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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. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. The relapse prevention programme combines a variety of cognitive behavioural strategies33. It skills training such as behavioural rehearsal, assertiveness training, communication skills to cope with social pressures and interpersonal problem solving to reduce impact of conflicts, arousal reduction strategies such as relaxation training to manage pain or anxiety as risk for relapse.
Self-efficacy (SE), the perceived ability to enact a given behavior in a specified context [26], is a principal determinant of health behavior according to social-cognitive theories. Although SE is proposed as a fluctuating and dynamic construct [26], most studies rely on static measures of SE, preventing evaluation of within-person changes over time or contexts [43]. Shiffman, Gwaltney and colleagues have used ecological momentary assessment (EMA; [44]) to examine temporal variations in SE in relation to smoking relapse. Findings from these studies suggested that participants’ abstinence violation effect SE was lower on the day before a lapse, and that lower SE in the days following a lapse in turn predicted progression to relapse [43,45]. One study [46] reported increases in daily SE during abstinent intervals, perhaps indicating mounting confidence as treatment goals were maintained [45]. The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985).
1. Review aims
Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). One critical goal will be to integrate empirically supported substance use interventions in the context of continuing care models of treatment delivery, which in many cases requires adapting existing treatments to facilitate sustained delivery [140]. Given its focus on long-term maintenance of treatment gains, RP is a behavioral intervention that is particularly well suited for implementation in continuing care contexts. However, it is imperative that insurance providers and funding entities support these efforts by providing financial support for aftercare services. It is also important that policy makers and funding entities support initiatives to evaluate RP and other established interventions in the context of continuing care models.
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]. While the overall number of studies examining neural correlates of relapse remains small at present, the coming years will undoubtedly see a significant escalation in the number of studies https://ecosoberhouse.com/ using fMRI to predict response to psychosocial and pharmacological treatments. In this context, a critical question will concern the predictive and clinical utility of brain-based measures with respect to predicting treatment outcome. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment.
2. Relationship between goal choice and treatment outcomes
For example, clients can be encouraged to increase their engagement in rewarding or stress-reducing activities into their daily routine. Overall, the RP model is characterized by a highly ideographic treatment approach, a contrast to the “one size fits all” approach typical of certain traditional treatments. Moreover, an emphasis on post-treatment maintenance renders RP a useful adjunct to various treatment modalities (e.g., cognitive-behavioral, twelve step programs, pharmacotherapy), irrespective of the strategies used to enact initial behavior change. Harm reduction therapy has also been applied 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).
The dynamic model of relapse has generated enthusiasm among researchers and clinicians who have observed these processes in their data and their clients. Marlatt’s cognitive-behavioral model of relapse has been an influential theory of relapse to addictive behaviors. The model defines the relapse process as a progression centered on “triggering” events, both internal and external, that can leave an individual in high-risk situations and the individual’s ability to respond to these situations.
Theoretical and empirical rationale for nonabstinence treatment
Marlatt & Gordon’s (1985) approach to relapse prevention with alcoholics provides a very useful framework within which to prevent relapse with gamblers (for a full discussion see Marlatt & Gordon, 1985).The most important aspect of this is to have gamblers understand that a lapse is not equivalent to a relapse. This realisation reduces the abstinence violation effect and ensures that patients no longer adhere to the “one drink, one drunk” mentality which leaves them at risk for relapse. If an individual uses a substance after experiencing a remission, he/she may be vulnerable to the abstinence violation effect (AVE), which refers to an individual’s response to the recognition that he/she has broken a self-imposed rule by engaging in substance use or other unwanted behavior. This response often creates a feeling of self-blame and loss of perceived control due to breaking a self-imposed rule regarding substance use.
