Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001). Although the magnitude was not as large, the average percentage of days on which participants were abstinent (PDA) tended to show an advantage in favor of AA/TSF interventions, especially in the more rigorous manualized RCTs compared to other active treatment orientations (e.g. CBT). Studies involving young people (Kelly, Kaminer, et al., 2017) and couples therapy (McCrady et al., 1996) showed equivalence, but not advantages, for PDA. One study with dual diagnosis participants in the US Veterans Administration healthcare system (Lydecker et al., 2010) found a disadvantage for PDA with AA/TSF. This may be because, although participants met criteria for AUD, the primary problem was mood disorder as opposed to AUD, which may represent a poorer fit with AA (Kelly et al., 2003). That said, a recent meta-analysis by Tonigan (Tonigan et al., 2018) found consistent abstinence benefits from participation in AA by those dually diagnosed.

AVE in the Context of the Relapse Process

This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD. We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms. We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. 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.

Drinks per Drinking Day

This could include further evaluating established intervention models (e.g., MI and RP) among individuals with DUD who have nonabstinence goals, adapting existing abstinence-focused treatments (e.g., Contingency Management) to nonabstinence applications, and testing the efficacy of newer models (e.g., harm reduction psychotherapy). Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness). However, it is also possible that adaptations will be needed for individuals with nonabstinence goals (e.g., additional abstinence violation effect support with goal setting and monitoring drug use; ongoing care to support maintenance goals), and currently there is a dearth of research in this area. An additional concern is that the lack of research supporting the efficacy of established interventions for achieving nonabstinence goals presents a barrier to implementation. Covert antecedents and immediate determinants of relapse and intervention strategies for identifying and preventing or avoiding those determinants. If stressors are not balanced by sufficient stress management strategies, the client is more likely to use alcohol in an attempt to gain some relief or escape from stress.

Critical appraisal of included studies

The common suffering of AA members may provide a sense of belonging or ‘universality’ that can help to diminish negative affect, particularly shame, loneliness and guilt, which is similar in principle to the dynamics of professional group psychotherapy (Yalom 2008). Furthermore, the observation of others who are sustaining recovery in AA can instill hope for a better future. 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.

Integrating implicit cognition and neurocognition in relapse models

Relative to the TAU group, the VM group reported significantly lower levels of substance use and alcohol-related consequences and improved psychosocial functioning at follow-up [116]. In a subsequent meta-analysis by Irwin, twenty-six published and unpublished studies representing a sample of 9,504 participants were included. Specifically, RP was most effective when applied to alcohol or polysubstance use disorders, combined with the adjunctive use of medication, and when evaluated immediately following treatment. Moderation analyses suggested that RP was consistently efficacious across treatment modalities (individual vs. group) and settings (inpatient vs. outpatient)22. Oxford English Dictionary defines motivation as “the conscious or unconscious stimulus for action towards a desired goal provided by psychological or social factors; that which gives purpose or direction to behaviour. Motivation may relate to the relapse process in two distinct ways, the motivation for positive behaviour change and the motivation to engage in the problematic behaviour.

• Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a).
• The last decade has seen numerous developments in the RP literature, including the publication of Relapse Prevention, Second Edition [29] and its companion text, Assessment of Addictive Behaviors, Second Edition [30].
• Efforts to develop, test and refine theoretical models are critical to enhancing the understanding and prevention of relapse [1,2,14].
• Rather, when people with SUD are surveyed about reasons they are not in treatment, not being ready to stop using substances is consistently the top reason cited, even among individuals who perceive a need for treatment (SAMHSA, 2018, 2019a).

• Cognitive restructuring, or reframing, is used throughout the RP treatment process to assist clients in modifying their attributions for and perceptions of the relapse process.
• The widespread adoption of AA and its influence on the professional treatment industry in some countries has spurred increasing efforts to evaluate its clinical and public health impact.
• For some, even a brief lapse may generate so much self-doubt, guilt, and a belief about personal failure, that the person gives up and continues to use.
• We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms.
• 1Classical or Pavlovian conditioning occurs when an originally neutral stimulus (e.g., the sight of a beer bottle) is repeatedly paired with a stimulus (e.g., alcohol consumption) that induces a certain physiological response.

Cognitive restructuring, or reframing, is used throughout the RP treatment process to assist clients in modifying their attributions for and perceptions of the relapse process. In particular, cognitive restructuring is a critical component of interventions to lessen the abstinence violation effect. Thus, clients are taught to reframe their perception of lapses—to view them not as failures or indicators of a lack of willpower but as mistakes or errors in learning that signal the need for increased planning to cope more effectively in similar situations in the future. This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future. This reframing of lapse episodes can help decrease the clients’ tendency to view lapses as the result of a personal failing or moral weakness and remove the self-fulfilling prophecy that a lapse will inevitably lead to relapse.

Theoretical and empirical rationale for nonabstinence treatment

Two cognitive mechanisms that contribute to the covert planning of a relapse episode—rationalization and denial—as well as apparently irrelevant decisions (AIDs) can help precipitate high-risk situations, which are the central determinants of a relapse. People who lack adequate coping skills for handling these situations experience reduced confidence in their ability to cope (i.e., decreased self-efficacy). Moreover, these people often have positive expectations regarding the effects of alcohol (i.e., outcome expectancies).

Outcome Studies for Relapse Prevention

• Recent studies have reported genetic associations with alcohol-related cognitions, including alcohol expectancies, drinking refusal self-efficacy, drinking motives, and implicit measures of alcohol-related motivation [51,52, ].
• Based on the cognitive-behavioral model of relapse, RP was initially conceived as an outgrowth and augmentation of traditional behavioral approaches to studying and treating addictions.
• These may serve to set up a relapse, for example, using rationalization, denial, or a desire for immediate gratification.
• The dynamic model of relapse assumes that relapse can take the form of sudden and unexpected returns to the target behavior.

Outcomes in which relapse prevention may hold particular promise include reducing severity of relapses, enhanced durability of effects, and particularly for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity21. 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.

Still, some have criticized the model for not emphasizing interpersonal factors as proximal or phasic influences [122,123]. Other critiques include that nonlinear dynamic systems approaches are not readily applicable to clinical interventions [124], and that the theory and statistical methods underlying these approaches are esoteric for many researchers and clinicians [14]. Rather than signaling weaknesses of the model, these issues could simply reflect methodological challenges that researchers must overcome in order to better understand dynamic aspects of behavior [45]. Ecological momentary assessment [44], either via electronic device or interactive voice response methodology, could provide the data necessary to fully test the dynamic model of relapse. Ideally, assessments of coping, interpersonal stress, self-efficacy, craving, mood, and other proximal factors could be collected multiple times per day over the course of several months, and combined with a thorough pre-treatment assessment battery of distal risk factors.