The Abstinence Violation Effect Following Smoking Lapses and Temptations Cognitive Therapy and Research

This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention. In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). 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).

Learn From Relapse

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. AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008).

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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. Unfortunately, there has been little empirical research evaluating this approach among individuals with DUD; evidence of effectiveness comes primarily from observational research. For example, at a large outpatient SUD treatment center in Amsterdam, goal-aligned treatment for drug and alcohol use involves a version of harm reduction psychotherapy that integrates MI and CBT approaches, and focuses on motivational enhancement, self-control training, and relapse prevention (Schippers & Nelissen, 2006).

Does 12-Step Contribute to the AVE?

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. For Jim and Taylor, this might involve acknowledging the months of sobriety and healthier lifestyle choices and understanding that a single incident does not erase that progress. 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.

• Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010).
• While there are multiple such intervention approaches for treating AUD with strong empirical support, we highlight a dearth of research testing models of harm reduction treatment for DUD.
• AVE also involves cognitive dissonance, a distressing experience people go through when their internal thoughts, beliefs, actions, or identities are put in conflict with one another.
• Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
• A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs.

Harm reduction treatments were designed to “meet people where they are” and with the philosophy that there is no “one size fits all.” It shifts the focus away from the problematic use itself and more about the harmful consequences of the behavior. As with all things 12-step, the emphasis on accumulating “time” and community reaction to a lapse varies profoundly from group to group, which makes generalizations somewhat unhelpful. However, broadly speaking, there are clear features of 12-step programs that can contribute to the AVE. 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. It includes thoughts and feelings like shame, guilt, anger, failure, depression, and recklessness as well as a return to addictive behaviors and drug use.

There are several factors that can contribute to the development of the AVE in people recovering from addiction. For example, I am a failure the abstinence violation effect refers to (labeling) and will never be successful with abstaining from drinking, eating healthier, or exercising (jumping to conclusions).

• 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.
• Although abstinence may be the ultimate goal for the clinician and the family and maybe on some level the patient, harm reduction programs involve a compassionate, pragmatic philosophy designed to reduce the harmful consequences of using.
• We first describe treatment models with an explicit harm reduction or nonabstinence focus.
• Lapses resulted in increased negative affect and decreased self-efficacy; participants also felt guilty and discouraged.

Historical context of nonabstinence approaches

A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982). Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995). Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985).

• Although there is a multitude of factors that go into the recommendations I make and I cannot make a blanket statement about what I would say, it is often helpful to get a little bit of time clean from substances to experience what that is like.
• Instead of surrendering to the negative spiral, individuals can benefit from reframing the lapse as a learning opportunity and teachable moment.
• In order to understand AVE, it is important to realize the difference between a lapse and relapse.