addiction

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

Theatre of Relapse

Sunday, December 13, 2009

Stimulus avoidance (the “people, places, and things” strategy) can get you only so far.  Complete relapse prevention training involves the kind of preparation that takes the “improv” element out of your problem-solving.  Sponsors are nice, but they are not always available and... they arenot always sober/abstinent themselves.  The following is a list of several hypothetical challenges to your substance use recovery that I have previously used as part of psychodrama Theatre of Relapse while running a drug and alcohol treatment program in a county jail (Somov, P. G. , 2008,  A Psychodrama Group for Substance Use Relapse Prevention Training, The Arts in Psychotherapy, 38 , 151-161). 

Here’s what I suggest: read each vignette, think about how you would deal with it; as you try to problem-solve your way through the situation, try to rely as much as you can on yourself; try to go it alone (at least in your mind), without a sponsor (if the sponsor is available, great, but that’s not always the case, as you will see from the vignettes below).   In my experience, a fool-proof lapse/relapse prevention plan is entirely self-sufficient and it involves a well thought-through method, rather than “flying by the seat of your pants” creativity.  If you find yourself stumped and unsure by some of these vignettes, consult a professional therapist (about craving control and lapse/relapse prevention training).  

Now, as you read this, you might feel that just reading these vignettes triggers you.  You might decide that relapse prevention is the same as planning for what to do should you relapse and that if you have a plan, you are giving yourself a permission to drink and/or use.  Let me quickly disabuse you of this notion.  If you bought a car with airbags it doesn’t mean that you should drive carelessly and speed.  Having a relapse prevention plan is not a permission to use.  A plan is just that: a plan, a responsible step of addressing various possible contingencies.  If, however, merely reading these vignettes sends you into a craving tailspin, there’ s some important feedback in that for you as to the frailty of your recovery status.  Much more the reason to seek professional support. 

 “Sponsor Gone Bad.”  You discover that your sponsor has lapsed/relapsed.   Alternatively, while feeling triggered and needing help, you invite your sponsor on the scene and your sponsor develops a craving of his/her own.

“Found a Stash.”  Imagine that you have found a stash of cash and/or drugs from the previous run.   How are you going to deal with it?  You have called the sponsor and he/she is not available.

“To Sell or Not to Sell.”  Recession time.  You’ve been unsuccessful in trying to get a job and have been approached with an offer of selling drugs.  Alternatively, you have been doing well for some time but something unexpected came up.  So you are thinking about “flipping a couple of Gs” from your savings account to fill up the deficit in his budget.   How are you going to deal with this?

“Street Come-on.”  This is a bread-and-butter scenario: you have been offered drugs on the street.  Maybe you’ve been waiting for a bus, or coming back from work, or just sitting in a park, or at a meeting.  What’s your plan for handling this?  You have a whopper of a craving, your sponsor’s out of town...

“Meeting Got to Me.”   After a self-help meeting, you’ve heard too much about other people’s bottoms and now you are pondering a peek into your own abyss.  It’s just you.  You don’t have a sponsor yet.  Or you do, but he/she is in rehab.  What’s your plan?

“Pay Day.”  You came into some cash and/or have been asked to go to a bar or to celebrate the end of the work week with his or her work buddies.   You are craving like there’s no tomorrow.   Your cell phone’s dead.  Your spouse/partner is out of town.  It’s weekend.  No one will know.  Your sponsor isn’t answering your calls.  What’s your plan?

“Let go.”  You’ve been let go (fired, terminated, downsized) with severance pay.   You got some money to blow and all the time in the world.  You are frustrated and you just wan to let loose.  What’s next?  You called your sponsor but he/she sounds a little off.   You hit the meeting or two, no effect.  What’s next?

 “Disabled Enabler.”   Your support person (spouse, partner) turns on you.  They say “it’s okay, one is not gonna kill you...”   You got nowhere to go.  Too late for a meeting.  Sponsor is in the hospital.  Prayer didn’t help.  Big book didn’t help.  What are you going to do about this craving?

“Back on the Set.”   You are back on the “set.”  Involuntarily.  Perhaps, your work route now runs through your old playground...  Or, perhaps, after years of keeping clear of certain places, you are back there – perhaps,  you have finally made a visit to your A-frame where you used to get wild or to your hunting camp...  And you got a killer craving...  What to do?

“Using Peer.”  A person you work with keeps talking about drinking/using.  It’s just the two of you.  In a car, on a sales route, exchanging war stories, you got a craving.  Or maybe you are on a sales trip and he/she hits the happy hour...

 “Drugs and Sex.”  You are having sex and you feel triggered to use because of the past combination of using and intimacy.   What’s your plan?

“Righteous Child.”  You have an altercation with your adolescent child who is either caught using or selling and righteously excuses his or her behavior by blaming you for modeling the very behavior in question.   You feel terrible.  You want to use/a drink.  Sponsor’s unavailable. 

 “Family Function.”  You are at a family reunion, pool party, backyard barbecue, wedding.  Rivers of booze.  And there are some pills going around.  You can’t quite leave (maybe you didn’t drive,  your leg’s broken or you just don’t want to be a party-pooper).   But you are craving as hell.  What’s the plan?

“Relationship Trouble.”  You lost a relationship (break-up, quarrel, separation, divorce) or having relationship trouble.  Feeling misunderstood, alone, wanting a drink or to numb out.  In between sponsor.  Too late for the meeting.  You got the picture...

Recovery is like an “improv” theatre.  The best prepared have the last laugh.  Test-drive this abstinence of yours through a couple of these hypothetical topsy-turvy recovery challenges, check your craving control breaks.  Inspection time.  How's your craving control?  I know you got your higher power all right, but how about craving control skillpower?  Do you have your lapse/relapse prevention plan down pat?  I hope so because winging won't do.

I wish you well.

Take the 12 Steps... and Sit Down!

Sunday, December 13, 2009

In my previous work as a clinical director of a drug and alcohol treatment program in a county jail and in my current outpatient work with substance use clients I continuously come across a certain iatrogenic (treatment-related) legacy of powerlessness which stems directly from the 1st of the 12 Steps of the AA/NA philosophy ("We admitted we were powerless over our addiction - that our lives had become unmanageable").

I get it: admitting that you have a problem is a psychologically healthy thing. But admitting that you are powerless to solve it?! What a self-deflating stumble of a step to start a journey of recovery... What were Bill W. and Dr. Bob thinking?!

Perhaps, Bill W. and Dr. Bob were trying to pull off a bit of East-West synthesis? Perhaps, the thinking was that surrender or letting go of one's attachment to the idea of being in control is power? That passively accepting and witnessing the urge to drink (or use drugs) rather than directly fighting the urge head-on would be akin to psychological judo or jujutsu, the "soft method" martial arts that harnesses the opponent's strength and adapts to changing circumstance?

Perhaps, perhaps, perhaps...

Or, perhaps, this confession of powerlessness over addiction is nothing more than a failure to appreciate the psychology of a craving.

Let's take a look!

Just the other day, a guy I've been working with, who's been through the revolving door of the 12 step programs and who had decided to seek psychotherapy in addition to "working the program," triumphantly announces that he "did" the first step. Again!

Now, he's known about my approach to substance use treatment and he has showed himself to be an open mind capable of critical thinking. So he seemed entirely non-defensive when I asked him about what he meant when he "admitted to being powerless over the Disease."

Keep in mind that by now he and I have spent many a session working exclusively on craving control skills.He paused... and, with a sheepish smile, dared: "I am powerful over the Disease, Doc?"

You have to appreciate the weight of 12 Step dogma that he was trying to raise from! Had he leaked this hypothesis at a meeting or in a session with a 12 Step "recovery zealot" he would have likely been accused of being in denial, "slipping," or "lapsing." So, for him to even dare to think that he might be, in fact, powerful over the Disease took guts...

It's basic and axiomatic: if you've been drinking and/or using for any length of time, you'll have craving thoughts. Nothing you can do about that. They'll pop into your mind, uninvited, particularly, when you are around certain "people, places, and things" or when you are in a certain state of mind.

This is plain ol' Classical Conditioning stimulus-response. And indeed, a person who has been using and/or drinking develops numerous conditioned associations between various stimuli and his/her drug of choice.

Naturally, until such person gets used to ("habituates to") these stimuli (in his/her post-cessation, post-drug-use life), he or she will experience conditioned cravings. So, in this sense, up to a point, you are powerless to entirely prevent and/or eliminate craving thoughts from their initial occurrence (after having been exposed to drinking/using stimuli).

But...

But just because you are powerless to prevent the craving thought from occurring in the first place, it doesn't mean that you are powerless to manage or control this thought.

Bottom-line: you are not powerless over how to respond to these cravings, over whether to act them out or to manage them. In fact, the Buddhist mindfulness meditation has been researched, clinically piloted and increasingly mainstreamed into the craving control repertoire of the contemporary drug and alcohol rehabilitation programs.

So, how about this for a first practical step: step aside (from the craving thought) and sit down (in mindfulness meditation) to restore your mind to its non-craving baseline.

Let's review what we got here...

Addiction is a habit. Habits are stimulus-response patterns. If you have had any given habit for some time, when you decide to stop, your mind will keep reminding you to engage in a certain conditioned response whenever you are triggered or exposed to certain stimuli. But just because, your mind reminds you that you used to do this or that in this or that situation, it doesn't necessarily mean that you are powerless to avoid doing this or that, once triggered. So, while you are powerless to completely avoid these mental reminders, these craving thoughts, you do have power to manage these thoughts (through good ol' self-talk or by merely witnessing these thoughts and controlling your experience through mindfulness and/or relaxation).

Now, take a look at the following equation (1).

Using/Drinking Episode = Access to the Drug + Desire to Use/Drink/Consume the Drug

In order for you to use/drink, two things have to be absolutely present: you have to actually have the boose or drugs in your immediate possession and you have to have an active, immediate desire to consume the substance.

For example, if I got some drugs on me but I've been pulled over for speeding, my desire to use is on hold. Right now, all I care about is to get back on my way preferably without a speeding ticket, let alone without a possession charge. So, even though I have immediate and direct access to the drug, I have lost my immediate craving to use. As such, there is no using episode.

Similarly, if I actually got busted for possession and now I am sitting in the county jail, and I got a "whopper" of a craving but no immediate access to drugs, there's not going to be a using episode as I have no direct, immediate means to satisfy my craving.

Or, say, I am sitting at home getting ready to shoot up. But then I think: I gotta see my PO (probation officer) tomorrow and pee in the cup. If my urine's dirty, the PO is gonna "violate" me and send me back to jail. So, here I am: I got access to the drug and I sure have a craving for it. But - based on my pragmatic calculations - I gotta wait till after I see my PO. So, I have the tactical motivation to control my cravings (even if I have no strategic, long-term commitment to recovery) and, if I have the skill-power to control the craving, the basic know-how of how to manage this moment of desire, I might just avoid a using episode (if only for a day).

Where's the unmanageable disease here? Which part exactly am I so fundamentally unable to control? So, even though I have direct access to the drug, by controlling my craving - albeit for an arguably myopic reason - I am able to avoid a using episode. No disease here: just applied, situational morality of avoiding adverse circumstances. Mere interplay of tactical motivation and craving control skill-power.

But what a laudable, promising self-regulatory precedent to build on! What a clinical treasure trove of the distinction between "can't control the craving" and "won't control the craving" to process and analyze!

What all this means is that in order to avoid a using/drinking episode, you have to either eliminate the access to the drug and/or to control the craving to use.

The former - elimination of the access to the drug - is a Stimulus Avoidance strategy best accomplished through a tried-and-true AA dictum of staying away from "people, places, and things."

The latter - elimination of the immediate desire to use the substance in question - is the Response Control strategy best accomplished through craving control.

It goes without saying that if you've been using for long, let alone drinking, avoidance of internal and external stimuli that may trigger a craving is simply impractical.

After all, even if you don't go to the block corner any more, you still got your cell phone. And even if erase your contacts on the phone, you still hear all about it wherever you go - at a meeting, in the movies, you name it... And even if you were to go on a 7-years-in-Tibet retreat, you still have your mind to remind you of the good ol' times, right?

So, the Stimulus Avoidance strategy, the strategy of avoiding access to the drug - let's face it - is limited. What's left - and that should be plenty enough - is craving control. If you work on cultivating a solid, no-nonsense craving control skill-power, you need no will-power or God-power, and you definitely have no need for this dubious relapse prevention scare-tactic of "powerlessness."

"What kinds of craving control methods are out there?" you might ask.

I am glad you finally asked: psychological and chemical.

Psychological craving control methods, in the descending order of my clinical preference, are Mindfulness (best, in my opinion), Relaxation (good), Self-Talk (satisfactory), Distraction (so-so).

Chemical craving control methods: you name it - from methadone to Cyboxin...

I can almost hear it: "Busted! Gotcha, sucka! You said "methodone," you said Cyboxin... See! See! It's a disease. A Disease!!! Not a habit! How can you be in control of a disease?!!! It's physical, not mental, don't you see?!!!"

I see, I see... I'll take an unpopular stab at this mind-body Cartesian non-sense in a minute... But for now, let me just reminisce a bit...

Back when I was running a non-12-step drug and alcohol program in a county jail, I'd get challenged on my assumptions (like above) all the time. In adrenaline overdrive for two years, at least, I had to fend off these Disease Model counterarguments from my inmate clients. There's nothing, nothing like Antisocials' thirst for justice... The energy, the righteousness, the hunger to stump the expert! I enjoyed that work greatly: it paid off: while imprisoned, many of these minds were admirably free...

So, back to this notion of disease... It's just, frankly, silly Cartesian mind-body dualism. Thoughts and feelings are real, they exist - therefore, they have a chemical (physiological) signature in this three-dimensional reality. Of course! No one's arguing with this - it is banally self-evident. So, just because somebody can show you what your "addicted" brain looks like on drugs, it doesn't mean that your habit is a disease.

I might be in a habit of tearing up every time I see a picture of that couple - holding hands - leaping out of the Twin Towers on 9/11. Think about it: I see the image and have a sad thought, and my eyes make water! A thought in my mind results in water pouring out of my eyes! Some fleeting event in my consciousness and look at this mess: I need a tissue, my eyes are red. A change in the state of mind led to a change in the state of body. Mind and Body are the Twin Towers: they stand together and they collapse together.

Need another example? Okay, here's one. I took a leak but forgot to zip up my fly. Now, when a client (God forbid!) points this out to me, I have a thought: "Oh, man! How could I?!" A fleeting event in my consciousness - and my face, my face (!) reddens as I blush. A thought of embarrassment - and blood, blood (!) re-distributes its flow and floods my face... What the hell... Must be a case of... "emotional-vascular" disease...

This mind-body connection is so tight that it's time we took the hyphen from this "mind-body" dualism...

So, what am I getting at? What I am saying is that addiction is a habit, and as any habit, it is a stimulus-response pattern, and as any human habit, addiction involves both mind and body (or better yet, the un-hyphenated bodymind), and that there is no difference between mind and body, they are a one indivisible whole, so when you control one part of this whole, you control the other part of this whole. That's how the whole thing works - as a whole! That's why craving control can be achieved either through psychological or chemical pathways. All roads lead to Rome, don't they?

You might say: "but what about the withdrawal effects, what about tolerance?" Again, everything you feel or think or do, has a physical/physiological manifestation.

If you want to have a sip of coffee, the thought "I want some coffee" translates into a complicated physiological cascade until this thought of yours eventuated in a motor behavior of your hand picking up a cup of coffee from a table and bringing it to your lips. If you drink coffee a lot, then eventually your bodymind adjusts to this ongoing and habitual intake of caffeine.

Namely (you are better off skipping this psychophysiological mumbo-jumbo straight from Wikipedia unless you've already had a cup of coffee yourself this morning): "Because caffeine is primarily an antagonist of the central nervous system's receptors for the neurotransmitter adenosine, the bodies of individuals who regularly consume caffeine adapt to the continual presence of the drug by substantially increasing the number of adenosine receptors in the central nervous system. This increase in the number of the adenosine receptors makes the body much more sensitive to adenosine, with two primary consequences. First, the stimulatory effects of caffeine are substantially reduced, a phenomenon known as a tolerance adaptation. Second, because these adaptive responses to caffeine make individuals much more sensitive to adenosine, a reduction in caffeine intake will effectively increase the normal physiological effects of adenosine, resulting in unwelcome withdrawal symptoms in tolerant users" (Wikipedia).

My point?

Just because we are not consciously supervising all this psycho-physiological re-calibration, it doesn't mean that it is a disease. When I cry, I do not consciously direct my tear glands to produce water. Nor do I instruct my circulatory system to divert a pint of blood to my face when I feel embarrassed. That's just what happens. The Cartesian mind-body paradigm of modern medicine, particularly, addiction medicine, latches on to the fact that what we do has a physiological signature and imbues it with the significance of the disease.

Just because my body reflects the workings of my mind in the mirror of flesh it doesn't mean that these workings are independent and uncontrollable. To think of addiction as a disease (rather than a habit with a physiological signature) is to presuppose a ghost in the (human) machine.

You might object: "But don't you see, drug use changes the bodily chemistry... Haven't you read the very passage you posted from Wikipedia... See, here they say, the increase in the number of adenosine receptors... These are actual structural changes!"

Yes, they are, indeed, structural changes. Real as they can be. Some structural changes are reversible as the postural crossing of the legs as I adjust my posture in the chair. And some, not so much: as you alter the pigmentation of your skin with the tat of your girl-friend's name on your shoulder.

The body documents what the mind does and the fact of this physiological signature is not a disease but a reality of our corporeal psychosomatic organization.

But let us get back to the point of this blog (and, by the way, if you want a more definitive de-construction of the Disease Model, read Stanton Peele's "Diseasing of America" and Jeffrey Schaler's "Addiction is a Choice;" while at it, you might also check out Santoro's "Kill the Craving" exposure-response prevention protocol).

So, the "steps." I am not opposed to them. In fact, I clinically treasure the vast networking and support resources the 12 Step paradigm has on tap for the folks embarking on recovery. But three of these steps, in my opinion, could stand a bit of revision.

With the above considerations in mind, the 1st, 2nd, and 11th Steps of the 12 Step approach could be reformulated as follows:

Step 1: "We admitted that while our minds become unmanageable when we are intoxicated, and while we are powerless over having an occasional conditioned craving for drugs and/or alcohol, we do have the power to control our cravings and thus to prevent drinking/using episodes in the future."

*It is, of course, true that once intoxicated, a person's capacity to render effective, strategically-savvy decisions is debilitated to the extent proportionate to the degree and type of intoxication as well as to the degree of one's metabolic processes and tolerance. Consequently, a person is powerless over drugs and/or alcohol when he or she, in fact, ceases to exist as an intact psycho-physiological entity that he or she is at a non-intoxicated baseline. That, however, does not mean that once the person sobers up he or she is powerless to prevent future substance use. The extent of your intoxication yesterday has nothing to do with whether you will or not control your craving to use again tomorrow. Sure, it's harder to control your cravings when you are "jonesing" than when you are not: but harder doesn't mean impossible...

Step 2: "We came to know that we, ourselves, could restore us to our functional baseline**"

**Note that in paraphrasing step 2, I have replaced the phrase "restores to sanity" with "restore to functional baseline." The term "sanity" implies that substance use is madness and therefore retrospectively invalidates substance use as a legitimate, albeit imperfect, form of coping. After all, in order to change, clients need a belief in their sanity; any implication of prior insanity only contributes to unnecessary sense of hopelessness. After all, if past predicts the future, then past insanity predicts future insanity. Clients should not be robbed of their phenomenology as being rational.

Step 11: "Sought through mindfulness meditation (or other craving control) to improve our conscious contact with ourselves and to control our cravings"

Re-processing of the Powerlessness legacy in such a way may allow the client with strong prior allegiance to the 12 Step philosophy to retain a modified version of the steps. Most of the 12 Steps, in my opinion, definitely take a person in recovery in the right direction. But, as the evidence on the use of mindfulness in craving control suggests, perhaps, it's a good idea to take a few mindful steps and then to sit down in Zazen (Buddhist "sitting meditation") once in a while.

So, to all of you, well-intentioned and hard-working steppers: march on! Just don't goose-step past the obvious. You have the power to control your cravings. Craving is but another train of thought: step aside and sit down....

The journey of recovery, a millions steps no less!, perhaps, begins with, first, sitting still - transfixed in meditation...

I wish you well in your struggle for self-empowerment.

Weak Willpower or Habitual Automaticity?

Thursday, May 17, 2012

Adapted from Choice Awareness Training: Logotherapy & Mindfulness for Treatment of Addictions :

The act of will, application of willpower, and making of a choice are synonymous.  The term willpower, however, has an unfortunate connotation of varying strength, as if to convey that some people have a more powerful will than others.  It should be noted that the term “willpower” is not an inherently incorrect term.  When used in the sense of “power of will (or volition),” the term heightens, if not extols, the human capacity to make a choice. 

The phrase “power of will” is free from any kind of interpersonal comparison, it is merely an acknowledgement that as humans we possess a power (a freedom) of self-determination through choice.  The term “willpower” becomes problematic, however, when the semantic focus shifts from “power of will” to “how powerful one’s will is.”

The Concise American Heritage Dictionary (1987) reflects this distinction by defining “will power” as:

1.             the ability to carry out one’s decisions, wishes, or plans, and

2.            the strength of mind. 

While the first meaning of willpower does exist, the second is nothing but a linguistic connotation of the word “power” that does not have a phenomenological reality.  Comparative perception of will or capacity for choice as being stronger or weaker is erroneous and psychologically damaging.  An act of will or a choice is a binary event: one either acts or does not act in a certain fashion.  Consequently, all people are equally strong choosers, with an equal power for will, i.e. of the same willpower. 

While equal in willpower, i.e. in the capacity for choice, people differ in:

     a)  how they apply their will/choice, and in

     b)  the degree of their conscious awareness of their capacity for choice. 

Pertaining to a), it is easy to see how judging of others’ actions leads to a conclusion that so and so has weak will.  It is the belief of this author that the process of moral comparison is the historical context for the emergence of the term willpower.  Say a person is faced with an opportunity to steal something of value.  He/she is tempted and, then, he acts upon that temptation.  To an outsider, this might seem like a battle between wanting to steal and not wanting to steal that has been resolved in the favor of the presumed temptation: the person could not withstand the promise of easy money, the allure of a financial short-cut.  Implicit in such interpretation is that one is weak since he surrendered, gave in to the temptation.  A verdict of "weak willpower" or "not having enough willpower" is the next logical step in such a chain of interpretation.

An alternative view of the situation is that one did not surrender or give in to the temptation.  One merely chose to act upon his desire to steal – for a variety of personal reasons.  According to such interpretation there is no weakness of will, there is only socially unacceptable misapplication of one’s will.  Consequently, the notion of strong or weak power appears to be a result of moralistic judgment in which there is an automatic para-religious implication that when faced with socially unsanctioned opportunities (drugs, sex, crime) people are taunted, tempted, lured by whatever is the cultural equivalent of the devil or the dark side and the weakest give in.

With this in mind, the notion of willpower has become a kind of implicit morality yard-stick that in the context of substance use treatment represents a circular double-bind, a kind of logical dead-end, a questionable asset in the change process.  In reality, people merely make choices that we may or may not agree with – and our disagreement has nothing to do with the measurement of a given person’s capacity for choice.  Just because one person insightfully chooses to “numb out” in order not to “go ballistic,” it does not mean that he or she has weak will – all it means is that at this moment this person had concluded (rightly or wrongly) that drinking or drugging was a strategy of choice, a calculated act of emotional self-regulation.

Pertaining to b) (above), mindless, reflexive, knee-jerk decisions seem “weak” since they are void of the power of conscious choosing.  Such unconscious decisions seem “weak” because in their unconsciousness they fail to represent the best interests of the chooser.  This is exactly the case when a person in recovery yields to a craving, to an impulse to use.  To an outsider, such an easy surrender to a craving appears like an act of weak will. 

In reality, the perceived weakness of the act stems from its conditioned unconsciousness (or habitual automaticity) rather than from the actor’s actual capacity to resist a craving impulse.  An unconscious choice is like a sleeping beauty whose charms are not in play while she is dormant. 

The therapeutic importance of deconstructing the myth of willpower cannot be overemphasized.  When one buys into the notion of willpower and uses lack of it as an excuse to use, he or she is beyond criticism.  In such a case, willpower adopts the rationalizing benefit of the doubt that ensures the belief in addiction as a medical disease. To ask a weak person to do something they do not have the strength to do is akin to Baron Munchausen’s pulling himself out of the swamp by his own pony-tail.  In other words, change based on willpower is similar to asking one to be strong when one is weak. 

People in recovery who have uncritically bought into the notion of willpower are well familiar with this double bind:  they are asked to use willpower to stay away from drugs and alcohol, to stay in control; but if they had the willpower to stay away from the drugs and alcohol in the first place they probably would have not been out of control to begin with.  With these considerations in mind, it is important to dissect the myth of willpower as a volitional muscle that varies in size from one person to another, and to substitute this hazardous term with a notion that everyone has the exact same capacity for choice.  Therefore, when one says “I can’t” they are really saying “I won’t.”

It should be pointed out that traditional substance use treatment models make the error of omission in not directly debunking the myth of willpower.  The present approach explicitly incorporates the discussion of the interplay between the notions of willpower and choice into the clinical curriculum.

[In sum, the treatment emphasis is on choice-awareness skillpower rather than on willpower.  Willpower-wise, we are all equally endowed.  But choice-awareness (mindfulness-powered) skillpower is, in fact, a resource that can be cultivated and leveraged for the purposes of recovery.]

Reference:

Choice Awareness Training: Logotherapy & Mindfulness for Treatment of Addictions (P. Somov)

The End of the War on Drugs

Monday, August 12, 2013

Earlier in my career I ran a drug and alcohol treatment program in a county jail. Most of the folks that I came across there, in my opinion, didn’t seem to belong in the correctional setting – most of them were nonviolent users and those who sold drugs only did so to support their habit.  With this in mind, I welcome the end of the clinically misguided war on drugs:

CNN: “Attorney General Eric Holder will announce Monday that the Justice Department will no longer pursue mandatory minimum sentences for “certain low-level, nonviolent drug offenders.”

In a speech at the annual meeting of the American Bar Association’s House of Delegates in San Francisco, he will make the case that the United States “cannot simply prosecute or incarcerate our way to becoming a safer nation.”

Holder set to announce that “drug offenders who have no ties to large-scale organizations, gangs, or cartels will no longer be charged with offenses that impose draconian mandatory minimum sentences.”

They now “will be charged with offenses for which the accompanying sentences are better suited to their individual conduct, rather than excessive prison terms more appropriate for violent criminals or drug kingpins.

Lessening the use of mandatory minimums — sentences that require a mandatory, “one-size-fits-all” punishment for those convicted of federal and state crimes — could mark the end of the tough-on-crime era, which began with strict anti-drug laws in the 1970s and accelerated with mandatory minimum prison sentences and so-called three-strikes laws.”

Finally!

A peace protest cliche is “Make Love, not War!”  This clinician’s protest is: “Fund Treatment, not War on Drugs!”

Somov's Approach, "Recovery Equation," Evaluated by IRETA

Wednesday, September 4, 2013

see full article at http://iretablog.org/2013/08/30/comparing-12-step-and-non-step-models-of-addiction-recovery/

excerpt from Andrea DeSimone's article:

"Recovery Equation is Pittsburgh psychologist Pavel Somov’s novel approach to drug and alcohol treatment.  His theory draws from a variety of teachings such as cognitive behavioral therapycognitive dissonancestress inoculation, and motivational enhancement therapy.  Somov views recovery as the sum of three components: the development of motivation for change, choice awareness, and use prevention skills.

Dr. Somov’s model has been implemented in the Allegheny County Jail and it has been well received by patients because it stresses useful skills that patients can put into practice almost immediately.  For example, clinicians first discuss the neurobiology and experience of cravings and how to disarm them.  The group leader may induce a craving by taking out a plastic bag filled with sugar and lining up the loose sugar with a credit card to simulate cocaine or heroin. Clients then have the opportunity to practice their skills in a safe environment.

Somov’s model uses one particular exercise to demonstrates that addicts retain control over their drug use.  Facilitators tell clients to imagine that someone is putting a gun to their head.  If they use, they will die.  Most people will admit that they would be able to refrain from using that one time.

This situation illustrates that the gun, an inanimate object, did not introduce the choice not to use; the choice was there all along.  The presence of the gun helped the client become aware of the choice.  Because many addicts have felt as though they were under the control of a substance for many years, this exercise can be very powerful."

Andrea DeSimone recently entered her second year of medical school at  the Rowan University of Osteopathic Medicine.  In June, she participated in IRETA’s Scaife Medical Student Fellowship, a three week intensive learning experience about addiction and its treatment hosted by IRETA since 1999.