Project MATCH evaluated the efficacy of three interventions–Motivational Enhancement Therapy (MET), Twelve-Step Facilitation (TSF), and Cognitive Behavioral Therapy (CBT)–for treating alcohol dependence. An increasing number of large-scale trials have allowed for statistically powerful evaluations of psychosocial interventions for alcohol use. Given that CBT is often used as a stand-alone treatment it may include additional components that are not always provided in RP. In addition, RP was more effective when delivered in conjunction with pharmacotherapy, when compared to wait-list (vs. active) comparison conditions, and when outcomes were assessed soon after treatment.
The RAP technique identifies negative thoughts and uses realistic, adaptive, and positive thoughts to restructure the negative thoughts. The RAP technique can restructure negative thoughts with realistic, adaptive, or positive thinking. Additionally, the support of a solid social network and professional help can play a pivotal role.
Katie Witkiewitz
- Based on the cognitive-behavioral model of relapse, RP was initially conceived as an outgrowth and augmentation of traditional behavioral approaches to studying and treating addictions.
- It’s full of self-blame and frames the lapse not as a simple mistake you can learn from, but as undeniable proof of some deep, personal failing.
- Broad implementation of a continuing care approach will require policy change at numerous levels, including the adoption of long-term patient-based and provider-based strategies and contingencies to optimize and sustain treatment outcomes 139,140.
- Relapse poses a fundamental barrier to the treatment of addictive behaviors by representing the modal outcome of behavior change efforts 1-3.
The findings also suggested that SE should ideally be measured after the cessation attempt, and that controlling for concurrent smoking is critical when examining SE in relation to prospective relapse . These findings support that higher distal risk can result in bifurcations (divergent patterns) of behavior as the level of proximal risk factors increase, consistent with predictions from nonlinear dynamic systems theory . However, these groups’ momentary ratings diverged significantly at high levels of urges and negative affect, such that those with low baseline SE had large drops in momentary SE in the face of increasingly challenging situations. When urge and negative affect were low, individuals with low, intermediate or high baseline SE were similar in their momentary SE ratings. One study reported increases in daily SE during abstinent intervals, perhaps indicating mounting confidence as treatment goals were maintained . Shiffman, Gwaltney and colleagues have used ecological momentary assessment (EMA; ) to examine temporal variations in SE in relation to smoking relapse.
There are mixed findings related to SUD symptom severity, with one study finding no differences by goal type (Adamson et al., 2010), and another reporting fewer SUD symptoms 2.5 years post treatment among those with abstinence goals, with no differences by five years post treatment (Berglund et al., 2019). This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020). Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches. 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).
Is abstinence a decision to avoid risk behaviors?
Self-efficacy (SE), the perceived ability to enact a given behavior in a specified context , is a principal determinant of health behavior according to social-cognitive theories. In contrast with the findings of Irvin and colleagues , Magill and Ray found that CBT was most effective for individuals with marijuana use disorders. Overall, the results were consistent with the review conducted by Irvin and colleagues, in that the authors concluded that 58% of individuals who received CBT had better outcomes than those in comparison conditions. Recently, Magill and Ray conducted a meta-analysis of 53 controlled trials of CBT for substance use disorders. Multiple matching hypotheses were proposed in evaluating differential treatment efficacy as a function of theoretically relevant client attributes.
The therapist also can use examples from the client’s own experience to dispel myths and encourage the client to consider both the immediate and the delayed consequences of drinking. Subsequently, the therapist can address each expectancy, using cognitive restructuring (which is discussed later in this section) and education about research findings. To accomplish this goal, the therapist first elicits the client’s positive expectations about alcohol’s effects using either standardized questionnaires or clinical interviews. This success can then motivate the client’s effort to change his or her pattern of alcohol use and increase the client’s confidence that he or she will be able to successfully master the skills needed to change. Therapists also can enhance self-efficacy by providing clients with feedback concerning their performance on other new tasks, even those that appear unrelated to alcohol use. Because an increase in self-efficacy is closely tied to achieving preset goals, successful mastery of these individual smaller tasks is the best strategy to enhance feelings of self-mastery.
Because the scope of this literature precludes an exhaustive review, we highlight select findings that are relevant to the main tenets of the RP model, in particular those that coincide with predictions of the reformulated model of relapse. There was limited evidence for the efficacy of other specific behavioral treatments, although there was general support for the efficacy of pharmacological treatments . 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. McCrady conducted a comprehensive review of 62 alcohol treatment outcome studies comprising 13 psychosocial approaches. RP was most effective for reducing alcohol and polysubstance use and less effective for tobacco and cocaine use–a contrast to Carroll’s finding of comparable efficacy across drug classes. The first comprehensive review of RP treatment outcome studies was Carroll’s descriptive account of 24 interventions focusing on substance use.
Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. 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). Perhaps the most notable gap identified by this review is the dearth of research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge. 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. The current review highlights multiple important directions for future research related to nonabstinence SUD treatment.
G Alan Marlatt, Ph.D.
The AVE in addiction is systemic, and some experts believe that too few treatment modalities identify both the mechanisms that lead to addictive disorders and the ones that keep them in place, even years after a client seems to have recovered. It’s an important part of any recovery program to address these preconceived notions of addiction and paint a more accurate portrait with the level of compassion, self-awareness, and support that is so essential to addiction recovery. While this may not completely make or break a diet or exercise commitment, it can wreak havoc on an individual’s commitment to sobriety if effective management strategies are not in place. Typically among those mechanisms are negative emotional states like shame, misunderstanding, and blame. It what is post-acute withdrawal syndrome paws arises when a person starts to feel that when a lapse occurs, it is indicative of a moral failure, loss of hope for continued recovery, or proof that recovery is ultimately not possible. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
Moderation analyses suggested that RP was consistently efficacious across treatment modalities (individual vs. group) and settings (inpatient vs. outpatient). 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 . The dynamic model further emphasizes the importance of nonlinear relationships and timing/sequencing of events.
Recent findings in support of RP model components
It is important to highlight that most of the studies cited above did not provide goal-matched treatment; thus, these outcomes generally reflect differences between individuals with abstinence vs. non-abstinence goals who participated in abstinence-based AUD treatment. Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015). Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. The study of implicit cognition and neurocognition in models of relapse would likely require integration of distal neurocognitive factors (e.g., baseline performance in cognitive tasks) in the context of treatment outcomes studies or EMA paradigms.
This may be at least in part because of the high prevalence of polysubstance use; indeed, multiple SUD diagnoses are the norm rather than the exception (Rounsaville, Petry, & Carroll, 2003), and about 1 in 8 individuals with SUD have co-occurring AUD and DUD (SAMHSA, 2019a). Psychologists have been studying nonabstinence psychotherapy for AUD since the 1970s, but this area of research is still considerably underdeveloped with regard to DUDs. However, additional research is needed to further examine for whom non-disordered drug use is possible, and how common recovery to non-problematic use is for individuals with lifetime DUDs. Other studies have also found subgroups of individuals who use heroin and cannabis who previously experienced dependence but returned to non-dependent use (Stea et al., 2015; Warburton et al., 2005). These data suggest that non-disordered drug use is possible, even for a substantial portion of individuals who use drugs such as heroin (about 45%). The most recent national survey assessing rates of illicit drug use and SUDs found that among individuals who report illicit drug use in the past year, approximately 15% meet criteria for one or more DUD (SAMHSA, 2019a).
Rather than labeling oneself as a failure, weak, or a loser, recognizing the effort and progress made before the lapse can provide a more balanced perspective. Understanding the AVE is crucial for individuals in recovery and those focused on healthier lifestyle choices. Taylor may think, “All that good work down the drain, I am never going to be able to keep this up for my life.” Like Jim, this may also trigger a negative mindset and a return to unhealthy eating and a lack of physical exercise.
4. Consequences of abstinence-only treatment
Thus, instead of focusing on a distant end goal (e.g., maintaining lifelong abstinence), the client is encouraged to set smaller, more manageable goals, such as coping with an upcoming high-risk situation or making it through the day without a lapse. 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. 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 RP model includes a variety of cognitive and behavioral approaches designed to target each step in the relapse process (see figure 2). Two cognitive mechanisms that contribute to the covert planning of a relapse episode—rationalization and denial—as well as apparently irrelevant decisions (AIDs) can help precipitate high-risk situations, which are the central determinants of a relapse. 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.
Overcoming the Abstinence Violation Effect:
These instructions reiterate the importance of stopping alcohol consumption and (safely) leaving the lapse-inducing situation. Despite precautions and preparations, many clients committed to abstinence will experience a lapse after initiating abstinence. In particular, considerable research has demonstrated that alcohol’s perceived positive effects on social behavior are often mediated by placebo effects, resulting from both expectations (i.e., “set”) and the environment (i.e., “setting”) in which drinking takes place (Marlatt and Rohsenow 1981). Positive expectancies regarding alcohol’s effects often are based on myths or placebo effects of alcohol (i.e., effects that occur because the drinker expects them to, not because alcohol causes the appropriate physiological changes). 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.
Identifying and Coping With High-Risk Situations
Overall, research on implicit cognitions stands to enhance understanding of dynamic relapse processes and could ultimately aid in predicting lapses during high-risk situations. In another recent study, researchers trained participants in attentional bias modification (ABM) during inpatient treatment for alcohol dependence and measured relapse over the course of three months post-treatment . As of 2009, meta-analyses had found no support for the efficacy of skills-based RP approaches in preventing relapse to smoking .
- After identifying those characteristics, the therapist works forward by analyzing the individual drinker’s response to these situations, as well as backward to examine the lifestyle factors that increase the drinker’s exposure to high-risk situations.
- That’s why adopting a more realistic, compassionate view of the recovery journey can be helpful, in addition to seeking the appropriate mental health support as needed.
- There was limited evidence for the efficacy of other specific behavioral treatments, although there was general support for the efficacy of pharmacological treatments .
- Previous reviews have recommended that treatment should be tailored to patient goals with consideration of SUD severity (Van Amsterdam & Van Den Brink, 2013; Witkiewitz & Alan Marlatt, 2006); however, some still argue that abstinence is favorable if patients are receptive (Mann, Aubin, & Witkiewitz, 2017).
The initial lapse—the single beer—isn’t the real disaster. Someone is several months into their recovery from alcohol use disorder and decides to catch a Red Sox game at Fenway. Once you understand these psychological forces, you can start to catch those negative thoughts before they gain momentum and steer you off course. Learning to spot and challenge these automatic negative thoughts is a cornerstone of effective therapy.
Expanding the continuum of substance use disorder treatment: Nonabstinence approaches
There is some evidence that patients with early-stage problem drinking are more successful at reducing alcohol consumption in treatment focused on moderation vs. abstinence (Sanchez-Craig et al., 1984), and that those with low-severity AUD have greater retention when working toward controlled drinking vs. abstinence goals (Haug, Eggli, & Schaub, 2017). Not surprisingly, these have generally found that individuals with abstinence goals are more likely to achieve abstinence outcomes (e.g., higher percent days abstinent) compared to those with controlled drinking goals (Adamson et al., 2010; Berglund et al., 2019; Bujarski, O’Malley, Lunny, & Ray, 2013; Meyer, Wapp, Strik, & Moggi, 2014). In addition to individuals with only nonabstinence goals, 20% of those seeking treatment for DUD simultaneously endorse a combination of abstinence and nonabstinence goals if given the option to select all that apply from a list of goal options (e.g., abstinence, stabilization, and safer use; McKeganey et al., 2004). There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment. Most U.S. treatment providers still utilize abstinence-focused approaches such as 12 Step Facilitation and AA/NA groups as a mandatory aspect of treatment (SAMHSA, 2017), and while providers demonstrate growing acceptance of controlled drinking, acceptance of nonabstinence outcomes for drug use remains very low (Rosenberg et al., 2020).