We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research. We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. 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.

• Being able to understand how your thoughts, emotions, and behaviors play off of each other can help you to better control and respond to them in a positive way.
• Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process.
• The use of functional magnetic resonance imaging (fMRI) techniques in addictions research has increased dramatically in the last decade 131 and many of these studies have been instrumental in providing initial evidence on neural correlates of substance use and relapse.
• Most notably, we provide a recent update of the RP literature by focusing primarily on studies conducted within the last decade.
• While this can affect anyone making behavioral changes, it’s particularly impactful for those recovering from mental health challenges and substance use disorders.

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Note that these script ideas were pulled from a UN training on cognitive behavioral therapy that is available online. Before any substance use even occurs, clinicians can talk to clients about the AVE and the cognitive distortions that can accompany it. This preparation can empower a client to avoid relapse altogether or to lessen the impact of relapse if it occurs.

Competencies for Recovery-Oriented Counseling

Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005). 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 Alcoholics Anonymous select body of findings reflective of the literature and relevant to RP theory.

Systematic reviews and large-scale treatment outcome studies

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. Additionally, momentary coping responses can serve as phasic events that may determine whether a high-risk situation culminates in a lapse. Substance use and its immediate consequences (e.g., impaired decision-making, the AVE) are additional phasic processes that are set into motion once a lapse occurs.

• Furthermore, the use of FDA-approved medications (which not all clients will view as “abstinence”) has been shown to produce the best health and recovery outcomes for people with opioid use disorders.
• 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).
• It was noted that in focusing on Marlatt’s relapse taxonomy the RREP did not comprehensive evaluation of the full RP model 121.
• For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment.
• For example, the therapist can use the metaphor of behavior change as a journey that includes both easy and difficult stretches of highway and for which various “road signs” (e.g., “warning signals”) are available to provide guidance.

Relapse prevention. An overview of Marlatt’s cognitive-behavioral model

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. Although many developments over the last decade encourage confidence in the RP model, additional research is needed to test its predictions, limitations and applicability. In particular, given recent theoretical revisions to the RP model, as well as the tendency for diffuse application of RP principles across different treatment modalities, there is an ongoing need to evaluate and characterize specific theoretical mechanisms of treatment effects.

As a result of stress, high-risk situations, or inborn anxieties, you are experiencing negative emotional responses. Emotional relapses can be incredibly difficult to recognize because they occur so deeply below the surface in your mind. When someone abuses a substance for a long time, they will have a higher tolerance for its effects. It is for this reason that someone’s tolerance declines following a period of abstinence and that they may overdose if they start using again at the same level as before.

G Alan Marlatt

Community recovery capital includes attitudes, policies, and resources in clients’ communities that promote recovery from substance use–related problems through multiple pathways. Several leading theorists of the strengths-based model have articulated principles relevant for counseling people recovering from problematic substance use. Someone actively using substances in a problematic way should not be referred to as a “substance abuser” or “addict,” which can suggest that they, the person, are the problem.

• Central to the RP model is the role of cognitive factors in determining relapse liability.
• Often, the therapist provides the client with simple written instructions to refer to in the event of a lapse.
• Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
• Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., 133) and there are increasing efforts to use imaging approaches to predict relapse 134.
• Understand the principles of harm reduction and the tools used to minimize harm, such as opioid education and naloxone, fentanyl and xylazine test strip distribution, and syringe services programs.
• Additionally, momentary coping responses can serve as phasic events that may determine whether a high-risk situation culminates in a lapse.

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Connections to other services and supports for clients in recovery, such as housing resources and child care. Collaboration with other providers from multiple disciplines who have a recovery-oriented approach to care. Opportunities to have better coordination with clients’ other providers, thereby promoting continuing, holistic care.

How The Abstinence Violation Effect Impacts Long-Term Recovery

Have knowledge of Food and Drug Administration–approved medications used to treat problematic substance use. Setting out competencies for counselors working with people in or considering recovery. Recovery-oriented counseling calls for counselors to possess certain competencies to work with clients effectively and empathetically.