Among the psychosocial interventions, the Relapse Prevention (RP), cognitive-behavioural approach, is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours. Here the assessment and management of both the intrapersonal and interpersonal determinants of relapse are undertaken. This article discusses the concepts of relapse prevention, relapse determinants and the specific interventional strategies. Related work has also stressed the importance of baseline levels of neurocognitive functioning abstinence violation effect (for example as measured by tasks assessing response inhibition and working memory; [56]) as predicting the likelihood of drug use in response to environmental cues. 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. Additionally, lab-based studies will be needed to capture dynamic processes involving cognitive/neurocognitive influences on lapse-related phenomena.

Cognitive Behavioral Therapy for Substance use Disorders

Irrespective of study design, greater integration of distal and proximal variables will aid in modeling the interplay of tonic and phasic influences on relapse outcomes. As was the case for Marlatt’s original RP model, efforts are needed to systematically evaluate specific theoretical components of the reformulated model [1]. The empirical literature on relapse in addictions has grown substantially over the past decade. Because the volume and scope of this work precludes an exhaustive review, the following section summarizes a select body of findings reflective of the literature and relevant to RP theory. 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].

1. Nonabstinence psychosocial treatment models

There are many relapse prevention models used in substance abuse treatment to counter AVE and give those in recovery important tools and coping skills. 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. AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse. Instead of viewing the incident as a temporary setback, the individual perceives it as evidence of personal failure, leading to increased feelings of guilt, shame, and hopelessness (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999).

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In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001). Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001). The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985).

• 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.
• Given how challenging it is to find differences in clinical outcomes among active psychosocial treatments, the magnitude of the advantage favoring AA/TSF interventions for continuous abstinence was impressive.
• 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.

Alternatively, researchers who conduct trials in community-based treatment centers will need to obtain buy-in to test nonabstinence approaches, which may necessitate waiving facility policies regarding drug use during treatment – a significant hurdle. Relapse Prevention (RP) is another well-studied model used in both AUD and DUD treatment (Marlatt & Gordon, 1985). In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985). More recent versions of RP have included https://ecosoberhouse.com/ mindfulness-based techniques (Bowen, Chawla, & Marlatt, 2010; Witkiewitz et al., 2014). The RP model has been studied among individuals with both AUD and DUD (especially Cocaine Use Disorder, e.g., Carroll, Rounsaville, & Gawin, 1991); with the largest effect sizes identified in the treatment of AUD (Irvin, Bowers, Dunn, & Wang, 1999). As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014).

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. 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. Elucidating the “active ingredients” of CBT treatments remains an important and challenging goal, Also, integration of neurocognitive parameters in relapse models as well as neural (such as functional circuitry involved in relapse) and genetic markers of relapse will be major challenges moving ahead19.

This reflects an absolute advantage of 9% points in favor of AA/TSF, which translates to a relative advantage for AA/TSF compared with CBT of 60% in the number of participants completely abstinent, and a relative advantage of 64%, when compared with MET. This pattern of relative advantage for AA/TSF interventions appeared quite consistent across both RCTs/quasi-experimental and nonrandomized studies. Enhancing rates of continuous abstinence and remission by 60% above what many clinicians might consider to be the current ‘state-of-the art’ intervention (i.e. CBT) are noteworthy, especially given the lethality of AUD. If we were talking about improving remission rates by this degree among a lethal health condition like as cancer, such an improvement in outcome would generate jubilation. Given also that AA/TSF produces these clinical benefits at a greatly reduced health care cost, there may be cause for even greater celebration.

• These results suggest that researchers should strive to consider alternative mechanisms, improve assessment methods and/or revise theories about how CBT-based interventions work [77,130].
• Alan Marlatt is a professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington.
• Looking back does have its benefits in that it helps us identify weaknesses in our program.
• Has received funding from the US National Institutes of Health and US Veterans Health Administration to evaluate a range of treatment and mutual-help organizations focused on alcohol and other drugs.
• In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985).
• 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.

We focus our review on two well-studied approaches that were initially conceptualized – and have been frequently discussed in the empirical literature – as client-centered alternatives to abstinence-based treatment. Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence. 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.

4. Consequences of abstinence-only treatment

To the extent that such attitudes emerge from a perception that AA is ineffective, we hope the Cochrane Review will prompt a re-evaluation and in turn a greater willingness to help AUD patients test out this remarkable fellowship for themselves. To prevent unit of analysis errors (i.e. double counting) that could inflate statistical significance, in cases where one intervention group was compared to two or more comparison groups, we split the intervention group sample in the meta-analysis in accordance with the Cochrane Handbook guidelines (Higgins and Green, 2019). Due to the fact that there is currently no consensus on the proper method for pooling estimates of cost-effectiveness studies (Shemilt et al., 2011; Higgins and Green, 2019), we summarized results from cost-effectiveness studies in the narrative.

• Phasic responses include cognitive and affective processes that can fluctuate across time and contexts–such as urges/cravings, mood, or transient changes in outcome expectancies, self-efficacy, or motivation.
• Brie graduated as a high school valedictorian with a major in Health Technologies and continued her studies at Springfield Technical Community College with a focus on healthcare.
• The evolution of cognitive-behavioral theories of substance use brought notable changes in the conceptualization of relapse, many of which departed from traditional (e.g., disease-based) models of addiction.
• Relapse occurs when this behavior accelerates back into prolonged and compulsive patterns of drug abuse.

Normalize Relapse

Against this backdrop, both tonic (stable) and phasic (transient) influences interact to determine relapse likelihood. Tonic processes include distal risks–stable background factors that determine an individual’s “set point” or initial threshold for relapse [8,31]. Personality, genetic or familial risk factors, drug sensitivity/metabolism and physical withdrawal profiles are examples of distal variables that could influence relapse liability a priori.