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In terms of clinical applications of RP, the most notable development in the last decade has been the emergence and increasing application of Mindfulness-Based Relapse Prevention (MBRP) for addictive behaviors 112,113. Given supportive data for the efficacy of mindfulness-based interventions in other behavioral domains, especially in prevention of relapse of major depression 114, there is increasing interest in MBRP for addictive behaviors. The merger of mindfulness and cognitive-behavioral approaches is appealing from both theoretical and practical standpoints 115 and MBRP is a potentially effective and cost-efficient adjunct to CBT-based treatments. In contrast to the cognitive restructuring strategies typical of traditional CBT, MBRP stresses nonjudgmental attention to thoughts or urges. From this standpoint, urges/cravings are labeled as transient events that need not be acted upon reflexively. This approach is exemplified by the “urge surfing” technique 115, whereby clients are taught to view urges as analogous to an ocean wave that rises, crests, and diminishes.
4.2. Negative impact on treatment retention and completion
He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). Nevertheless, the study provides relatively good support for other aspects of the RP model.
Awareness of SUD Treatment Barriers and Inequities
Be familiar with problematic behavioral issues other than substance use, such as problematic gambling and sexual behaviors. Outlining some of the benefits that clients receive when counselors participate in recovery-oriented systems of care. Introducing an approach to promoting a healthy life for clients who are beyond early recovery.
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. In so doing, the client learns that rather than building interminably until they become overwhelming, urges and cravings peak and subside rather quickly if they are not acted on. The client is taught not to struggle against the wave or give in to it, thereby being “swept away” or “drowned” by the sensation, but to imagine “riding the wave” on a surf board. Like the conceptualization of urges and cravings as the result of an external stimulus, this imagery fosters detachment from the urges and cravings and reinforces the temporary and external nature of these phenomena.
Reassessing the Client’s Treatment Plan or Recovery Plan and Support Services
Understand the importance of empathy, authenticity, warmth, and unconditional positive regard. This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission. 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. Feelings of guilt, shame, and self-blame may lead people to question their ability to overcome addiction and exacerbate underlying issues of low self-esteem.
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. One of the biggest problems with the AVE is that periods of abstinence from opioids increase a person’s risk of overdose and today’s heroin is often tainted with super-potent fentanyl analogs. Because of heightened overdose risk, treatment providers can offer naloxone and overdose prevention training to all clients, even those whose “drug of choice” does not include opioids. Rather than communicating pessimism about a client’s potential to recover, these overdose prevention measures acknowledge the existence of the AVE and communicate that safety is more important than maintaining perfect abstinence.
Develop Coping Skills
Lastly, treatment staff should help you to learn how to recognize the signs of an impending lapse or relapse so that you can ask for help before it happens. Gordon as part of their cognitive-behavioral model of relapse prevention, and it is used particularly in the context of substance use disorders. Although abstinence from all substances is an excellent recovery goal for some, research consistently shows that many people who resolve alcohol and drug problems follow a path of moderation. Furthermore, the use of amphetamine addiction treatment FDA-approved medications (which not all clients will view as “abstinence”) has been shown to produce the best health and recovery outcomes for people with opioid use disorders. Although there may be practical reasons for your client to choose abstinence as a goal (e.g., being on probation), it is inaccurate to characterize abstinence-based recovery as the only path to wellness.
Strengths-Based, Person-Centered Intake Approaches
One of the key distinctions between CBT and RP in the field is that the term “CBT” is more often used to describe stand-alone primary treatments that are based on the cognitive-behavioral model, whereas RP is more often used to describe aftercare treatment. Given that CBT is often used as a stand-alone treatment it may include additional components that are not always provided in RP. For example, the CBT intervention developed in Project MATCH 18 (described below) equated to RP with respect to the core sessions, but it also included elective sessions that are not typically a focus in RP (e.g., job-seeking skills, family involvement). Perhaps the most notable gap identified by this review is the dearth of research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. Given low treatment engagement and high rates of health-related harms among individuals who use drugs, combined with evidence of nonabstinence goals among a substantial portion of treatment-seekers, testing nonabstinence treatment for drug use is a clear next step for the field.
- Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment.
- RP modules are standard to virtually all psychosocial interventions for substance use 17 and an increasing number of self-help manuals are available to assist both therapists and clients.
- More recent versions of RP have included mindfulness-based techniques (Bowen, Chawla, & Marlatt, 2010; Witkiewitz et al., 2014).
- 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.
They found that their controlled drinking intervention produced heroin addiction 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). Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process. These covert antecedents include lifestyle factors, such as overall stress level, as well as cognitive factors that may serve to “set up” a relapse, such as rationalization, denial, and a desire for immediate gratification (i.e., urges and cravings) (see figure 2). These factors can increase a person’s vulnerability to relapse both by increasing his or her exposure to high-risk situations and by decreasing motivation to resist drinking in high-risk situations.
- Consider that affirming clients can have many useful impacts, such as strengthening clients’ engagement in therapy and sense of agency.
- Our addiction treatment network offers comprehensive care for alcohol addiction, opioid addiction, and all other forms of drug addiction.
- If the person succumbs to the urge and violates their self-imposed rule, the Abstinence Violation Effect is activated.
- RP strategies can now be disseminated using simple but effective methods; for instance, mail-delivered RP booklets are shown to reduce smoking relapse 135,136.
- 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.
It was written based on peer-reviewed medical research, reviewed by medical and/or clinical experts, and provides objective information on the disease and treatment of addiction (substance use disorders). Triggers include cravings, problematic thought patterns, and external cues or situations, all of which can contribute to increased self-efficacy (a sense of personal confidence, identity, and control) when properly managed. 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. It’s important to establish that a one-time lapse in a person’s recovery from drugs or alcohol is not considered a full blown relapse. Addressing the AVE in the context of addiction treatment involves helping people develop healthier coping strategies and challenging negative beliefs that contribute to addiction. 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.
This reframing of lapse episodes can help decrease the clients’ tendency to view lapses as the result of a personal failing or moral weakness and remove the self-fulfilling prophecy that a lapse will inevitably lead to relapse. Another approach to preventing relapse and promoting behavioral change is the use of efficacy-enhancement procedures—that is, strategies designed to increase a client’s sense of mastery and of being able to handle difficult situations without lapsing. One of the most important efficacy-enhancing strategies employed in RP is the emphasis on collaboration between the client and therapist instead of a more typical “top down” doctor-patient relationship. In the RP model, the client is encouraged to adopt the role of colleague and to become an objective observer of his or her own behavior. In developing a sense of objectivity, the client is better able to view his or her alcohol use as an addictive behavior and may be more able to accept greater responsibility both for the drinking behavior and for the effort to change that behavior.
The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge. For example, despite being widely cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown.
As a result, it’s important that those in recovery internalize this difference and establish the proper mental and behavioral framework to avoid relapse and continue moving forward even if lapses occur. It includes thoughts and feelings like shame, guilt, anger, failure, depression, and recklessness as well as a return to addictive behaviors and drug use. By providing comprehensive care, our treatment programs create a supportive environment in which our clients can build a solid foundation for lasting sobriety. Fortunately, professional treatment for addiction can improve outcomes for people experiencing the Abstinence Violation Effect.
