Content
In a recent review of the literature on relapse precipitants, Dimeff and Marlatt (1998) also concluded that considerable support exists for the notion that an abstinence violation effect can precipitate a relapse. 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. These covert antecedents include lifestyle factors, such as overall stress level, as well as cognitive factors that may serve to “set up” a relapse, such as rationalization, denial, and a desire for immediate gratification (i.e., urges and cravings) (see figure 2). These factors can increase a person’s vulnerability to relapse both by increasing his or her exposure to high-risk situations and by decreasing motivation to resist drinking in high-risk situations.
In addition, specific cognitive-behavioral skills training approaches, such as relaxation training, stress-management, and time management, can be used to help clients achieve greater lifestyle balance. 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 https://ecosoberhouse.com/ 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. The second strategy, which is possibly the most important aspect of RP, involves evaluating the client’s existing motivation and ability to cope with specific high-risk situations and then helping the client learn more effective coping skills. The desire for immediate gratification can take many forms, and some people may experience it as a craving or urge to use alcohol.
Theoretical and Practical Support for the RP Model
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.
- She is a current member of the Golden Key International Honor Society and the Delta Epsilon Iota Honor Society.
- Hopefully, one does not lose all the knowledge and experience gained along the journey.
- Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001).
- Preventing relapse or minimizing its extent is therefore a prerequisite for any attempt to facilitate successful, long-term changes in addictive behaviors.
- In the absence of triggers, or cues, cravings are headed toward extinction soon after quitting.
- In another recent study, researchers trained participants in attentional bias modification (ABM) during inpatient treatment for alcohol dependence and measured relapse over the course of three months post-treatment [62].
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. To date there has been limited research on retention rates in nonabstinence treatment. This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention. 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.
The reformulated cognitive-behavioral model of relapse
Third, variants implicated in broad traits relevant for addictive behaviors–for instance, executive cognitive functioning (e.g., COMT) or externalizing traits (e.g., GABRA2, DRD4)–could influence relapse proneness via general neurobehavioral mechanisms, irrespective of drug class or treatment modality. As summarized below, preliminary empirical support exists for each of these possibilities. Some researchers propose that the self-control required to maintain behavior change strains motivational resources, and that this „fatigue” can undermine subsequent self-control efforts [78]. Consistent with this idea, EMA studies have shown that social drinkers report greater alcohol consumption and violations of self-imposed drinking limits on days when self-control demands are high [79]. Limit violations were predictive of responses consistent with the AVE the following day, and greater distress about violations in turn predicted greater drinking [80].
Such feelings sabotage recovery in other ways as well—negative feelings are disquieting and are often what drive people to seek relief or escape in substances to begin with. In addition, feelings of guilt and shame are isolating and discourage people from getting the support that that could be of critical help. A great deal of research demonstrates that a pile-up of adverse childhood experiences (ACEs) such as trauma, especially when combined with a chaotic childhood, raises the risk for a number of types of dysfunctional behavior later on, of which addiction is only one. The more ACEs children have, the greater the possibility of poor school performance, unemployment, and high-risk health behaviors including smoking and drug use. Craving is an overwhelming desire to seek a substance, and cravings focus all one’s attention on that goal, shoving aside all reasoning ability. Perhaps the most important thing to know about cravings is that they do not last forever.
Continued empirical evaluation of the RP model
Findings concerning possible genetic moderators of response to acamprosate have been reported [99], but are preliminary. Additionally, other findings suggest the influence of a DRD4 variable number of tandem repeats (VNTR) polymorphism on response to olanzapine, abstinence violation effect a dopamine antagonist that has been studied as an experimental treatment for alcohol problems. Olanzapine was found to reduce alcohol-related craving those with the long-repeat VNTR (DRD4 L), but not individuals with the short-repeat version (DRD4 S; [100,101]).
Overall, the results were consistent with the review conducted by Irvin and colleagues, in that the authors concluded that 58% of individuals who received CBT had better outcomes than those in comparison conditions. In contrast with the findings of Irvin and colleagues [36], Magill and Ray [41] found that CBT was most effective for individuals with marijuana use disorders. The dynamic model of relapse assumes that relapse can take the form of sudden and unexpected returns to the target behavior. This concurs not only with clinical observations, but also with contemporary learning models stipulating that recently modified behavior is inherently unstable and easily swayed by context [32].
It is currently not clear, however, how a small indulgence, which itself might not be problematic, escalates into a full-blown binge [29]. The neurotransmitter serotonin has been the focus of considerable research in patients with anorexia nervosa and bulimia nervosa. Laboratory studies have shown that patients with eating disorders often experience abnormal patterns of hunger and satiety over the course of a meal.
- Staying clean from drugs and alcohol or abstaining from unwanted behaviors is part of living a balanced life.
- 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].
- It is currently not clear, however, how a small indulgence, which itself might not be problematic, escalates into a full-blown binge [29].
- A critical implication is that rather than signaling a failure in the behavior change process, lapses can be considered temporary setbacks that present opportunities for new learning to occur.
- This reaction focuses on the drinker’s emotional response to an initial lapse and on the causes to which he or she attributes the lapse.
Despite the empirical support for many components of the cognitive-behavioral model, there have also been many criticisms of the model for being too static and hierarchical. 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.