This is why many individuals who have been abstinent (or “clean”) for awhile accidentally overdose by starting to use again at the same level of use they were at before their abstinence period. Equally bad can be the sense of failure and shame that a formerly “clean” individual can experience following a return to substance use. 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).

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• Equally bad can be the sense of failure and shame that a formerly “clean” individual can experience following a return to substance use.
• 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.
• Overall, a large volume of research has yielded no consensus operational definition of the term 14,15.
• A key contribution of the reformulated relapse model is to highlight the need for non-traditional assessment and analytic approaches to better understand relapse.
• It is inevitable that everyone will experience negative emotions at one point or another.

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. Initial evidence suggests that implicit measures of expectancies are correlated with relapse outcomes, as demonstrated in one study of heroin users 61. 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. Relative to a control condition, ABM resulted in significantly improved ability to disengage from alcohol-related stimuli during attentional bias tasks.

• Certain fee schedules make it difficult or impossible to be reimbursed for needed services.
• More and more, behavioral health organizations are moving away from “kicking people out of treatment” if they return to substance use.
• Rather than communicating pessimism about a client’s potential to recover, these overdose prevention measures acknowledge the existence of the AVE and communicate that safety is more important than maintaining perfect abstinence.
• The competencies, strategies, and resources discussed in this chapter apply to recovery-oriented counseling, regardless of the setting or the particular counseling approach used in work with individuals considering or in recovery.

Awareness of SUD Treatment Barriers and Inequities

Many treatment centers already provide RP as a routine component of aftercare programs. 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. In general, more research on the acquisition and long-term retention of specific RP skills is necessary to better understand which RP skills will be most useful in long-term and aftercare treatments for addictions. In the last several years increasing emphasis has been placed on “dual process” models of addiction, which hypothesize that distinct (but related) cognitive networks, each reflective of specific neural pathways, act to influence substance use behavior.

Recovery-Oriented Systems of Care and Strengths-Based Counseling

It is important to advance our understanding of the smoking relapse process, so that we might improve our ability to affect clinical outcomes. According to RPM, each lapse in the process represents a potential target for interventions designed to bolster coping resources and renew commitment to change. However, RPM interventions have generally failed to improve smoking cessation outcomes the abstinence violation effect refers to (Irvin et al., 1999; Lancaster et al., 2006). This may be because RPM interventions have focused on reducing what were seen as negative and counter-productive responses such as self-blame and guilt. Instead of learning and growing from their mistake, an individual may believe that they are unable to complete a successful recovery and feel shame and guilt.

This can include abstinence from substance abuse, overeating, gambling, smoking, or other behaviors a person has been working to avoid. Following the initial introduction of the RP model in the 1980s, its widespread application largely outpaced efforts to systematically validate the model and test its underlying assumptions. Given this limitation, the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) sponsored the Relapse Replication and Extension Project (RREP), a multi-site study aiming to test the reliability and validity of Marlatt’s original relapse taxonomy.

Recurrent lapses and AVE responses were thus expected to synergistically drive one another toward relapse, and our analysis attempts to capture and elucidate this cascading downward spiral driven by cognitive and affective responses to recurrent lapses during self-imposed abstinence. 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.

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 https://supremegutters.co.za/2025/01/30/relapse-triggers-people-places-things-causing/ in relation to smoking relapse. Findings from these studies suggested that participants’ 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.

Related work has also stressed the importance of baseline levels of neurocognitive functioning (for example as measured by tasks assessing response inhibition and working memory; 56) as predicting the likelihood of drug use in response to environmental cues. The study of implicit cognition and neurocognition in models of relapse would likely require integration of distal neurocognitive factors (e.g., baseline performance in cognitive tasks) in the context of treatment outcomes studies or EMA paradigms. Additionally, lab-based studies will be needed to capture dynamic processes involving cognitive/neurocognitive influences on lapse-related phenomena. Most notably, we provide a recent update of the RP literature by focusing primarily on studies conducted within the last decade. We also provide updated reviews of research areas that have seen notable growth in the last few years; in particular, the application of advanced statistical modeling techniques to large treatment outcome datasets and the development of mindfulness-based relapse prevention.

• It is important to advance our understanding of the smoking relapse process, so that we might improve our ability to affect clinical outcomes.
• Smokers who were eligible, who passed a medical screening, and who signed an informed consent form were enrolled.
• Of note, alternative definitions of low-level resumption did not change the observed pattern of results.
• A relapse is the result of a series of events that occur over time, according to psychologist and researcher Alan Marlatt, Ph.D.

Knowledge about the role of NA in drinking behavior has benefited from daily process studies in which participants provide regular reports of mood and drinking. Such studies have shown that both positive and negative moods show close temporal links to alcohol use 73. One study 74 found evidence suggesting a feedback cycle of mood and drinking whereby elevated daily levels of NA predicted alcohol use, which in turn predicted spikes in NA. Other studies have similarly found that relationships between daily events and/or mood and drinking can vary based on intraindividual or situational factors 73, suggesting dynamic interplay between these influences. The client’s appraisal of lapses also serves as a pivotal intervention point in that these reactions can determine whether a lapse escalates or desists.

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Our measures of AVE responses did not correspond literally to the abstract constructs in the RPM, but they were derived from RPM, and did in fact demonstrate ability to predict progression from one lapse to the next. Another limitation is that our operational definition of relapse was necessarily arbitrary (Miller, 1996), and is more conservative than the 7-days’ smoking criterion used in other studies. Regardless, both of these relapse thresholds fall well short of resumption of participants’ pre-quit, “normal” smoking rates, which have been shown to take months and maybe years to reestablish (e.g., Conklin et al., 2005). drug addiction treatment We also supplemented our pre-specified relapse criterion with a criterion marking the resumption of low-level daily smoking. This provided a more sensitive measure of “routine” smoking that made it possible for us to improve our focus on true abstinence violations.

Counselors should refer to someone as having SUD only if they have received a clinical diagnosis. Become familiar with and advocate for needed recovery services and social services not available in the community. Make warm handoffs when transferring clients to other providers or recovery communities. Understand the importance of empathy, authenticity, warmth, and unconditional positive regard. Know how to use motivational interviewing (MI) and motivational enhancement to promote engagement in recovery services. Have knowledge of Food and Drug Administration–approved medications used to treat problematic substance use.