Cognitive behavioural interventions in addictive disorders PMC

The AVE was introduced into the substance abuse literature within the context of the “relapse process” (Marlatt & 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). The term relapse may be used to describe a prolonged return to substance use, whereas lapsemay be used to describe discrete,… Despite precautions and preparations, many clients committed to abstinence will experience a lapse after initiating abstinence.

Marlatt and Gordon (1985) have proposed that the covert antecedent most strongly related to relapse risk involves the degree of balance in the person’s life between perceived external demands (i.e., “shoulds”) and internally fulfilling or enjoyable activities (i.e., “wants”). A person whose life is full of demands may experience a constant sense of stress, which not only can generate negative emotional states, thereby creating high-risk situations, but also enhances the person’s desire for pleasure and his or her rationalization that indulgence is justified (“I owe myself a drink”). In the absence of other non-drinking pleasurable activities, the person may view drinking as the only means of obtaining pleasure or escaping pain. A critical difference exists between the first violation of the abstinence goal (i.e., an initial lapse) and a return to uncontrolled drinking or abandonment of the abstinence goal (i.e., a full-blown relapse). Although research with various addictive behaviors has indicated that a lapse greatly increases the risk of eventual relapse, the progression from lapse to relapse is not inevitable.

Etiological Influences in Eating Disorders

A more recent development in the area of managing addictive behaviours is the application of the construct of mindfulness to managing experiences related to craving, negative affect and other emotional states that are believed to impact the process of relapse34. Relapse is a process in which a newly abstinent patient experiences a sense of perceived control over his/her behaviour up to a point at which there is a high risk situation and for which the person may not have adequate skills or a sense of self-efficacy. Self- efficacy increases and the probability of relapsing decreases when one is able to cope with this situation31. Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success. Despite findings like these, many studies of treatment mechanisms have failed to show that theoretical mediators account for salutary effects of CBT-based interventions. Also, many studies that have examined potential mediators of outcomes have not provided a rigorous test [129] of mechanisms of change.

• Against this backdrop, both tonic (stable) and phasic (transient) influences interact to determine relapse likelihood.
• While analysing high-risk situations the client is asked to generate a list of situations that are low-risk, and to determine what aspects of those situations differentiate them from the high-risk situations.
• 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.
• Findings concerning possible genetic moderators of response to acamprosate have been reported [99], but are preliminary.
• Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence.

As noted by McLellan [138] and others [124], it is imperative that policy makers support adoption of treatments that incorporate a continuing care approach, such that addictions treatment is considered from a chronic (rather than acute) care perspective. Broad implementation of a continuing care approach will require policy change at numerous levels, including the adoption of long-term patient-based and provider-based strategies and contingencies to optimize and sustain treatment outcomes [139,140]. 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’).

Cognitive-behavioral and response-prevention treatments for bulimia nervosa

This imagery technique is known as “urge surfing” and refers to conceptualizing the urge or craving as a wave that crests and then washes onto a beach. In so doing, the client learns that rather than building interminably until they become overwhelming, urges and cravings peak and subside rather quickly if they are not acted on. The client is taught not to struggle against the wave or give in to it, thereby being “swept away” or “drowned” by the sensation, but to imagine “riding the wave” on a surf board.

• Furthermore, in that study the majority of relapse episodes after treatment occurred during situations involving negative emotional states, a finding that has been replicated in other studies (Cooney et al. 1997; McKay 1999; Shiffman 1992).
• However, many of the treatments ranked in the top 10 (including brief interventions, social skills training, community reinforcement, behavior contracting, behavioral marital therapy, and self-monitoring) incorporate RP components.
• Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005).
• Modifying social and environmental antecedents and consequences another approach to working with addictive behaviours18.
• Within the groups, each cluster represented multiple perceived predictors; this made it impossible to do a group comparison on cluster level.

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. This resistance to nonabstinence abstinence violation effect treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. 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.