Based on activation patterns in several cortical regions they were able to correctly identify 17 of 18 participants who relapsed and 20 of 22 who did not. Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., [133]) and there are increasing efforts to use imaging approaches to predict relapse [134]. While the overall number of studies examining neural correlates of relapse remains small at present, the coming years will undoubtedly see a significant escalation in the number of studies using fMRI to predict response to psychosocial and pharmacological treatments. In this context, a critical question will concern the predictive and clinical utility of brain-based measures with respect to predicting treatment outcome. Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995).
Cognitive Behavioural model of relapse
In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). 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. As the foregoing review suggests, validation of the reformulated RP model will likely progress slowly at first because researchers are only beginning to evaluate dynamic relapse processes. Currently, the dynamic model can be viewed as a hypothetical, theory-driven framework that awaits empirical evaluation.
1. Nonabstinence psychosocial treatment models
In viewing relapse as a common (albeit undesirable) event, emphasizing contextual antecedents over internal causes, and distinguishing relapse from treatment failure, the RP model introduced a comprehensive, flexible and optimistic alternative to traditional approaches. Specific intervention strategies include helping the person identify and cope with high-risk situations, eliminating myths regarding a drug’s effects, managing lapses, and addressing misperceptions about the relapse process. Other more general strategies include helping the person develop positive addictions and employing stimulus-control and urge-management techniques. The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.
What does cue-reactivity have to offer clinical research?
Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020). Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches. Indeed, a prominent harm reduction psychotherapist and researcher, Rothschild, argues that the harm reduction approach represents a “third wave of addiction treatment” which follows, and is replacing, the moral and disease models (Rothschild, 2015a). Ultimately, individuals who are struggling with behavior change often find that making the initial change is not as difficult as maintaining behavior changes over time. Many therapies (both behavioral and pharmacological) have been developed to help individuals cease or reduce addictive behaviors and it is critical to refine strategies for helping individuals maintain treatment goals. As noted by McLellan [138] and others [124], it is imperative that policy makers support adoption of treatments that incorporate a continuing care approach, such that addictions treatment is considered from a chronic (rather than acute) care perspective.
Trajectories of abstinence-induced internet gaming withdrawal symptoms: A prospective pilot study
Although some high-risk situations appear nearly universal across addictive behaviors (e.g., negative affect; [25]), high-risk situations are likely to vary across behaviors, across individuals, and within the same individual over time [10]. 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. 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.
Abstinence tasks also require practicing self-control, which might increase capacity for self-control strength (Muraven & Baumeister, 2000), and successful abstinence attempts might increase abstinence/avoidance self-efficacy (e.g., Hodgins, Peden, & Makarchuk, 2004; Kraus, Rosenberg, Martino, Nich, & Potenza, 2017). All in all, short-term abstinence as a temporary intervention need not be conflated with long-term abstinence as an indefinite treatment goal and can be regarded as a separate intervention. For gambling disorder, controlled gambling is increasingly being advocated as a viable goal alongside traditional abstinence treatment goals (e.g., Stea, Hodgins, & Fung, 2015).
Psychology of Sport and Exercise
- Because detailed accounts of the model’s historical background and theoretical underpinnings have been published elsewhere (e.g., [16,22,23]), we limit the current discussion to a concise review of the model’s history, core concepts and clinical applications.
- The studies reviewed focus primarily on alcohol and tobacco cessation, however, it should be noted that RP principles have been applied to an increasing range of addictive behaviors [10,11].
- Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., [133]) and there are increasing efforts to use imaging approaches to predict relapse [134].
- Additionally, the intervention had no effect on subjective measures of craving, suggesting the possibility that intervention effects may have been specific to implicit cognitive processes [62].
One study [46] reported increases in daily SE during abstinent intervals, perhaps indicating mounting confidence as treatment goals were maintained [45]. An important part of RP is the notion of Abstinence violation effect (AVE), which refers to an individual’s response to a relapse where often the client blames himself/herself, with a subsequent loss of perceived control4. It occurs when the client perceives no intermediary step between a lapse and relapse i.e. since they have violated the rule of abstinence, “they may get most out” of the lapse5. People who attribute the lapse to their own personal failure are likely to experience guilt and negative emotions that can, in turn, lead to increased drinking as a further attempt to avoid or escape the feelings of guilt or failure7. Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success.
Journal of Behavioral Addictions
- First, withdrawal symptoms refer to unpleasant emotional states that are experienced when a behavior is abruptly ceased.
- As the foregoing review suggests, validation of the reformulated RP model will likely progress slowly at first because researchers are only beginning to evaluate dynamic relapse processes.
- Relapse prevention (RP) is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours4.
- 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].
In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008). Together, this suggests a promising degree of alignment between goal selection and probability of success, abstinence violation effect and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation. Initial evidence suggests that implicit measures of expectancies are correlated with relapse outcomes, as demonstrated in one study of heroin users [61].
- Relative to a control condition, ABM resulted in significantly improved ability to disengage from alcohol-related stimuli during attentional bias tasks.
- Some researchers propose that the self-control required to maintain behavior change strains motivational resources, and that this “fatigue” can undermine subsequent self-control efforts [78].
- Overall, the Abstinence Violation Effect is a complex phenomenon influenced by a combination of cognitive, emotional, and biological factors.
- The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004).
- It includes thoughts and feelings like shame, guilt, anger, failure, depression, and recklessness as well as a return to addictive behaviors and drug use.
- It is inevitable that the next decade will see exponential growth in this area, including greater use of genome-wide analyses of treatment response [109] and efforts to evaluate the clinical utility and cost effectiveness of tailoring treatments based on pharmacogenetics.
Further, there was strong support that increases in self-efficacy following drink-refusal skills training was the primary mechanism of change. 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. Nonetheless, attempted periods of short-term abstinence, while plausibly having benefits, may also have adverse or counterproductive consequences. For example, individuals who attempt quitting a behavior ‘cold turkey’ may lack effective coping skills in dealing with withdrawal symptoms and engage in harmful behavior as a result. A recent report indicated that gamers might engage in compensatory behaviors (e.g., searching for gaming-related pornography) during periods of ‘forced abstinence’ from gaming (Castro-Calvo, Ballester-Arnal, Potenza, King, & Billieux, 2018).
- Dr Neighbors has authored more than 120 peer-reviewed scholarly publications, the majority of which have focused on addictive behaviors among young adults.
- Beyond its use as a methodological tool, the possibility of abstinence also being a potentially useful intervention for problematic behaviors needs to be given due consideration within behavioral addiction treatment research.
- 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.
Addictive Behaviors
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). Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. Upon breaking the self-imposed rule, individuals often experience negative emotions such as guilt, shame, disappointment, and a sense of failure.