As such, Buddhist psychology is the Psychology of Moderation.

As a psychology, Buddhism aims to restore the "flow" of the mind, by unanchoring it from what was (but no longer is) and from what will be (but isn't yet), by refocusing the mind on the present, on what still is.

As such, Buddhist psychology is the Psychology of Presence, the Psychology of Existence.

Buddhist psychology aims to help you return to a point of balance, to that proverbial center, to that dialectical pivot of "what is" - out of the categorical extremes of interpretation and judgement of others and self.

As such, Buddhist psychology is the Psychology of Compassion.

Buddhist psychology aims to de-automatize the conditioned mind - to wake up the zombie from his or her conditioned stimulus-response algorithms; to wake up the robot from his or her reflexive, conditioned, unconscious, mechanical, schematic, impulsive, compulsive automaticity; to override the default presets of our reactions with the freedom of conscious choice; i.e. to re-humanize the mind.

As such, Buddhist psychology is the Psychology of Habit Modification and Conscious Choice and Freedom.  and as such, Buddhist psychology is the Psychology of Existential Rehabilitation.

Buddhist psychology doesn't just aim to wake up the brain, it tries to change it - permanently. Through consciousness-training know-how of mindfulness, the Buddhist psychology tries to override the knee-jerk limbic mind-jerks with the brakes of frontal lobe activity.

As such, Buddhist psychology is the Psychology of Neural Plasticity.

Buddhist psychology aims to increase mindfulness to facilitate change of what can be changed and to facilitate the wisdom of letting what cannot be changed just be as it is.

As such, Buddhist psychology is the Psychology of Acceptance, of Dialectical Wisdom, not of passivity.

Check Tribut to Thich to learn about self-control!

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.

Self-talk, another traditional craving control strategy, involves the use of self-motivational statements that reiterate the benefits of sticking to a plan and remind the person of his or her health goals. Self-talk, in its reliance on logic and reason, is of limited utility: craving is an emotional state that takes the otherwise rational brain and reduces it to irrational simplicity. Rational self-talk is hard to pull off when your mind's wisdom has been reduced to a nutritional tantrum of "I want!"

Breath-based relaxation for craving control is an improvement on either distraction or self-talk as it allows the craving-aroused mind to return to its rational baseline.

Mindfulness, as a craving control technique, involves "just witnessing" or "just noticing" craving thoughts as they pass. Mindfulness has received much clinical attention, particularly in the area of substance use treatment where the goals of relapse prevention closely parallel the challenges faced by chronic overeaters (Marlatt, 2002).

In my opinion, mindfulness and relaxation are the first echelon of craving control, followed by self-talk and distraction strategies. But don't just take my word for it: experiment with all four to make an informed choice.

Skill Combinations

There are many ways to combine the four craving control skills. My favorite combinations are mindfulness + relaxation and relaxation + self-talk.

Taking the Guess-work Out of Craving Control

Try all four different methods for controlling your cravings and track your impressions on their effectiveness. Doing so will help you take the guess-work out of craving control. This way, instead of trying to improvise a craving control strategy on the fly, in the future you would default to a craving control method that you've tested and found to be effective.

Taking the Exposure Risk

Any exposure to triggers creates an opportunity to practice your craving control strategies. Purposeful exposure accelerates the learning curve. Therefore, two ways to expedite craving control training are imaginary exposure (which involves imagining an eating-related trigger) and in-vivo exposure (which involves actively seeking out real-life eating-related stimuli).

Craving Control through Mindfulness

Mindfulness, as a craving control method, involves two essential mechanisms: a certain kind of attention and dis-identification. Attention can be active or passive, that of an active observer and that of an uninvolved witness. This distinction is easy to understand through the contrast of such verbs as "to look" and "to see." "To look" implies an active visual scanning, a kind of goal-oriented visual activity. "To see" implies nothing other than a fact of visual registration. Say, I lost my house keys. I would have to look for them. But in the process of looking for my house keys, I might also happen to see an old concert ticket. Mindfulness is about seeing, not looking. It is about "just" noticing and "just" witnessing without an attachment or identification with what is being noticed and witnessed.

This latter element is called dis-identification. "To identify" means to relate, to draw a sign of equality between yourself and something else. When we are experiencing a craving, there is a risk of getting lost in it, becoming overwhelmed. And yet cravings come and go. For us to identify with something that is inherently transient and fleeting is to lose our sense of self, a sense of our immutable continuity. This kind of identification with something impermanent is what imbues craving with its suffering. Mindfulness allows us to recognize that a craving is but a part of the overall experience, a transient, fleeting state of mind, not the mind itself. Mindfulness practice teaches you to realize that this thought, this feeling, this sensation (whatever it might be at any given moment) is but an object inside your mind, no more significant than a paper cup on your kitchen counter. Yes, it is a part of you, but not all of you. A craving is no more a part of your mind than a reflection of your face is a part of the mirror. And that's exactly why you can "just" notice it, "just" see it without having to stare at it.

Mindfulness, as a craving control method, is less effortful than the other methods. Unlike distraction, you are not pushing thoughts of food aside. You are letting go of any attempt to block them, and instead you are letting them in and just noticing them as thoughts and sensations. Unlike self-talk, you are not trying to change your mind, you are accepting your mind as just mind. Unlike relaxation, you are not trying to calm yourself down from the excitation of the craving, you are calmly accepting your excitation as just a part of the craving. In sum, mindfulness is a form of controlling by letting go of control.

Craving Control Exercise 1: Counting Craving Thoughts

Next time you have a craving, pop into the nearest restaurant and order a cup of tea but keep the menu. Look around, smell, read at the pictures in the menu, and watch your mind. Notice the craving thoughts, the food-related thoughts of desire. Each time you notice a craving thought, mark down a dot on a piece of paper. Spend at least five minutes watching your mind like this while marking down dots, one after another. As you do this, you might compare your mind to a stream or a river, and yourself to a dispassionate observer sitting on the bank of this river, watching the craving thoughts pass down the stream, staying put where you are, without getting carried away. As you watch these cravings come and leave, take a note of your mindful presence in this moment: here you are, just noticing the craving thoughts, not going anywhere, staying in the moment, not fleeing, unafraid. Finish the exercise by counting the craving thoughts. Ponder the result: you have controlled all these craving thoughts by not controlling them, just by being non-reactively aware of them enough for them to pass. Congratulations! Practice this at home (staring at a food you like). Should you satisfy your cravings after you have mindfully managed them? That's really for you to decide.
Craving Control Exercise 2: The Mind Lava Lamp

I am sure you've seen a lava lamp. If not, let me describe one. It's a sealed see-through container with a glob of wax submerged inside a liquid. As the liquid warms up from the power source, the wax melts and begins to float up and down morphing into various shapes. The mind is like a lava lamp. Close your eyes right now for a moment and notice your thoughts, feelings, and sensations. All of this mind content is not unlike a glob of wax that moves and morphs from one form to another. Your awareness of this content is not unlike the liquid inside the lava lamp that surrounds the ever-changing glob of wax. And then there is you - the container of all these mental gymnastics. Borrow or purchase a lava lamp. In the weeks to come, spend some time watching it. Turn on the lava lamp and just sit and watch. First, watch the glob of wax come to life. Notice it morph and change. Then, after a while, watch the liquid that surrounds the glob of wax. Watch it remain the same. Then, close your eyes and watch your "mind lava" - the thoughts, the feelings, and the sensations; the content of your mind. Allow yourself the realization: "Wow, all these thoughts and feelings inside of me... Here's one... Here's another one..." Then, after a while, become aware of your awareness of this "mind lava." Allow yourself the realization: "Here I am, being aware of my thoughts and feelings coming and going... These thoughts and feelings are just like an ever-morphing glob of wax inside the liquid of my conscious awareness. And while these thoughts and feelings morph and pass, I - the I that is aware of all this internal commotion - remain the same..." Rest assured: if you feel confused, you're actually on the right track. Just go ahead and watch the mind lava flow past you.

Craving Control Exercise 3: It's Just a Craving, For Crying Out Loud!!!

For those of you who might feel that all this discussion of mindfulness is a bit too esoteric, here's a chance to get real. Let's practice craving control bravado! Here's what I mean. Set yourself up to have a craving (I am sure you know how). As soon as you have a craving, first, put on your calm mindfulness cap: notice, don't identify. Think: "This is just a craving, I am not a craving, this craving is just a part of me, a fleeting, transient, ephemeral, insignificant part of me, not even worth my attention." Then, add a touch of mindfulness bravado: do not "just" notice the craving, but notice it with the kind of scorn that does justice to the insignificance of this mental event. After all, it's just another craving, one of thousands. And, indeed, where's the crisis? Who's on fire?! You've been through this before: it's just the same old banal stimulus-response connection in your brain. You saw something, it triggered you to crave, so here you are, having a craving thought. Feel the scoff, throw in some attitude: "A craving... whoop-tee-doo! So what if it lasts?! Have I ever had a craving that didn't go away?! Of course not! This too shall pass. Craving, my ass!"

Be well!

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.

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

This forced, driven, un-free nature of the compulsive experience is reflected in the cattle-prodding history of the verb "to compel" which derives its meaning from the Latin compellere "to drive together."

But who is this invisible driver that shepherds (sheep-herds) the addicted mind? What is this ominous entity that takes over the steering wheel of human volition to drive us into a functional abyss as we take the backseat to our appetites and drives?

Is addictive behavior really compulsive, in the sense of being driven by an external force that is outside of our control? Or is addictive behavior nothing more than a choice that has become a habit (whether it is with or without a physiological signature of dependence/tolerance/withdrawal)?

How you answer these questions to yourself determines the therapeutic ceiling of your recovery.

If you have previously thought that your boozing and using was by choice but then you have come to think of your behavior as being compulsive (i.e. driven), then, you have , in a sense, shifted away from the position of Free Will (a responsible stance of being the driver of your life) to a position of Existential Passivity and Determinism (a victimized stance of being driven).

The key humanistic challenge of recovery from substance use and other compulsive spectrum disorders is the Recovery of one's Sense of Freedom to Choose, to act freely, to determine one's behavior, and to control the controllable aspects of one's life.

And, indeed, without a regained sense of freedom-to-change, how can a journey of change even begin?

Change, after all, is based on a perceived freedom to choose a novel path, an alternative course of action, a different way.

Recovery from compulsive behavior without the recovery of one's sense of control and self-efficacy is merely behavioral rehabilitation without Existential Rehabilitation.

Indeed, if we - therapists and clients - diagnostically define addiction as being accompanied by a sense of loss of control, then substance use treatment that only eliminates the compulsive behavior of boozing and using without reinstating a sense of control falls short of recovery and is nothing more than symptom management.

Open your mind to the possibility that you are not sick with an incurable disease - but just stuck in ineffective coping.