A great deal of research demonstrates that a pile-up of adverse childhood experiences (ACEs) such as trauma, especially when combined with a chaotic childhood, raises the risk for a number of types of dysfunctional behavior later on, of which addiction is only one. The more ACEs children have, the greater the possibility of poor school performance, unemployment, and high-risk health behaviors including smoking and drug use. Also critical is building a support network that understands the importance of responsiveness. Not least is developing adaptive ways for dealing with negative feelings and uncertainty. Those ways are essential skills for everyone, whether recovering from addiction or not—it’s just that the stakes are usually more immediate for those in recovery.
These covert antecedents include lifestyle factors, such as overall stress level, one’s temperament and personality, as well as cognitive factors. These may serve to set up a relapse, for example, using rationalization, denial, or a desire for immediate gratification. Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse. It involves the degree of balance in the person’s life between perceived external demands and internally fulfilling or enjoyable activities.
Abstinence violation effect: Validation of an attributional construct with smoking cessation
These individuals are considered good candidates for harm reduction interventions because of the severity of substance-related negative consequences, and thus the urgency of reducing these harms. Indeed, this argument has been central to advocacy around harm reduction interventions for people who inject drugs, such as SSPs and safe injection facilities (Barry et al., 2019; Kulikowski & Linder, 2018). It has also been used to advocate for managed abstinence violation effect alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). Two publications, Cognitive Behavioral Coping Skills Training for Alcohol Dependence (Kadden et al., 1994; Monti, Kadden, Rohsenow, Cooney, & Abrams, 2002) and Cognitive Behavioral Therapy for Cocaine Addiction (Carroll, 1998), are based on the RP model and techniques.
A significant proportion (40–80%) of patients receiving treatment for alcohol use disorders have at least one drink, a “lapse,” within the first year of after treatment, whereas around 20% of patients return to pre-treatment levels of alcohol use3. Relapse prevention (RP) is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours4. The abstinence violation effect (AVE) occurs when an individual, having made a personal commitment to abstain from using a substance or to cease engaging in some other unwanted behavior, has an initial lapse whereby the substance or behavior is engaged in at least once. The AVE occurs when the person attributes the cause of the initial lapse (the first violation of abstinence) to internal, stable, and global factors within (e.g., lack of willpower or the underlying addiction or disease). 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.
Celibacy vs. Abstinence
Recovery is an opportunity for creating a life that is more fulfilling than what came before. Attention should focus on renewing old interests or developing new interests, changing negative thinking patterns, and developing new routines and friendship groups that were not linked to substance use. Engaging in self-care may sound like an indulgence, but it is crucial to recovery. For one, it bolsters self-respect, which usually comes under siege after a relapse but helps motivate and sustain recovery and the belief that one is worthy of good things. Too, maintaining healthy practices, especially getting abundant sleep, fortifies the ability to ride out cravings and summon coping skills in crisis situations, when they are needed most.
As such, further research may be required before these findings can be generalized to real-world primary care settings. For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment. To date there has been limited research on retention rates in nonabstinence treatment. This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention.
Encouragement and understanding from friends, family, or support groups can help individuals overcome the negative emotional aftermath of the AVE. Another example is Taylor, who has been doing a wonderful job taking walks and engaging in healthier eating. Taylor uses an app to watch her intake of calorie limit and does see positive outcomes to her new lifestyle. One night, she craves pizza and wings, orders out, and goes over her calories for the day.