The present analysis provides additional detail, demonstrating that active patch slowed progression from each lapse to the next, but that this protective effect was limited to the first 8–10 lapses. This suggests that smokers should be encouraged to remain on treatment even after they have lapsed, at least through the first 8–10 lapses, while persisting in efforts to recover abstinence as soon as possible. Conversely, it also suggests when it may no longer be productive to persist in patch treatment in the face of an extended series of recurring lapses. We also observed that the effects of active abstinence violation effect patch assignment on progression were moderated by lapse-related guilt, such that elevated guilt accelerated progression among those on active patch, while it was protective among those on placebo. Further exploration of the interaction between guilt and NRT treatment – and, more broadly, between pharmacological and psychological factors in relapse – is warranted.

Future research

• This provided a more sensitive measure of “routine” smoking that made it possible for us to improve our focus on true abstinence violations.
• These choices have been termed “apparently irrelevant decisions” (AIDs), because they may not be overtly recognized as related to relapse but nevertheless help move the person closer to the brink of relapse.
• This process may lead to a relapse setup or increase the client’s vulnerability to unanticipated high-risk situations.
• In one of the first studies to examine this effect, Herman and Mack experimentally violated the diets of dieters by requiring them to drink a milkshake, a high-calorie food, as part of a supposed taste perception study 27.

This remoteness of environmental factors is also reflected in the so-called fundamental attribution error, which is defined as ‘the tendency for attributors to underestimate the impact of situational factors and to overestimate the role of dispositional factors in controlling behavior’ (Ross, 1977). Participants’ greater focus on individual factors could furthermore be stimulated by the current stigma surrounding overweight and obese individuals and the notion that they are to blame for their weight (Puhl & Heuer, 2010). The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use.

Clinical perfectionism: A cognitive-behavioural analysis

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. 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. Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). 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).

Decoupling Goal Striving From Resource Depletion by Forming Implementation Intentions

This provided a more sensitive measure of “routine” smoking that made it possible for us to improve our focus on true abstinence violations. The role of pre-lapse abstinence appears to be more subtle, interacting with AVE responses in a way that influences progression to additional lapses. Rather than undermining self-efficacy after a lapse, results indicate that longer periods of pre-lapse abstinence potentiated the effect of self-efficacy in protecting against subsequent progression. In such instances, the individual’s feeling of confidence may be better grounded in real experience; i.e., their ability to maintain abstinence for a longer time before the lapse event. In contrast, high self-efficacy following a very short period of abstinence may be less realistic and more brittle in the face of challenge, and hence have a weaker association with subsequent behavior. To account for correlated observations due to repeated measures within subjects (i.e., recurrent lapse events), we used parametric shared-frailty models, the survival-data analog to mixed-effects (i.e., multilevel or hierarchical linear) regression models (Hougaard, 1999; Hosmer, Lemeshow, & May, 2008).

Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995). Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985). Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). 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.

Cognitive neuroscience of self-regulation failure

Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research. We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. 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.

• An abstinence violation can also occur in individuals with low self-efficacy, since they do not feel very confident in their ability to carry out their goal of abstinence.
• We expected that individuals more prone to daily resumption and relapse would reach these milestones earlier and thereby drop from the sample of those at risk for an additional lapse.
• Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation.