The Bananas of Slip/Lapse/Re-Lapse Prevention

The essay below is adapted from Recovery Equation (Somov, Somova 2003-4) and is written up with a prospective client in mind. 

Slip, Lapse, Relapse – Aren’t These All the Same?! Resolving the Relapse Prevention Confusion through the Banana Peel Metaphor

Here's a way of sorting out all of these slippery distinctions between "slip," "lapse," and "relapse." I developed this "metaphor" for my clients in a county jail drug and alcohol treatment program a good many years ago. While many of them had been in and out of rehabs and had heard about "relapse prevention", they seemed to be hopelessly confused about what it all meant and, aside from the willpower to stay clean, they didn't have much to show in the way of substance-use prevention skillpower.

But proceed at your own risk: this conceptual "system" will make it annoyingly difficult for you to converse with addiction counselors and the representatives of the "recovery industry" since from this point on you will be using familiar to them terms yet in an often unfamiliar context. So, while you might find yourself conceptually out of sync with your support group and possibly treatment providers, the upside is that you become aware of additional prevention "u-turns."

Another caveat: while written up in reference to substance use, this mnemonic-metaphor can be applied to any compulsive/addictive behavior (whether it's boozing or using, or gambling, or binge-eating, or compulsive shopping, etc.).

Understanding the Loss of Abstinence through a Banana Peel Metaphor

Slip and Slip Prevention:

Say, you are walking down the street and you see a banana peel. When you see the banana peel and realize its slippery potential, you might walk around it in order to avoid a slip. In this see-but-not-slip scenario, you are preventing a slip (Slip Prevention). If you hadn't been paying attention, you would have stepped on the banana peel and slipped - i.e. lost your balance...

Lapse and Lapse Prevention:

Say, you are walking down the street and you are not paying attention. So, you step on the banana peel and as a result you slip up - i.e. you lost your balance. Reflexively, you flail your hands and gyrate your torso so as to regain your balance. And voila! - you did not fall even though you slipped. You regained the balance and prevented a fall. In this slip-but-not-fall scenario you prevented a lapse (i.e. a fall) (which constitutes Lapse Prevention).

Relapse and Relapse Prevention

Say, you are walking down the street and you are not paying attention. You step on the banana peel and slip up, i.e. lose your balance. You flail your hands and gyrate your torso - but to no avail. You are not able to regain your balance and you fall (i.e. lapse). As you try to get back up on your feet, you might fall again (re-fall, re-lapse). The three reasons you might fall again while you are trying to get back up are a) you got too hurt and it is too painful to get back up, b) you lose your balance as you try to get up and fall back again, and c) you are feeling a little shaky and unsteady on your feet and as you have nothing to lean on or support yourself with you fall back down again. If, however, you look around, mindfully size up what you need in order to safely get back on your feet, if, perhaps, you first calm down, maybe rest, and possibly ask for help to prop you up as you plan to steady yourself once back on your feet, you just might be able to prevent another fall (re-lapse) (which would constitute Re-Lapse Prevention).

Review: Slip vs. Lapse vs. Relapse

The Disease Model of substance use does not make a distinction between a lapse and a relapse. In fact, a slip - a craving, a potentially transient loss of psycho-physiological balance - is synonymous with a relapse. Lewis, Dana, and Blevin (1994), in their review of various prevention models, note that the Disease view of addiction "defines the client as either abstinent or relapsed" (p. 171). This catastrophized, all-or-nothing view is based on the idea that "because it is so difficult to fight against the powerful and uncontrollable forces of the disease, the relapse is seen as a probable event" (Lewis et al, 1994, p. 171).

What a truly disempowering and dehumanizing prognosis this is, I have to say.

Abraham Twerski (the founder of the Gateway Rehabilitation Center) provides a vignette that has the beginning of the Banana Peel metaphor that had the promise of elucidating the distinctions between the slip, lapse, and relapse. Unfortunately, his own experience of not being able to regain a loss of balance that led to a fall (see below) led to a conceptual denial of an important prevention U-turn opportunity to Twerski's clients.

Twerski (1997) writes that one day he had a package at the mail to pick up and since his car battery was dead he decided to walk to the post-office on a winter day. Twerski writes: "I tried to watch for slippery spots on the sidewalk, but, in spite of my caution, I slipped and fell hard" (p. 118). Twerski continues: "I knew that whether I fell because of the deceptive appearance of the sidewalk or my negligence, I was not going to get to the post office unless I got up and walked, pain and all." In the next paragraph, Twerski continues: "In spite of my painful fall, I was two blocks closer to my destination than when I had started," and adds "This is how we can view relapse. Regardless of its pain, relapse is not a regression back to square one" (p. 118).

That is indeed so, but let us regress a bit to the middle of the story. Twerski, in this vignette, experienced a slip (loss of balance), which he failed to control and, therefore, fell, i.e. lapsed. He got back on his feet, by restating his goals (he was interested in getting that package from the post-office) and by decatastrophizing ("I was still two blocks closer to my destination than when I had started"). What Twerski did not do is stay down on the ice, nor did he fall again in the process of trying to get back up or after he got back up on yet another slippery spot.

In summary, Twerski did not relapse. There was no "re" to his "lapse." In retelling this story he, however, misses this important distinction as well as the distinction between slip and lapse and relapse, essentially lumping them together. I wonder what conclusions Twerski might have drawn if he had slipped, flailed his hands wildly, stumbled a few feet forward, and caught himself from falling. Maybe Twerski would have drawn a conclusion that it is not just about watching out for the slippery spots, but also about trying to keep oneself from falling even after one slips up on the icy patch.

Slip: review

Metaphorically, a slip is an act of stepping on a banana peel, losing balance temporarily, but regaining balance, and preventing the fall. Clinically, a slip is a moment of having a craving/desire to use but not using. It's a loss of balance without a fall.

Distinguishing a slip from a lapse makes good sense. An act of slipping does not equal an act of falling - the two are psychologically and behaviorally different events which is reflected in the actual semantics of the words involved: a lapse literally means a fall, a slip does not mean a fall, therefore a slip does not equal a lapse.

A slip is a moment of a craving. A craving is a state of frustrated desire: you want something but you can't have it or you are not allowing yourself to have it. As such, a craving is a momentary lapse of balance. Here you were: all was fine and all of a sudden you feel tempted, out of sorts, out of balance. But just because you lost balance, it doesn't mean that you cannot regain it. Just because you lost balance, it doesn't mean that you have to fall. You can regain balance by engaging in craving control - and this will help you prevent a fall, i.e. a lapse (see below).

Lapse: a review

Metaphorically, a lapse means not being able to regain one's balance and falling but getting right back up. Clinically, a lapse means surrendering to the craving/desire to use and using, i.e. having one substance-using episode, but not returning to original (pre-abstinence) level of substance use. In other words, following the one substance-using episode, you re-establish abstinence.

It should be noted that "using once" is an imprecise definition of "lapse" since, depending on the drug of choice, a "lapse" may involve multiple use of the drug in the context of one using episode. Albeit academic, the distinction between using "once" and "one using episode" is real: while a person may be relatively unaffected after one can of beer and therefore is in a position to choose the next drink while having most of his psychological presence, a person who uses heavier drugs such as cocaine or heroin, in essence, ceases to exist as "a consciously deciding party" until the effects of the intoxication have worn off.

Case in point. Say, you were smoking dope everyday. You've quit. Now, at a party, somebody's passing around a joint. You toke up. When the party is over and you wake up the next day, you learn from the lessons of what happened and re-commit to not using. And you go on without using as a result. In this case, your smoking weed that one night was only a lapse. You fell but got right back up... If you, however, went back to smoking weed like you used to, on a daily basis, then that toke would have been the beginning of a re-lapse (see below). If, however, your smoking weed that one night remained an isolated using episode, then, that would be just a lapse. Note that my use of "only a lapse" and "just a lapse" is not an attempt to minimize the significance of your lapse but merely an emphasis to more clearly distinguish between a lapse and a re-lapse.

Applying the same idea to, say, binge-eating. Say, you have been "good" and not binge-eating. But yesterday night you really did it. You stuffed yourself as you were vegging in front of the TV. If your goal was to not binge and you binged, then, what happened yesterday constitutes a lapse. If, after binge-eating yesterday, you gave up your overall goal to not binge-eat and, as a result, return to your habitual binge-eating, then you have re-lapsed (see below).

Or, say, you are struggling with the gambling addiction. You used to gamble online every night after work, but you've quit. On a business trip, while passing a casino, you popped in and blew a hundred bucks. That's a lapse. If, however, as a result, you stop working on the problem (stop going to meetings and/or seeing your therapist), and go back to gambling online, then that's a re-lapse (see below).

But just because you fell (used, binged, gambled) once, it doesn't mean that you have to stay fallen. One fall is not two falls - a lapse is not a re-lapse! To lump these two situations together is to miss an opportunity for a prevention "u-turn."

Relapse: a review

Metaphorically, relapse is falling and staying down. So, re-lapse is either an accident of slipping up, losing balance as a result, failing to regain balance, and, thus, falling (lapsing), and then falling back again until you give up on trying to get back up again. Or it's a conscious choice to return the pre-abstinence level of use.

Distinguishing lapse from relapse follows from the semantics of these two words: suffix "re" means "repetition;" consequently, relapse is a repetition of lapse, and to equate lapse and relapse is to ignore a psychologically and behaviorally valid distinction.

"Homework"

If you are working on some kind of recovery from addictive or compulsive behavior and if your goal is abstinence (from whatever behavior you consider to be no longer acceptable to you), in the weeks to come, as you come across the Banana Peels of your temptations, ask yourself:

"In terms of the banana peel metaphor, what is going on here? Have I just lost balance but regained my balance (just slipped)? Or have I fallen and gotten right back up (lapsed)? Or have I fallen and ended up staying on the ground (re-lapsed)?"

By making sense of "where" you are in terms of your recovery slip/lapse/re-lapse status, you stand to better know what you need to prevent - a slip, a lapse or a re-lapse.

In closing: 

Knowing the differences between slip, lapsse and re-lapse isn't enough.  You also have to have:  solid craving control skills and compassion for your recovery efforts.  You've been doing the best that you can - slip, lapse or relapse.  And you will continue to do the best that you can - slip, lapse or relapse.   Recovery isn't simple: so help yourself instead of diseasing yourself.

 

References:

Somov, P. G. (2008)A Psychodrama Group for Substance Use Relapse Prevention Training.The Arts in Psychotherapy, 38, 151-161.

Somov, P.G. (2007).Meaning of Life Group: Group Application of Logotherapy for Substance Use Treatment.Journal for Specialists in Group Work, 32 (4), 316 - 345.

Somov, P. & Somova, M. (2003)Recovery Equation: Motivational Enhancement, Choice Awareness, Use Prevention: an Innovative Clinical Curriculum for Substance Use Treatment. Imprint Books, ISBN: 1594571929