Proximal risks actualize, or complete, the distal predispositions and include transient lapse precipitants (e.g. stressful situations) and dynamic individual characteristics (e.g. negative affect, self-efficacy). Combinations of precipitating and predisposing risk factors are innumerable for any particular individual and may create a complex system in which the probability of relapse is greatly increased. 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.

• 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).
• 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.
• Based on operant conditioning, the motivation to use in a particular situation is based on the expected positive or negative reinforcement value of a specific outcome in that situation5.
• The expected drug effects do not necessarily correspond with the actual effects experienced after consumption.
• 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.
• Marlatt (1985) describes an abstinence violation effect (AVE) that leads people to respond to any return to drug or alcohol use after a period of abstinence with despair and a sense of failure.

When abstinence is violated, individuals typically also have an emotional response consisting of guilt, shame, hopelessness, loss of control, and/or a sense of failure; they may use drugs or alcohol in an attempt to cope with the negative feelings that resulted from their abstinence violation. A person may experience a particularly stressful emotional event in their lives and may turn to alcohol and/or drugs to cope with these negative emotions. An abstinence violation can also occur in individuals with low self-efficacy, since they do not feel very confident in their ability to carry out their goal of abstinence. 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.

Katie Witkiewitz

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, https://ecosoberhouse.com/ by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). The current review highlights multiple important directions for future research related to nonabstinence SUD treatment.

Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD). In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders.

3. Summary of the state of the literature

Amanda completed her Doctor of Nursing Practice and Post Masters Certification in Psychiatry at Florida Atlantic University. She is a current member of the Golden Key International Honor Society and the Delta Epsilon Iota Honor Society. The first thing we must do after a relapse is check our thinking abstinence violation effect for signs of irrationality. Sometimes we must be hard on ourselves, but we must never view ourselves through a lens of hatred and self-loathing. Marlatt notes that one of the most important aspects of handling abstinence violation effect is the need to develop our coping mechanisms.

Our addiction treatment network offers comprehensive care for alcohol addiction, opioid addiction, and all other forms of drug addiction. Our treatment options include detox, inpatient treatment, outpatient treatment, medication-assisted treatment options, and more. 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. For instance, a person recovering from alcohol use disorder who has a drink may feel a sense of confusion or a lack of control and they may make unhealthy attributions or rationalizations to try to define and understand what they’re doing.

1. Review aims

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). It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). The onset of bulimia nervosa is often preceded by extended periods of recurrent dieting occurring in the context of other psychosocial stressors. Other behavioral characteristics that have been identified in patients with bulimia nervosa include impulsivity and mood lability, and it is possible that these traits may contribute to the onset or perpetuation of symptoms in this disorder.

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). Teasdale and colleagues (1995) have proposed a model of depressive relapse which attempts to explain the process of relapse in depression and also the mechanisms by which cognitive therapy achieves its prophylactic effects in the treatment of depression. It hypothesizes that following recovery, mild states of depression can reactivate depressogenic cycles of cognitive processing similar to those found during a major depressive episode.

Additionally, no studies identified in this review compared reasons for not completing treatment between abstinence-focused and nonabstinence treatment. Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992). For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986).

• Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review.
• Another factor that may occur is the Problem of Immediate Gratification where the client settles for shorter positive outcomes and does not consider larger long term adverse consequences when they lapse.
• 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.
• Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically.