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]. In addition to these areas, which already have initial empirical data, we predict that we could learn significantly more about the relapse process using experimental manipulation to test specific aspects of the cognitive-behavioral model of relapse. Thus, one could test whether increasing self-efficacy in an experimental design is related to better treatment outcomes.

Self-control and coping responses

Outcome expectancies (anticipated effects of substance use; [27]) also figure prominently in the RP model. Additionally, attitudes or beliefs about the causes and meaning of a lapse may influence whether a full relapse ensues. Viewing a lapse as a personal failure may lead to feelings of guilt and abandonment of the behavior change goal [24].

Cognitive behavioural models of substance use

• 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).
• Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies.
• Given the rapid growth in this area, we allocate a portion of this review to discussing initial evidence for genetic associations with relapse.
• Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment.
• Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse.
• Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019).
• Self-monitoring, behavior assessment, analyses of relapse fantasies, and descriptions of past relapses can help identify a person’s high-risk situations.

For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986). Miller, whose seminal work on motivation and readiness for treatment led to multiple widely used measures of SUD treatment readiness and the development of Motivational Interviewing, also argued for the importance of goal choice in treatment (Miller, 1985). Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches. A key point in Miller’s theory is that motivation for change is “action-specific”; he argues that no one is “unmotivated,” but that people are motivated to specific actions or goals (Miller, 2006).

AVE in the Context of the Relapse Process

• We focus our review on two well-studied approaches that were initially conceptualized – and have been frequently discussed in the empirical literature – as client-centered alternatives to abstinence-based treatment.
• Definitions of relapse are varied, ranging from a dichotomous treatment outcome to an ongoing, transitional process [8,12,13].
• When the minimal effective response (such as informing friends that “I do not drink”) is not sufficient to bring about change, the individual is instructed to escalate to a stronger response, such as warning, threat, involving others’ support.
• The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985).
• However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to treatment.

Marlatt, based on clinical data, describes categories of relapse determinants which help in developing a detailed taxonomy of high-risk situations. These components include both interpersonal influences by other individuals or social networks, and intrapersonal factors in which the person’s response is physical or psychological. An important part of RP is the notion of Abstinence violation effect (AVE), which refers to an individual’s response to a relapse where often the client blames himself/herself, with a subsequent loss of perceived control4.

Treatment strategies in the relapse prevention

Each of the five stages that a person passes through are characterized as having specific behaviours and beliefs. The Trans theoretical model (TTM), describes stages of behavioral change, processes of change and the decisional balance and self-efficacy which are believed to be intertwined to determine an individual’s behaviour11. As the foregoing review suggests, validation of the reformulated RP model will likely progress slowly at first because researchers are only beginning to evaluate dynamic relapse processes. Currently, the dynamic model can be viewed as a hypothetical, theory-driven framework that awaits empirical evaluation. Testing the model’s components will require that researchers avail themselves of innovative assessment techniques (such as EMA) and pursue cross-disciplinary collaboration in order to integrate appropriate statistical methods.

Empirical findings relevant to the RP model

Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied. The mechanisms of mindfulness include being non-judgemental, acceptance, habituation and extinction, relaxation and cognitive change35.

Persons who regained weight

AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse. Instead of viewing the incident as a temporary setback, the individual perceives it as evidence of personal failure, leading to increased feelings of guilt, shame, and hopelessness (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999). It can impact someone who is trying to be abstinent from alcohol and drug abstinence violation effect use in addition to someone trying to make positive changes to their diet, exercise, and other aspects of their lives. Individuals with greater SUD severity tend to be most receptive to therapist input about goal selection (Sobell, Sobell, Bogardis, Leo, & Skinner, 1992). This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment.

Others high risk situations include physical states such as hunger, thirst, fatigue, testing personal control, responsivity to substance cues (craving). The RP model highlights the significance of covert antecedents such as lifestyle patterns craving in relapse. Expectancy research has recently started examining the influences of implicit cognitive processes, generally defined as those operating automatically or outside conscious awareness [54,55]. Recent reviews provide a convincing rationale for the putative role of implicit processes in addictive behaviors and relapse [54,56,57].

RP Intervention Strategies

Concept mapping is a structured methodology combining qualitative and quantitative methods to integrate group thought and perspectives about a particular topic, in order to produce a conceptual framework (Burke et al., 2005). Concept mapping has been applied successfully to address complex issues in health care (W. Trochim & Kane, 2005). Apart from theories, insight into predictors of relapse can be obtained from previous studies; such as the recent literature review by Roordink and colleagues (Roordink et al., 2021) on the predictors of lapse and relapse in physical activity and dietary behavior, based on 37 prospective studies. Regarding physical activity, this study found a higher risk of relapse for people with a lower self-efficacy, fewer behavioral processes of change (i.e. covert and overt activities to modify behavior), and less self-regulation. For dietary behavior, it found that people with lower self-efficacy had a higher risk of relapsing (Roordink et al., 2021). However, the review also showed that there is still insufficient evidence for most predictors of relapse.

Integrating implicit cognition and neurocognition in relapse models

Like the conceptualization of urges and cravings as the result of an external stimulus, this imagery fosters detachment from the urges and cravings and reinforces the temporary and external nature of these phenomena. One helpful cognitive strategy in the initial phase of CBT includes using the Advantage/disadvantage technique with the patient29. The therapist and patient collaboratively review the advantages/disadvantages of engaging in substance use or addictive behaviour.