What Is The Abstinence Violation Effect AVE?

For example, at a large outpatient SUD treatment center in Amsterdam, goal-aligned treatment for drug and alcohol use involves a version of harm reduction psychotherapy that integrates MI and CBT approaches, and focuses on motivational enhancement, self-control training, and relapse prevention (Schippers & Nelissen, 2006). Participants with controlled use goals in this center are typically able to achieve less problematic (38%) or non-problematic (32%) use, while a minority achieve abstinence with (8%) or without (6%) incidental relapse (outcomes were not separately assessed for those with AUD vs. DUD; Schippers & Nelissen, 2006). The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse.

• “Frailty effects” account for such individual differences in vulnerability, as distinct from factors that influence survival for each individual episode.
• Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995).
• This constellation of responses, coupled with the subjective effects of drug ingestion, is posited to predispose the person to further lapses, thus driving the lapse-relapse process in an accelerating downward spiral (Marlatt & Gordon, 1985).
• Her long-term research interests include the development of a comprehensive understanding of how problematic alcohol use and interpersonal relationship processes interact to influence various physical, emotional, and relational outcomes for individuals and their relationship partners.

Future research

• The current review highlights multiple important directions for future research related to nonabstinence SUD treatment.
• The desire for immediate gratification can take many forms, and some people may experience it as a craving or urge to use alcohol.
• The AVE occurs when a client is in a high-risk situation and views the potential lapse as so severe, that he or she may as well relapse.
• Lapse-management strategies focus on halting the lapse and combating the abstinence violation effect to prevent an uncontrolled relapse episode.
• Researchers have long posited that offering goal choice (i.e., nonabstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995).

Abstinence rates became the primary outcome for determining SUD treatment effectiveness (Finney, Moyer, & Swearingen, 2003; Kiluk, Fitzmaurice, Strain, & Weiss, 2019; Miller, 1994; Volkow, 2020), a standard which persisted well into the 1990s (Finney et al., 2003). Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. Clayton Neighbors is a professor and Director of the Social Psychology Program at the University of Houston, USA. His work focuses on abstinence violation effect social, motivational, and spiritual influences in etiology, prevention, and treatment of health and risk behaviors.

AVE in the Context of the Relapse Process

Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a). Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization. Instead, the literature indicates that most people with SUD do not want or need – or are not ready for – what the current treatment system is offering. These properties of the abstinence violation effect also apply to individuals who do not have a goal to abstain, but instead have a goal to restrict their use within certain self-determined limits. The limit violation effect describes what happens when these individuals fail to restrict their use within their predetermined limits and the subsequent effects of this failure.

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• Lapses distributed by the sequence they occurred (Left Axis), along with median hours of abstinence preceding each lapse (Right Axis).
• When people don’t have the proper tools to navigate the challenges of recovery, the AVE is more likely to occur, which can make it difficult to achieve long-term sobriety.
• It is, however, most commonly used to refer to a resumption of substance use behavior after a period of abstinence from substances (Miller 1996).
• In general, success in accomplishing even simple tasks (e.g., showing up for appointments on time) can greatly enhance a client’s feelings of self-efficacy.
• Working with Dr Lindgren, she has investigated implicit alcohol cognitions, along with the impact of the environment on self-reported measures of alcohol consumption.

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). Although the majority of perceived predictors were mentioned by both stakeholder groups, they had different opinions regarding their importance. In addition, the two stakeholder groups also differed regarding how often certain perceived predictors were mentioned; a few predictors were mentioned by all practitioner groups, but not by the persons who regained weight, and vice versa. A possible explanation for these differences is that health practitioners base their knowledge on their experience with many clients, and therefore generate and rate statements based on the average person (seeing ‘the bigger picture’). The persons who regained weight may have generated and rated statements based on their own experiences, leaving more room for diversity.

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). As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014). The AVE was introduced into the substance abuse literature within the context of the “relapse process” (Marlatt and Gordon 1985, p. 37). Relapse has been variously defined, depending on theoretical orientation, treatment goals, cultural context, and target substance (Miller 1996; White 2007). It is, however, most commonly used to refer to a resumption of substance use behavior after a period of abstinence from substances (Miller 1996).

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. The results reported in the RREP study indicate that the original relapse taxonomy of the RP model has only moderate inter-rater reliability at the highest level of specificity, although reliability of the more general categories (e.g., negative affect and social pressure) was better. The model’s predictive validity also was modest; however, the definition of the key relapse episodes utilized in these studies failed to clarify whether these were voluntary change episodes or simply a return to drinking following a short period of abstinence that did not represent a serious attempt to quit drinking. Although specific intervention strategies can address the immediate determinants of relapse, it is also important to modify individual lifestyle factors and covert antecedents that can increase exposure or reduce resistance to high-risk situations. Global self-control strategies are designed to modify the client’s lifestyle to increase balance as well as to identify and cope with covert antecedents of relapse (i.e., early warning signals, cognitive distortions, and relapse set-ups).

Overall, the Abstinence Violation Effect is a complex phenomenon influenced by a combination of cognitive, emotional, and biological factors. There are several factors that can contribute to the development of the AVE in people recovering from addiction. One of the key features of the AVE is its potential to trigger a downward spiral of further relapse and continued substance use. Not applicable (-), indicates a perceived predictor was not mentioned during the concept mapping session within this group. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission. Maintain a balanced lifestyle by eating healthily, exercising regularly, getting enough sleep, and engaging in activities that bring you happiness and fulfillment.

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Recognizing the factors that contributed to the lapse, such as stressors or triggers, helps individuals to develop strategies and techniques to navigate similar challenges in the future. At Bedrock, we use evidence-based approaches such as cognitive-behavioral therapy (CBT) to help our clients develop coping skills and enhance resilience in the face of setbacks. The research team discussed whether fewer or more clusters would represent participants’ statements better, by evaluating the coherence between statements in each cluster. After defining the final number of clusters, each statement within a cluster was evaluated and allocated to a perceived predictor (e.g. the statement ‘lack of motivation’ was allocated to the perceived predictor ‘motivation’).

Learn From Relapse

Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness.

• 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.
• While our findings suggest it may be useful to reconceptualize aspects of the AVE and its implications for treatment, they clearly support the notion that subjective psychological responses to lapsing during cessation are an important determinant of progression toward relapse.
• To account for correlated observations due to repeated measures within subjects (i.e., recurrent lapse events), we used parametric shared-frailty models, the survival-data analog to mixed-effects (i.e., multilevel or hierarchical linear) regression models (Hougaard, 1999; Hosmer, Lemeshow, & May, 2008).
• This remoteness of environmental factors is also reflected in the so-called fundamental attribution error, which is defined as ‘the tendency for attributors to underestimate the impact of situational factors and to overestimate the role of dispositional factors in controlling behavior’ (Ross, 1977).

The analysis evaluated the way emotional and cognitive responses to smoking lapses prospectively affect subsequent lapse progression. We assessed the implications of Marlatt’s AVE concept, which holds that each lapse – not just the first – represents a pivotal situation after which the lapser will either become increasingly demoralized or remain confident and committed to cessation. The cognitive-behavioral model of the relapse process posits a central role for high-risk situations and for the drinker’s response to those situations.