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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. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation. Specific intervention strategies include helping the person identify and cope with high-risk situations, eliminating myths regarding a drug’s effects, managing lapses, and addressing misperceptions about the relapse process.
Substance use and its immediate consequences (e.g., impaired decision-making, the AVE) are additional phasic processes that are set into motion once a lapse occurs. Thus, whereas tonic processes can determine who is vulnerable for relapse, phasic processes determine when relapse occurs [8,31]. Multiple versions of harm reduction psychotherapy for alcohol and drug use have been abstinence violation effect described in detail but not yet studied empirically. However, to date there have been no published empirical trials testing the effectiveness of the approach. Here we provide a brief review of existing models of nonabstinence psychosocial treatment, with the goal of summarizing the state of the literature and identifying notable gaps and directions for future research.
Consistent with the tenets of the reformulated RP model, several studies suggest advantages of nonlinear statistical approaches for studying relapse. Understanding the AVE is crucial for individuals in recovery and those focused on healthier lifestyle choices. Instead of surrendering to the negative spiral, individuals can benefit from reframing the lapse as a learning opportunity and teachable moment.
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 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. 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. According to these models, the relative balance between controlled (explicit) and automatic (implicit) cognitive networks is influential in guiding drug-related decision making [54,55]. Dual process accounts of addictive behaviors [56,57] are likely to be useful for generating hypotheses about dynamic relapse processes and explaining variance in relapse, including episodes of sudden divergence from abstinence to relapse.
For example, a spouse who still smokes may be threatened by your quitting if they aren’t yet ready to make the effort themselves. If you find that the people around you don’t want you to make beneficial changes in your life, it may be time to seek therapy to figure out how to navigate those relationships. Lapse management includes drawing a contract with the client to limit use, to contact the therapist as soon as possible, and to evaluate the situation for factors that triggered the lapse6. The myths related to substance use can be elicited by exploring the outcome expectancies as well as the cultural background of the client. Following this a decisional matrix can be drawn where pros and cons of continuing or abstaining from substance are elicited and clients’ beliefs may be questioned6. 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.
Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment. This literature – most of which has been conducted in the U.S. – suggests a strong link between abstinence goals and treatment entry. For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002).