Abstinence Violation Effect AVE

Inaction has typically been interpreted as the acceptance of substance cues which can be described as “letting go” and not acting on an urge. Approach coping may involve attempts to accept, confront, or reframe as a means of coping, whereas avoidance coping may include distraction from cues or engaging in other activities. Approach oriented participants may see themselves as more responsible for their actions, including lapse, while avoidance-based coping may focus more on their environment than on their own actions14. Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies.

Katie Witkiewitz

It’s important to challenge negative beliefs and cognitive distortions that may arise following a relapse. 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. As a result, the AVE can trigger a cycle of further relapse and continued substance use, since people may turn to substances as a way to cope with the emotional distress. This can create a cycle of self-recrimination and further substance use, making it challenging to maintain long-term abstinence. With the right help, preparation, and support, you and your loved ones can still continue to build a long-lasting recovery from substance abuse. These patterns can be actively identified and corrected, helping participants avoid lapses before they occur and continue their recovery from substance use disorder.

Relapse prevention

Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). The Form 90 (Miller & Del Boca, 1994; Tonigan, Miller, & Brown, 1997) was used to obtain pretreatment measures of drinking and the Time-Line Follow-Back (TLFB) interview (Sobell & Sobell 1992) was used to obtain daily reports of the number of drinks consumed during the 16 week treatment period. Developed for Project MATCH, the Form 90 incorporates aspects of TLFB and grid-averaging methodologies in order to accurately assess participants’ alcohol consumption. Percent days abstinent (PDA), drinks per drinking day (DPDD), and days to relapse during treatment were calculated from the TLFB interview data.

Abstinence Violation Effect (AVE) What It Is & Relapse Prevention Strategies

It includes thoughts and feelings like shame, guilt, anger, failure, depression, and recklessness as well as a return to addictive behaviors and drug use. Rather than labeling oneself as a failure, weak, or a loser, recognizing the effort and progress made before the lapse can provide a more balanced perspective. For Jim and Taylor, this might involve acknowledging the months of sobriety and healthier lifestyle choices and understanding that a single incident does not erase that progress. Taylor may think, “All that good work down the drain, I am never going to be able to keep this up for my life.” Like Jim, this may also trigger a negative mindset and a return to unhealthy eating and a lack of physical exercise.

The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge. For example, despite being widely cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown. In addition to evaluating nonabstinence treatments specifically, researchers could help move the field forward by increased attention to nonabstinence goals more broadly. For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type.

• Although abstinence from all substances is an excellent recovery goal for some, research consistently shows that many people who resolve alcohol and drug problems follow a path of moderation.
• Positive social support is highly predictive of long-term abstinence rates across several addictive behaviours.
• In a subsequent meta-analysis by Irwin, twenty-six published and unpublished studies representing a sample of 9,504 participants were included.
• Critical for craving and relapse is the process of associative learning, whereby environmental stimuli repeatedly paired with drug consumption acquire incentive-motivational value, evoking expectation of drug availability and memories of past drug euphoria15.
• Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization.

While there are many obstacles to the widespread acceptance of CD as a treatment approach (Sobell & Sobell 2006), it is important to note that not all individuals entering treatment do so with the goal of achieving abstinence. To that end, the use of abstinence as the dominant drinking goal across alcoholism treatment programs in the United States may in fact deter individuals who would otherwise seek treatment for alcohol problems should CD be proposed as an acceptable goal. Sobell et al. (1992) found that many patients entering an outpatient treatment facility for alcohol problems preferred self-selection of treatment goals, versus adoption of the goals selected by the therapist.

Factors That Contribute To The Abstinence Violation Effect

• 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.
• Sobell et al. (1992) found that many patients entering an outpatient treatment facility for alcohol problems preferred self-selection of treatment goals, versus adoption of the goals selected by the therapist.
• Another example is Taylor, who has been doing a wonderful job taking walks and engaging in healthier eating.
• Self-efficacy is defined as the degree to which an individual feels confident and capable of performing certain behaviour in a specific situational context5.

Cognitive behavioral therapy (CBT) for alcoholism has received empirical support since the 1980s (Marlatt & Gordon, 1985). CBT for alcohol use disorders is grounded in social-cognitive theory (Bandura, 1986) and employs skills training in order to help patients cope more effectively with substance use triggers, including life stressors (Longabaugh & Morgenstern, 1999; Morgenstern & Longabaugh, 2000). The ultimate goal of CBT is to provide the skills that can prevent a relapse and maintain drinking goals, whether they be abstinence or controlled drinking (Marlatt & Gordon, abstinence violation effect 1985; Marlatt & Witkiewitz, 2005). A recent meta-analysis of CBT for substance use disorders found support for a modest benefit of CBT over treatment as usual (Magill & Ray, 2009). Furthermore, one report using a trajectory analysis of the COMBINE study data found the Combined Behavioral Intervention (CBI), which is principally grounded in CBT, to reduce the risk of being in an “increasing to nearly daily drinking” trajectory. This study suggests that CBI may help participants control their drinking as opposed to simply encouraging abstinence (Gueorguieva et al., 2010).

• 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.
• Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008).
• About 10% of individuals who report cannabis use in the past year meet criteria for a cannabis use disorder, while this proportion increases to 18%, 19%, 58%, and 65% of those with past year use of cocaine, opioids (misuse), methamphetamine, and heroin, respectively.
• The abstinence violation effect (AVE) refers to the negative cognitive (i.e., internal, stable, uncontrollable attributions; cognitive dissonance) and affective responses (i.e., guilt, shame) experienced by an individual after a return to substance use following a period of self-imposed abstinence from substances (Curry et al. 1987).
• Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation, there is evidence for the effectiveness of relapse prevention compared with no treatment controls.

Does 12-Step Contribute to the AVE?