Reframing the Abstinence Violation Effect

Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still others argue that one never recovers from a SUD and remains in a perpetual stage of “recovering,” but only if abstinence is maintained.

Be that as it may, a perennial threat to recovering, especially if abstinence is perceived as the prerequisite of changing one’s substance using behavior, is to use, even once. This use, however, small or infrequent, is viewed as having “botched” one’s efforts to change and is referred to in many ways—a relapse, a slip, falling-off-the-wagon, etc.—but no matter the nomenclature it is all but certainly accompanied by a personal sense of having failed. In formal treatment circles, this sense of failure is referred to as the abstinence violation effect or AVE and is perhaps the single greatest contributor to a return to active involvement in one’s SUD. 

Faced with working with individuals trying to change who tend to see use as tantamount to having “F-ed up,” practitioners who treat SUDs routinely are charged with helping them reframe such use as something other than “failure” lest they return to active use. Practitioners accomplish this in various ways, however, all necessitate helping these individuals to view their use as something other than personal failure and indicative of the absence of willpower, moral turpitude, or somehow evidence that recovery is beyond one’s grasp.

Reframing use as something other than failure requires a change in perspective. Just as a patient would rather hear a surgeon discuss a 90% chance of success in a procedure rather than a 10% chance of failure, those treating individuals with a SUD who use can discuss the opportunity the “lapse” presents to recognize previously hidden risks and high-risk triggers that can sabotage recovery. Referring to use following a period of abstinence as a “lapse” rather than having “F-ed up” presents individuals with the opportunity to “act on” their use rather than “react to” it. In addition to reframing, it is also helpful to invite individuals to appreciate the temporal nature of such experiences.

Substance dependent individuals and practitioners alike recognize the risk that urges to use and the triggers associated with them can play in sabotaging a treatment plan. What is often overlooked, however, is the time that elapses between these triggers and urges and the action taken or reaction that one has in response to them. It is this time between the onset of the urge to use and the decision one makes to use or not use that presents the opportunity for the substance-dependent individual to “do something,” the result of which is to move closer to or farther away from use.

The space separating the “urges” and “triggers” from the decision to “use” or “not use” is representative of the “time” that exists between these two phenomena. Depending upon individual circumstances, the precise amount of time separating these as two poles can be minutes or days but irrespective of the specific amount of time, the fact that this separation can be measured in time presents the individual with the realization of an opportunity to do something…if you will, to act rather than react. As a matter of fact, one cannot not do something during this time as to do nothing is in itself to do something.

The individual who grasps the temporal nature of a lapse is presented with an opportunity to take the steps necessary to prevent it. Just as one can learn about how personal actions when using set oneself up for use, following this model, so can this individual appreciate the significance of having a plan in place to deal with urges and triggers should they occur…and most any recovering individual will tell you that it is not “if” these urges and triggers will occur but “when” they will. NOTE: The list of things that can be done during this time is essentially limitless. Exploring “proactive” steps to avoid use and/or cope with urges to use becomes an important topic for discussion with one’s treatment specialist or sponsor.

Alcoholics Anonymous has a slogan that speaks to the importance of being prepared; change people, places, and things. Preparing to avoid the expected triggers that can initiate an urge to drink will increase the likelihood of avoiding lapses. In addition, should use occur, viewing it as a lapse rather than a failure—not to mention an opportunity to learn something new about preventing potential future risks to recovery—increases the likelihood of maintaining sobriety.

Wayne Dyer once wrote that the only difference between a flower and a weed is a judgment. Now, apply this reasoning to one’s use after a period of abstinence: the only difference between a lapse and a failure is _____.

What do you think?

Dr. Robert

Thank you to Jessica Williams of IRETA whose blog post "Combatting the Abstinence Violation Effect" prompted the thinking that resulted in this essay.