A common pattern of self-regulation failure occurs for addicts and chronic dieters when they ‘fall off the wagon’ by consuming the addictive substance or violating their diets [5]. Marlatt coined the term abstinence violation effect to refer to situations in which addicts respond to an initial indulgence by consuming even more of the forbidden substance [11]. In one of the first studies to examine this effect, Herman and Mack experimentally violated the diets of dieters by requiring them to drink a milkshake, a high-calorie food, as part of a supposed taste perception study [27]. Although non-dieters ate less after consuming the milkshakes, presumably because they were full, dieters paradoxically ate more after having the milkshake (Figure 1a). This disinhibition of dietary restraint has been replicated numerous times [20,28] and demonstrates that dieters often eat a great deal after they perceive their diets to be broken. It is currently not clear, however, how a small indulgence, which itself might not be problematic, escalates into a full-blown binge [29].
Findings indicated nonlinear relationships between SE and urges, such that momentary SE decreased linearly as urges increased but dropped abruptly as urges peaked. Moreover, this finding appeared attributable to individual differences in baseline (tonic) levels of SE. When urge and negative affect were low, individuals with low, intermediate or high baseline SE were similar in their momentary SE ratings. However, these groups’ momentary ratings diverged significantly at high levels of urges and negative affect, such that those with low baseline SE had large drops in momentary SE in the face of increasingly challenging situations.
As summarized below, preliminary empirical support exists for each of these possibilities. Cognitions—specifically, thoughts and expectations about drinking behavior and sobriety—contribute importantly to the process of relapse. These alcohol-related cognitions are placed in the relapse prevention model within the overlap of the tonic stable processes and the phasic fluid responses. As such, these cognitive constructs have both a stable and enduring effect emanating from the individual’s general cognitive beliefs as well as a malleable and plastic effect emanating from upon the individual’s moment-to-moment experiences. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019).
However, broadly speaking, there are clear features of 12-step programs that can contribute to the AVE. It is hoped that more severely mentally ill people will obtain life-saving treatment and pathways to better housing. If you are at a gathering where provocation arises because alcohol or other substances are available, leave. Cravings can intensify in settings where the substance is available and use is possible. One of the most notable developments in the last decade has been the emergence and increasing application of Mindfulness-Based Relapse Prevention (MBRP) for addictive behaviours.
Following structured treatment, access to recovery and aftercare support to aid abstinence from alcohol is important, especially for those who have struggled with AUD for several months or years. Recovery benefits from a detailed relapse prevention plan kept in a handy place—next to your phone charger, taped to the refrigerator door or the inside of a medicine cabinet—for immediate access when cravings hit. A good relapse prevention plan specifies a person’s triggers for drug use, lists some coping skills to summon up and distractions to engage in, and lists people to call on for immediate support, along with their contact information. Good treatment programs recognize the relapse process and teach people workable exit strategies from such experiences. Relapse is most likely in the first 90 days after embarking on recovery, but in general it typically happens within the first year.
The focus is on identifying and accepting the urge, not acting on the urge or attempting to fight it4. 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”. Another possible outcome of a lapse is that the client may manage to abstain and thus continue to go forward in the path of positive change, “prolapse”4.
Currently, the dynamic model can be viewed as a hypothetical, theory-driven framework that awaits empirical evaluation. Testing the model’s components will require that researchers avail themselves of innovative assessment techniques (such as EMA) and pursue cross-disciplinary collaboration in order to integrate appropriate statistical methods. 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].
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. The study, which included nearly 5 million people, found that low-volume drinkers had a significantly lower mortality risk than did lifetime abstainers. After adjusting for biases in the studies, such as non-representative samples and the inclusion of people who used to drink in the abstainer groups, the mortality risk from alcohol consumption increased for all drinking categories but became insignificant for low-volume and occasional drinkers. When one returns to substance use after a period of abstinence, they experience a negative cognitive and affective reaction known as an abstinence violation effect in psychotherapy.
With the right help, preparation, and support, you and your loved ones can still continue to build a long-lasting recovery from substance abuse. Otherwise, recovering individuals are likely to make the worst of a single mistake and accelerate back through the relapse process as a result. As a result, it’s important that those in recovery internalize this difference and establish the proper mental and behavioral framework to avoid relapse and continue moving forward even if lapses occur.
McCrady [37] conducted a comprehensive review of 62 alcohol treatment outcome studies comprising 13 psychosocial approaches. Two approaches–RP and brief intervention–qualified as empirically validated treatments based on established criteria. Interestingly, Miller and Wilbourne’s [21] review of clinical trials, which evaluated the efficacy of 46 different alcohol treatments, ranked “relapse prevention” as 35th out of 46 treatments based on methodological quality and treatment effect sizes. However, many of the treatments ranked in the top 10 (including brief interventions, social skills training, community reinforcement, behavior contracting, behavioral marital therapy, and self-monitoring) incorporate RP components. These two reviews highlighted the increasing difficulty of classifying interventions as specifically constituting RP, given that many treatments for substance use disorders (e.g., cognitive behavioral treatment (CBT)) are based on the cognitive behavioral model of relapse developed for RP [16].
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. Harm reduction therapy has also been applied abstinence violation effect in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010). These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006).
