Alan Marlatt is a professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington. He has received continuous funding for his research from a variety of agencies including the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the Alcoholic Beverage Medical Research Foundation, and the Robert Wood Johnson Foundation. For example, I am a failure (labeling) and will never be successful with abstaining from drinking, eating healthier, or exercising (jumping to conclusions).
The selective adaptation of the alcoholics anonymous program by gamblers anonymous
Nonabstinence goals have become more widely accepted in SUD treatment in much of Europe, and evidence suggests that acceptance of controlled drinking has increased among U.S. treatment providers since the 1980s and 1990s (Rosenberg, Grant, & Davis, 2020). 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). A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs.
2. Controlled drinking
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). To date, however, there has been little empirical research directly testing this hypothesis. Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment.
Historical context of nonabstinence approaches
Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving abstinence violation effect moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008). Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013). 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, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation.
- Unfortunately, a single lapse can cause you to fall into a full relapse because of something called the abstinence violation effect (AVE).
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- This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment.
- These individuals also experience negative emotions similar to those experienced by the abstinence violators and may also drink more to cope with these negative emotions.
The limit violation effect describes what happens when these individuals fail to restrict their use within their predetermined limits and the subsequent effects of this failure. These individuals also experience negative emotions similar to those experienced by the abstinence violators and may also drink more to cope with these negative emotions. Cognitive dissonance also arises, and attributions are then made for the violation. In a similar fashion, the nature of these attributions determines whether the violation will lead to full-blown relapse.
Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013). Additionally, no studies identified in this review compared reasons for not completing treatment between abstinence-focused and nonabstinence treatment. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment.
The RP model views relapse not as a failure, but as part of the recovery process and an opportunity for learning. 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. By undermining confidence, these negative thoughts and feelings increase the likelihood that an isolated “lapse” will lead to a full-blown relapse. If, however, individuals view lapses as temporary setbacks or errors in the process of learning a new skill, they can renew their efforts to remain abstinent. 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.
- The abstinence violation effect can be defined as a tendency to continue to engage in a prohibited behavior following the violation of a personal goal to abstain.
- For example, an individual who has successfully abstained from alcohol, after having one beer, may drink an entire case of beer, thinking that since he or she has “fallen off the wagon,” he or she might as well go the whole way.
- In addition to shaping mainstream addiction treatment, the abstinence-only 12-Step model also had an indelible effect on the field of SUD treatment research.
- When abstinence violation occurs, individuals typically enter a state of cognitive dissonance, defined as an aversive experience resulting from the discrepancy created by having two or more simultaneous and inconsistent cognitions.
Indeed, about 95% of people with SUD say they do not need SUD treatment (SAMHSA, 2019a). Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a). Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization.
Prolonged use of a substance causes a level or physical tolerance but after a period of abstinence that tolerance declines substantially. This is why many individuals who have been abstinent (or “clean”) for awhile accidentally overdose by starting to use again at the same level of use they were at before their abstinence period. Equally bad can be the sense of failure and shame that a formerly “clean” individual can experience following a return to substance use. In psychotherapy, an abstinence violation effect refers to the negative cognitive and affective reactions one experiences after returning to substance use after a period of abstinence.
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. Understanding the AVE is crucial for individuals in recovery and those focused on healthier lifestyle choices. Instead of surrendering to the negative spiral, individuals can benefit from reframing the lapse as a learning opportunity and teachable moment. Recognizing the factors that contributed to the lapse, such as stressors or triggers, helps individuals to develop strategies and techniques to navigate similar challenges in the future. Does it mean a person must continue to drink or drug until the use returns to the initial level? You have not unchanged all that you have changed in your life to support your recovery.