In response to these criticisms, Witkiewitz and Marlatt proposed a revision of the cognitive-behavioral model of relapse that incorporated both static and dynamic factors that are believed to be influential in the relapse process. The “dynamic model of relapse” builds on several previous studies of relapse risk factors by incorporating the characterization of distal and proximal risk factors. Distal risks, which are thought to increase the probability of relapse, include background variables (e.g. severity of alcohol dependence) and relatively stable pretreatment characteristics (e.g. expectancies). 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. The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.
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. Cognitions—specifically, thoughts and expectations about drinking behavior and sobriety—contribute importantly to the process of relapse.
Persons who regained weight
Experts in the recovery process believe that relapse is a process and that identifying its stages can help people take preventative action. However, it’s important to realize that relapse isn’t guaranteed, especially if you are vigilant about managing your recovery. More than half of those who achieve sobriety relapse, which can be disheartening but can also lead to relapse because you believe that you will relapse.
- Indeed, because of the way the brain is wired, each time an addict lets an urge pass without engaging in the unwanted behavior, it weakens the neural connections that underlie the desire; each time he or she rewards the craving with the bad habit, the brain pathways, and the addiction, are strengthened.
- A single lapse in abstinence can result in a full relapse due to a phenomenon known as the abstinence violation effect (AVE).
- For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002).
- By the end of treatment, most gamblers will have experienced a prolonged abstinence from gambling.
If the reason for the violation is attributed to internal, stable, and/or global factors, such as lack of willpower or possession of an underlying disease, then the individual is more likely to have a full-blown relapse after the initial violation occurs. On the other hand, if the reason for the violation is attributed to external, unstable, and/or local factors, such as an extremely tempting situation, then the individual is more likely to recover from the violation and get back onto the path of abstinence. Another efficacy-enhancing strategy involves breaking down the overall task of behavior change into smaller, more manageable subtasks that can be addressed one at a time (Bandura 1977). Thus, instead of focusing on a distant end goal (e.g., maintaining lifelong abstinence), the client is encouraged to set smaller, more manageable goals, such as coping with an upcoming high-risk situation or making it through the day without a lapse. Because an increase in self-efficacy is closely tied to achieving preset goals, successful mastery of these individual smaller tasks is the best strategy to enhance feelings of self-mastery.
Common Features Of The Abstinence Violation Effect
A key feature of the dynamic model is its emphasis on the complex interplay between tonic and phasic processes. As indicated in Figure Figure2,2, distal risks may influence relapse either directly or indirectly (via phasic processes). For instance, the return to substance use can have reciprocal effects on the same cognitive or affective factors (motivation, mood, self-efficacy) that contributed to the lapse. Lapses may also evoke physiological (e.g., alleviation of withdrawal) and/or cognitive (e.g., the AVE) responses that in turn determine whether use escalates or desists. The dynamic model further emphasizes the importance of nonlinear relationships and timing/sequencing of events. For instance, in a high-risk context, a slight and momentary drop in self-efficacy could have a disproportionate impact on other relapse antecedents (negative affect, expectancies) [8].
Additionally, no studies identified in this review compared reasons for not completing treatment between abstinence-focused and nonabstinence treatment. Broadly speaking, there are at least three primary contexts in which genetic variation could influence liability for relapse during or following treatment. First, in the context of pharmacotherapy interventions, relevant genetic variations can impact drug pharmacokinetics or pharmacodynamics, thereby moderating treatment response (pharmacogenetics). Second, the likelihood of abstinence following a behavioral or pharmacological intervention can be moderated by genetic influences on metabolic processes, receptor activity/expression, and/or incentive value specific to the addictive substance in question.
2. Relationship between goal choice and treatment outcomes
However, despite findings that coping can prevent lapses there is scant evidence to show that skills-based interventions in fact lead to improved coping [75]. Marlatt’s cognitive-behavioral model of relapse has been an influential theory of relapse to addictive behaviors. The model defines the relapse process as a progression centered on “triggering” events, both internal and external, that can leave an individual in high-risk situations and the individual’s ability abstinence violation effect to respond to these situations. In this process, after experiencing a trigger, an individual will make a series of choices and thoughts that will lead to being placed in a high-risk situation or not. There are two major types of high-risk situations, those with intrapersonal determinants, in which the person’s response is physical or psychological in nature, and interpersonal determinants, those that are influenced by other individuals or social networks.
Furthermore, 12-step programs often celebrate abstinence milestones and encourage participants to count abstinent days, leading to a perception that someone who resumes substance use is “going back to the beginning” and has not made progress in recovery. Twelve-step can certainly contribute to extreme and negative reactions to drug or alcohol use. This does not mean that 12-step is an ineffective or counterproductive source of recovery support, but that clinicians should be aware that 12-step participation may make a client’s AVE more pronounced. You may also have a similar thought to the reward thought after a period of sobriety. After a period of success in your recovery, you may think you can control your drug or alcohol use again.
As much as we would like to believe in mind over matter, we actually live our lives at the mercy of the pull of gravity, the need to eat, sleep, and earn money, and our interdependence on other people. The following section reviews selected empirical findings that support or coincide with tenets of the RP model. Because the scope of this literature precludes an exhaustive review, we highlight select findings that are relevant to the main tenets of the RP model, in particular those that coincide with predictions of the reformulated model of relapse. Another example is Taylor, who has been doing a wonderful job taking walks and engaging in healthier eating. Taylor uses an app to watch her intake of calorie limit and does see positive outcomes to her new lifestyle. One night, she craves pizza and wings, orders out, and goes over her calories for the day.
The weight of this guilt often correlates to the amount of time spent in recovery leading up to the relapse. Those with only a few weeks of sobriety will not feel as bad as those with years under their belt. Not out of the same warped practicality mentioned above, but because they simply feel as if they are hopeless.
Limit violations were predictive of responses consistent with the AVE the following day, and greater distress about violations in turn predicted greater drinking [80]. Findings also suggested that these relationships varied based on individual differences, suggesting the interplay of static and dynamic factors in AVE responses. Evidence further suggests that practicing routine acts of self-control can reduce short-term incidence of relapse. For instance, Muraven [81] conducted a study in which participants were randomly assigned to practice small acts self-control acts on a daily basis for two weeks prior to a smoking cessation attempt. Compared to a control group, those who practiced self-control showed significantly longer time until relapse in the following month.
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