we each need to decide what is really important to be doing and commit ourselves to acting on those values, taking us each in our own valued life directions. Carry, review and update a Cost-Benefit Analysis or list of reasons for sticking to your change plan. Through these tools, a counselor can explore a client’s internal and external reasons for entering and staying in treatment and recovery.
Understand structural competency and inequities that contribute to and perpetuate health disparities. Understand how chronic stress, adverse childhood experiences, and discrimination can contribute to trauma. Prioritize self-care activities that promote physical, emotional, and mental well-being. Though it may be tempting to isolate yourself, do your best to surround yourself with people who understand your struggles and can offer a sense of connection. Reach out to friends, family, or support groups for encouragement during difficult times. Instead of sinking into self-blame, reframe setbacks as temporary obstacles rather than insurmountable failures, and replace blame with self-compassion and understanding.
These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006). Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008). Important features common to these groups include low program barriers (e.g., drop-in groups, few rules) and inclusiveness of clients with difficult presentations (Little & Franskoviak, 2010). Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019). These individuals are considered good candidates for harm reduction interventions because of the severity of substance-related negative consequences, and thus the urgency of reducing these harms. Indeed, this argument has been central to advocacy around harm reduction interventions for people who inject drugs, such as SSPs and safe injection facilities (Barry et al., 2019; Kulikowski & Linder, 2018).
Cognitive Behavioral Treatments for Substance Use Disorders
Additionally, in the United Kingdom, where there is greater access to nonabstinence treatment (Rosenberg & Melville, 2005; Rosenberg abstinence violation effect & Phillips, 2003), the proportion of individuals with opioid use disorder engaged in treatment is more than twice that of the U.S. (60% vs. 28%; Burkinshaw et al., 2017). Cognitive restructuring, or reframing, is used throughout the RP treatment process to assist clients in modifying their attributions for and perceptions of the relapse process. In particular, cognitive restructuring is a critical component of interventions to lessen the abstinence violation effect. Thus, clients are taught to reframe their perception of lapses—to view them not as failures or indicators of a lack of willpower but as mistakes or errors in learning that signal the need for increased planning to cope more effectively in similar situations in the future. This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future.
For example, overeaters may have an AVE when they express to themselves, “one slice of cheesecake is a lapse, so I may as well go all-out, and have the rest of the cheesecake.” That is, since they have violated the rule of abstinence, they “may as well” get the most out of the lapse. Treatment in this component involves describing the AVE, and working with the client to learn alternative coping skills for when a lapse occurs, such that a relapse is prevented. The AVE occurs when a client is in a high-risk situation and views the potential lapse as so severe, that he or she may as well relapse. The treatment is not lapse prevention; lapses are to be expected, planned for, and taken as opportunities for the client to demonstrate learning. Most often, relapse tends to be construed as a return to pretreatment levels of occurrence of the targeted behavior.