Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Although more research on the predictors of relapse in weight loss maintenance behaviors is recommended, careful implications for practice can be made. The differences between the predictors perceived by health practitioners and those perceived by persons who regained weight may provide an opportunity to enhance lifestyle coaching, by creating more awareness of these possible discrepancies and ensuring that both points of view are included during coaching. Clients are more likely to be satisfied and follow advice on health behavior change when they feel they have been heard and understood, and are given information they recognize as relevant to them (Gable, 2007). Planning coping responses to anticipated, personal, high-risk situations helps an individual to cope with difficult situations, such as negative emotions or being tempted by their social or physical environment (Sniehotta, Schwarzer, Scholz, & Schüz, 2005). Coping planning has been shown to be an efficacious technique to promote health behavior change, especially when individuals receive support when forming coping plans (Kwasnicka, Presseau, White, & Sniehotta, 2013). Therefore, we advise health practitioners to support their clients by helping them to identify personal risk situations and formulating corresponding coping plans.

1. Review aims

• The way pre-lapse abstinence duration and amount smoked might modulate recurrent AVEs and subsequent progression remains unclear.
• In a similar fashion, the nature of these attributions determines whether the violation will lead to full-blown relapse.
• Moreover, people who have coped successfully with high-risk situations are assumed to experience a heightened sense of self-efficacy (i.e., a personal perception of mastery over the specific risky situation) (Bandura 1977; Marlatt et al. 1995, 1999; Marlatt and Gordon 1985).
• 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.
• Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged.

The term relapse may be used to describe a prolonged return to substance use, whereas lapsemay be used to describe discrete, circumscribed… For example, overeaters may have an AVE when they express to themselves, “one slice of cheesecake is a lapse, so I may as well go all-out, and have the rest of the cheesecake.” That is, since they have violated the rule of abstinence, they “may as well” get the most out of the lapse. Treatment in this component involves describing the AVE, and working with the client to learn alternative coping skills for when a lapse occurs, such that a relapse is prevented.

Focus On Self-Care

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. One of the most important efficacy-enhancing strategies employed in RP is the emphasis on collaboration between the client and therapist instead of a more typical “top down” doctor-patient relationship. In the RP model, the client is encouraged to adopt the role of colleague and to become an objective observer of his or her own behavior.

2. Controlled drinking

While there is evidence that a subset of individuals who use drugs engage in low-frequency, non-dependent drug use, there is insufficient research on this population to determine the proportion for whom moderation is a feasible treatment goal. However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. In the 1980s and 1990s, the HIV/AIDS epidemic prompted recognition of the role of drug use in disease transmission, generating new urgency around the adoption of a public health-focused approach to researching and treating drug use problems (Sobell & Sobell, 1995). The realization that HIV had been spreading widely among people who injected drugs in the mid-1980s led to the first syringe services programs (SSPs) in the U.S. (Des Jarlais, 2017). Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991).

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%). However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD. 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.

Clinical outcomes have been reported elsewhere (Shiffman, Ferguson, & Gwaltney, 2006; Shiffman, Scharf, et al., 2006). In such a matrix, the client lists both the positive and negative immediate and delayed consequences of remaining abstinent versus abstinence violation effect resuming drinking. This list can facilitate the client’s decisionmaking process regarding his or her future alcohol consumption. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment.

• Self-monitoring, behavior assessment, analyses of relapse fantasies, and descriptions of past relapses can help identify a person’s high-risk situations.
• If stressors are not balanced by sufficient stress management strategies, the client is more likely to use alcohol in an attempt to gain some relief or escape from stress.
• 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).
• Because relapse is the most common outcome of treatment for addictions, it must be addressed, anticipated, and prepared for during treatment.
• Support for this research has been provided by the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the National Institute on Mental Health, and the Department of Defense.

Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches. A key point in Miller’s theory is that motivation for change is “action-specific”; he argues that no one is “unmotivated,” but that people are motivated to specific actions or goals (Miller, 2006). The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.

• This article presents one influential model of the antecedents of relapse and the treatment measures that can be taken to prevent or limit relapse after treatment completion.
• The term “predictive validity” refers to the ability of a test or method to predict a certain outcome (e.g., relapse risk) accurately.
• As the client gains new skills and feels successful in implementing them, he or she can view the process of change as similar to other situations that require the acquisition of a new skill.
• Shaded boxes indicate steps in the relapse process and intervention measures that are specific to each client and his or her ability to cope with alcohol-related situations.

Experimental aspects of bulimia nervosa. Implications for cognitive-behavioral therapy

Classical or Pavlovian conditioning occurs when an originally neutral stimulus (e.g., the sight of a beer bottle) is repeatedly paired with a stimulus (e.g., alcohol consumption) that induces a certain physiological response. After the two stimuli have been paired repeatedly, the neutral stimulus becomes a conditioned stimulus that elicits the same physiological response. CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript. SD assisted with conceptualization of the review, and SD and KW both identified relevant literature for the review and provided critical review, commentary and revision. Alan Marlatt is a professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington.