What Is The Abstinence Violation Effect AVE?

In a subsequent meta-analysis by Irwin, twenty-six published and unpublished studies representing a sample of 9,504 participants were included. Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment. Moderation analyses suggested that RP was consistently efficacious across treatment modalities (individual vs. group) and settings (inpatient vs. outpatient)22. In conclusion, the abstinence violation effect is a psychological effect that impacts those in recovery, as well as those who are focused on making more positive behavioral choices in their lives. By reframing lapses as learning opportunities and teachable moments, cultivating self-compassion, and seeking support, individuals can navigate these challenges more effectively, increasing their chances of leading a healthier lifestyle.

Drinking Goal Item of the Treatment Experiences and Expectations questionnaire

Following this a decisional matrix can be drawn where pros and cons of continuing or abstaining from substance are elicited and clients’ beliefs may be questioned6. Interpersonal relationships and support systems are highly influenced by intrapersonal processes such as emotion, coping, and expectancies18. The Institute for Research, Education and Training in Addictions (IRETA) is an independent 501(c)3 nonprofit located in Pittsburgh, PA. 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.

Drinks per Drinking Day

• For example, in AUD treatment, individuals with both goal choices demonstrate significant improvements in drinking-related outcomes (e.g., lower percent drinking days, fewer heavy drinking days), alcohol-related problems, and psychosocial functioning (Dunn & Strain, 2013).
• Most scientists who studied SUD treatment believed that abstinence was the only acceptable treatment goal until at least the 1980s (Des Jarlais, 2017).
• Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment.
• The relationship between self-efficacy and relapse is possibly bidirectional, meaning that individuals who are more successful report greater self-efficacy and individuals who have lapsed report lower self-efficacy4.

The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this abstinence violation effect is especially true regarding DUD (vs. AUD). 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. In summary, these analyses of the COMBINE study provide strong evidence that drinking goal represents an important clinical predictor of treatment outcomes and thus should be an integral part of the clinical assessment of problem drinkers.

The Effects of Drinking Goal on Treatment Outcome for Alcoholism

• AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse.
• Regarding pharmacological interventions for alcohol use disorders, recent laboratory studies of naltrexone have elucidated its mechanisms of action.
• Relapse has been variously defined, depending on theoretical orientation, treatment goals, cultural context, and target substance (Miller 1996; White 2007).
• The Minnesota Model involved inpatient SUD treatment incorporating principles of AA, with a mix of professional and peer support staff (many of whom were members of AA), and a requirement that patients attend AA or NA meetings as part of their treatment (Anderson, McGovern, & DuPont, 1999; McElrath, 1997).
• As far as treatment outcomes are considered, there is no universally accepted definition of what constitutes successful CD.
• Rather than only focusing on the end goal, celebrate small victories and all positive steps you’ve taken thus far.

Miller, whose seminal work on motivation and readiness for treatment led to multiple widely used measures of SUD treatment readiness and the development of Motivational Interviewing, also argued for the importance of goal choice in treatment (Miller, 1985). 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). Additionally, given the nature of the COMBINE study, the effects of a medically oriented intervention (i.e., MM) without a pharmacological component could not be investigated. Furthermore, it should be noted that the literature does not offer consensus on the operational definition of drinking goal (Luquiens et al., 2011).

Clients are taught to reframe their perception of lapses, to view them not as failures but as key learning opportunities resulting from an interaction between various relapse determinants, both of which can be modified in the future. Another factor that may occur is the Problem of Immediate Gratification where the client settles for shorter positive outcomes and does not consider larger long term adverse consequences when they lapse. This can be worked on by creating a decisional matrix where the pros and cons of continuing the behaviour versus abstaining are written down within both shorter and longer time frames and the therapist helps the client to identify unrealistic outcome expectancies5. The initial transgression of problem behaviour after a quit attempt is defined as a “lapse,” which could eventually lead to continued transgressions to a level that is similar to before quitting and is defined as a “relapse”.

2. Established treatment models compatible with nonabstinence goals

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). It can impact someone who is trying to be abstinent from alcohol and drug use in addition to someone trying to make positive changes to their diet, exercise, and other aspects of their lives. Relapse factors can be viewed as distal risk factors (vulnerability in the form of temperament, personality, family loading, environment including social and economic background) and proximal factors being the various determinants of relapse acting and these factors interacting among themselves in a complex manner to lead onto relapse. Shiffman and colleagues describe stress coping where substance use is viewed as a coping response to life stress that can function to reduce negative affect or increase positive affect. They assume a distinction between stress coping skills, which are responses intended to deal with general life stress, and temptation coping skills, which are coping responses specific to situations in which there are temptations for substance which could contribute to relapse13.

1. Nonabstinence psychosocial treatment models

Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically. Consistent with the philosophy of harm reduction as described by Marlatt et al. (2001), harm reduction psychotherapy is accepting of a wide range of client goals, including risk reduction, moderation, and abstinence (of note, abstinence is conceptualized as consistent with harm reduction when it is a goal chosen by the client). Publications about harm reduction psychotherapy have included numerous case studies and client examples that highlight the utility of the approach for helping clients achieve reductions in drug and alcohol use and related problems, moderate/controlled use, and abstinence (Rothschild, 2015b; Tatarsky, 2002; Tatarsky & Kellogg, 2010). However, to date there have been no published empirical trials testing the effectiveness of the approach. The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.

1. Nonabstinence treatment effectiveness

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). 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 finding is consistent with an abstinence violation effect wherein abstinence oriented participants are more likely to engage in heavy drinking following an initial lapse (Marlatt & Gordon, 1985). While CBI should theoretically reduce the impact of the abstinence violation effect by providing the opportunity to accurately process a lapse, the results presented herein did not support this effect (i.e., no goal × CBI interaction was observed). Regarding pharmacological interventions for alcohol use disorders, recent laboratory studies of naltrexone have elucidated its mechanisms of action.