Relapse Prevention
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Relapse Prevention
Relapse Prevention Therapy: A Cognitive-Behavioral Approach
By George A. Parks, Ph.D. and G. Alan Marlatt, Ph.D.
Relapse Prevention Therapy (RPT) was originally designed as a maintenance program for use following the treatment of addictive behaviors although it is also used as a stand-alone treatment program (Marlatt & Gordon, 1985; Parks & Marlatt, 1999). In the most general sense, RPT is a behavioral self-control program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse.
Relapse refers to a breakdown or failure in a person's attempt maintain change in any set of behaviors. Like other cognitive-behavioral therapies, RPT combines behavioral and cognitive interventions in an overall approach that emphasizes self-management and rejects labeling clients with traits like "alcoholic" or "drug addict."
The Relapse Process
Relapse rates, usually measured as any use of a substance after a period of abstinence, are notoriously high. Research has demonstrated that the temporal patterning of the relapse process and circumstances under which relapses occur are similar across addictive behaviors.
These commonalties provide clues to a general relapse process. As we conceptualize the relapse process, it involves clients experiencing a sense of perceived control and self-efficacy while maintaining changes gained through quitting or moderating their use. The longer the period of successful abstinence or controlled use, the greater the individual's perception of self-efficacy.
This continues until an individual experiences a high-risk situation that poses a threat to their perceived control, decreases self-efficacy, and eventually increases the probability of relapse. In an analysis of relapse episodes obtained from clients with a variety of addictive behavior problems, we identified three high-risk situations that were associated with almost 75% of the relapses reported (Marlatt & Gordon, 1985). They were negative emotional states, interpersonal conflict, and social pressure.
If an individual has an effective coping response to deal with a high-risk situation, the probability of relapse decreases significantly. When a person copes effectively with a high-risk situation, he or she is likely to experience an increased of self-efficacy. As the duration of abstinence (or controlled use) increases, an individual has the experience of coping effectively with one high-risk situation after another and the probability of relapse decreases accordingly.
However, what happens if a person has not learned or cannot implement an effective coping response when confronted with a high-risk situation? Failure to master a high-risk situation is likely to create decreased self-efficacy and a sense of powerlessness. This is followed by positive expectancies for the effects of alcohol or drugs as alternative coping mechanisms. At this point, a lapse is likely.
If a slip does occur, an abstinence violation effect (AVE) follows which consists of cognitive dissonance and the attribution of responsibility for the lapse to internal and stable characteristics of the person. The AVE combined with the intoxicating effects of substance use increases the likelihood that a full-blown relapse will occur.
Relapse Set-Ups
In most of the relapse episodes we have studied or worked with clinically, the first lapse is precipitated in a high-risk situation that clients report they were not expecting and/or were poorly prepared for.
Often, our clients found themselves in rapidly escalating circumstances they could not deal with effectively. Usually, after extensive debriefing, the lapse or subsequent relapse appear to be the last link in a chain of events that preceded exposure to the high-risk situation itself. It seems as if, perhaps unknowingly, even paradoxically, clients set themselves up for relapse because they did not or could not see the early warning signs.
Cognitive distortions such as denial and rationalization make it easier to set up one's own relapse episode. The process of relapse set-ups is determined by a number of covert antecedents that eventually lead to exposure to a high-risk situation, but also allow the individual to deny any responsibility for it.
Relapse Prevention Therapy
RPT intervention strategies can be grouped into three categories: coping skills training, cognitive therapy, and lifestyle modification. Coping skills training strategies include both behavioral and cognitive techniques. Cognitive therapy procedures are designed to provide clients with ways to reframe the habit change process as learning experience with errors and setbacks expected as mastery develops. Finally, lifestyle modification strategies such as meditation, exercise, and spiritual practices are designed to strengthen a client's overall coping capacity.
In clinical practice, coping skills training forms the cornerstone of RPT, teaching clients strategies to:
(a) understand relapse as a process,
(b) identify and cope effectively with high-risk situations,
(c) cope with urges and craving,
(d) implement damage control procedures during a lapse to minimize its negative consequences,
(e) stay engaged in treatment even after a relapse, and
(f) learn how to create a more balanced lifestyle.
Encouraging evidence is provided by recent treatment outcome research for the effectiveness of RPT as a psychosocial treatment for alcohol and drug problems (Irvin et al., 1999).
References
Irvin, J. E., Bowers, C.A., Dunn, M.E., and Wang, M.C. (1999). Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology.
Marlatt, G. A. & Gordon, J.R. (Ed.). (1985). Relapse Prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.
Parks, G. A. and Marlatt, G. A. (1999) Relapse Prevention Therapy for Substance-Abusing Offenders: A Cognitive-Behavioral Approach in What Works: Strategic Solutions: The International Community Corrections Association Examines Substance Abuse edited by E. Latessa. Lanham, MD: American Correctional Association, p. 161- 233.
--------------------------------------------------------------------------------
George A. Parks, Ph.D. is a clinical psychologist practicing in Seattle and a research consultant with the Addictive Behaviors Research Center at the University of Washington. George conducts research and training on integrated cognitive-behavioral therapies for co-occurring disorders including Relapse Prevention Therapy and Harm; Reduction Therapy.
G. Alan Marlatt, Ph.D; is Professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington. Dr. Marlatt's focus is applied clinical research on the effectiveness of relapse prevention and harm reduction in the prevention and treatment of addictive behavior problems.
From the September/October, 2000 (vol. 9, no. 5) of The National Psychologist.
By George A. Parks, Ph.D. and G. Alan Marlatt, Ph.D.
Relapse Prevention Therapy (RPT) was originally designed as a maintenance program for use following the treatment of addictive behaviors although it is also used as a stand-alone treatment program (Marlatt & Gordon, 1985; Parks & Marlatt, 1999). In the most general sense, RPT is a behavioral self-control program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse.
Relapse refers to a breakdown or failure in a person's attempt maintain change in any set of behaviors. Like other cognitive-behavioral therapies, RPT combines behavioral and cognitive interventions in an overall approach that emphasizes self-management and rejects labeling clients with traits like "alcoholic" or "drug addict."
The Relapse Process
Relapse rates, usually measured as any use of a substance after a period of abstinence, are notoriously high. Research has demonstrated that the temporal patterning of the relapse process and circumstances under which relapses occur are similar across addictive behaviors.
These commonalties provide clues to a general relapse process. As we conceptualize the relapse process, it involves clients experiencing a sense of perceived control and self-efficacy while maintaining changes gained through quitting or moderating their use. The longer the period of successful abstinence or controlled use, the greater the individual's perception of self-efficacy.
This continues until an individual experiences a high-risk situation that poses a threat to their perceived control, decreases self-efficacy, and eventually increases the probability of relapse. In an analysis of relapse episodes obtained from clients with a variety of addictive behavior problems, we identified three high-risk situations that were associated with almost 75% of the relapses reported (Marlatt & Gordon, 1985). They were negative emotional states, interpersonal conflict, and social pressure.
If an individual has an effective coping response to deal with a high-risk situation, the probability of relapse decreases significantly. When a person copes effectively with a high-risk situation, he or she is likely to experience an increased of self-efficacy. As the duration of abstinence (or controlled use) increases, an individual has the experience of coping effectively with one high-risk situation after another and the probability of relapse decreases accordingly.
However, what happens if a person has not learned or cannot implement an effective coping response when confronted with a high-risk situation? Failure to master a high-risk situation is likely to create decreased self-efficacy and a sense of powerlessness. This is followed by positive expectancies for the effects of alcohol or drugs as alternative coping mechanisms. At this point, a lapse is likely.
If a slip does occur, an abstinence violation effect (AVE) follows which consists of cognitive dissonance and the attribution of responsibility for the lapse to internal and stable characteristics of the person. The AVE combined with the intoxicating effects of substance use increases the likelihood that a full-blown relapse will occur.
Relapse Set-Ups
In most of the relapse episodes we have studied or worked with clinically, the first lapse is precipitated in a high-risk situation that clients report they were not expecting and/or were poorly prepared for.
Often, our clients found themselves in rapidly escalating circumstances they could not deal with effectively. Usually, after extensive debriefing, the lapse or subsequent relapse appear to be the last link in a chain of events that preceded exposure to the high-risk situation itself. It seems as if, perhaps unknowingly, even paradoxically, clients set themselves up for relapse because they did not or could not see the early warning signs.
Cognitive distortions such as denial and rationalization make it easier to set up one's own relapse episode. The process of relapse set-ups is determined by a number of covert antecedents that eventually lead to exposure to a high-risk situation, but also allow the individual to deny any responsibility for it.
Relapse Prevention Therapy
RPT intervention strategies can be grouped into three categories: coping skills training, cognitive therapy, and lifestyle modification. Coping skills training strategies include both behavioral and cognitive techniques. Cognitive therapy procedures are designed to provide clients with ways to reframe the habit change process as learning experience with errors and setbacks expected as mastery develops. Finally, lifestyle modification strategies such as meditation, exercise, and spiritual practices are designed to strengthen a client's overall coping capacity.
In clinical practice, coping skills training forms the cornerstone of RPT, teaching clients strategies to:
(a) understand relapse as a process,
(b) identify and cope effectively with high-risk situations,
(c) cope with urges and craving,
(d) implement damage control procedures during a lapse to minimize its negative consequences,
(e) stay engaged in treatment even after a relapse, and
(f) learn how to create a more balanced lifestyle.
Encouraging evidence is provided by recent treatment outcome research for the effectiveness of RPT as a psychosocial treatment for alcohol and drug problems (Irvin et al., 1999).
References
Irvin, J. E., Bowers, C.A., Dunn, M.E., and Wang, M.C. (1999). Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology.
Marlatt, G. A. & Gordon, J.R. (Ed.). (1985). Relapse Prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.
Parks, G. A. and Marlatt, G. A. (1999) Relapse Prevention Therapy for Substance-Abusing Offenders: A Cognitive-Behavioral Approach in What Works: Strategic Solutions: The International Community Corrections Association Examines Substance Abuse edited by E. Latessa. Lanham, MD: American Correctional Association, p. 161- 233.
--------------------------------------------------------------------------------
George A. Parks, Ph.D. is a clinical psychologist practicing in Seattle and a research consultant with the Addictive Behaviors Research Center at the University of Washington. George conducts research and training on integrated cognitive-behavioral therapies for co-occurring disorders including Relapse Prevention Therapy and Harm; Reduction Therapy.
G. Alan Marlatt, Ph.D; is Professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington. Dr. Marlatt's focus is applied clinical research on the effectiveness of relapse prevention and harm reduction in the prevention and treatment of addictive behavior problems.
From the September/October, 2000 (vol. 9, no. 5) of The National Psychologist.
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Join Date: Oct 2004
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Relapse Prevention
If you don't want to slip, stay out of slippery places.
This information on relapse prevention & recovery tools is general in nature & is merely suggestive. It is based on the combined practical experience of various DRA members & represents some of the tools & techniques they have used as part of their dual recovery.
People in dual recovery learn to identify the warning signs that may lead to a lapse in their abstinence and take positive steps to stay clean and sober. At the same time, they follow a practical plan that addresses their emotional or psychiatric illness in a positive and constructive way. The quicker they learn to spot these signs and signals the sooner they can take positive action for their own well-being and dual recovery.
Many factors can lead to a relapse or flare-up to one or both of our no-fault illnesses. A flare-up of psychiatric symptoms can leave us more vulnerable to relapsing on drugs or alcohol. Drinking and drugging can lead to a flare-up of our psychiatric illness. Alcohol and drugs can also change the effects of psychiatric medications with unpredictable results. Maintaining abstinence allows us the freedom to grow as individuals and manage our no-fault illnesses in the healthiest possible way.
In chemical dependency, relapse is the act of taking that first drink or drug after being deliberately clean and sober for a time. It helps though to view relapse as a process that begins well in advance of that act. People who have relapsed can usually point back to certain things that they thought and did long before they actually drank or used that eventually caused the relapse. They may have become complacent in their program of recovery in some way or refused to ask for help when they needed it. Each persons relapse factors are unique to them, their diagnosis, and personal plan of recovery.
Relapse is usually caused by a combinations of factors. Some possible factors and warning signs might be:
Stopping medications on one’s own or against the advice of medical professionals
Hanging around old drinking haunts and drug using friends – slippery places
Isolating – not attending meetings – not using the telephone for support
Keeping alcohol, drugs, and paraphernalia around the house for any reason
Obsessive thinking about using drugs or drinking
Failing to follow ones treatment plan – quitting therapy – skipping doctors appointments
Feeling overconfident – that you no longer need support
Relationship difficulties – ongoing serious conflicts – a spouse who still uses
Setting unrealistic goals – perfectionism – being too hard on ourselves
Changes in eating and sleeping patterns, personal hygiene, or energy levels
Feeling overwhelmed – confused – useless – stressed out
Constant boredom – irritability – lack of routine and structure in life
Sudden changes in psychiatric symptoms
Dwelling on resentments and past hurts – anger – unresolved conflicts
Avoidance – refusing to deal with personal issues and other problems of daily living
Engaging in obsessive behaviors – workaholism – gambling – sexual excess and acting out
Major life changes – loss – grief – trauma – painful emotions – winning the lottery
Ignoring relapse warning signs and triggers
Almost everyone in recovery has times when compelling thoughts of drinking or using drugs resurface. In early recovery, drinking or drugging dreams are not uncommon. It helps to remind ourselves that the reality of drinking and using has caused many problems in our lives. That no matter how bad things get, the benefits of staying abstinent will far outweigh any short term relief that might be found in drugs or alcohol. Recovery takes time. Eventually the cravings, relapse dreams, and uncertainties of early recovery fade. When we are committed to dual recovery we slowly but surely develop a new confidence in our new way of life without drugs and alcohol.
Staying clean and sober and managing ones psychiatric symptoms constructively is an ongoing process. Abstinence and dealing positively with a dual disorder go hand in hand. DRA members build a personal inventory of recovery tools that help them meet these goals by staying involved in the process of dual recovery. An individual is in dual recovery when they are actively following a program that focuses on the recovery needs for both their chemical dependency and their psychiatric illness. People in dual recovery make sure to use some of their recovery tools each and every day. Their personal recovery tool kit serves as the best protection against a relapse.
By identifying things that put us at risk for relapse and using the various recovery tools on an ongoing basis, we try to prevent a relapse before it happens. We can periodically review our relapse prevention plans with our doctors, treatment professionals and sponsors and modify them as needed.
By becoming familiar with our triggers and warning signs, utilizing the various recovery tools, and having a practical plan of action, we greatly minimize the tendency to lapse back into our addictions. If and when lapses do happen, we do not judge or blame--we are not bad people. We seek progress not perfection. We simply learn what we can from the situation and move on with our program of dual recovery. Sharing our relapse experience with our sponsor, group, and helping professionals is an important way to figure out what went wrong. Our experience may also help others in recover --------------------------------------------------------------------------------
Preventing Relapse Main Page
A few common tools that sustain recovery and help in times of crisis are:
Journaling our progress in recovery
Meetings, attending DRA and other 12 Step support meetings
The telephone, reaching out
Prayer and meditation seeking guidance
Reading recovery books and literature
A plan of action, a written list of things to do when sudden cravings strike or symptoms increase
Additional forms and lists that can help us to build a personal relapse prevention plan
Relaxation techniques
Service work, helping others
The Steps, the basis of our recovery
Talking to sponsors, caring advisors, and recovering friends
Recovery slogans
First Things First
This Too Shall Pass
One Day At A Time
Easy Does It
H.A.L.T.
Keep It Simple
Live And Let Live
The Serenity Prayer
Today I will do one thing
More Slogans
™
Dual Recovery Anonymous
World Services Central Office
P.O. Box 8107, Prairie Village, Kansas, 66208
Toll Free 1-877-883-2332
Relapse Prevention
If you don't want to slip, stay out of slippery places.
This information on relapse prevention & recovery tools is general in nature & is merely suggestive. It is based on the combined practical experience of various DRA members & represents some of the tools & techniques they have used as part of their dual recovery.
People in dual recovery learn to identify the warning signs that may lead to a lapse in their abstinence and take positive steps to stay clean and sober. At the same time, they follow a practical plan that addresses their emotional or psychiatric illness in a positive and constructive way. The quicker they learn to spot these signs and signals the sooner they can take positive action for their own well-being and dual recovery.
Many factors can lead to a relapse or flare-up to one or both of our no-fault illnesses. A flare-up of psychiatric symptoms can leave us more vulnerable to relapsing on drugs or alcohol. Drinking and drugging can lead to a flare-up of our psychiatric illness. Alcohol and drugs can also change the effects of psychiatric medications with unpredictable results. Maintaining abstinence allows us the freedom to grow as individuals and manage our no-fault illnesses in the healthiest possible way.
In chemical dependency, relapse is the act of taking that first drink or drug after being deliberately clean and sober for a time. It helps though to view relapse as a process that begins well in advance of that act. People who have relapsed can usually point back to certain things that they thought and did long before they actually drank or used that eventually caused the relapse. They may have become complacent in their program of recovery in some way or refused to ask for help when they needed it. Each persons relapse factors are unique to them, their diagnosis, and personal plan of recovery.
Relapse is usually caused by a combinations of factors. Some possible factors and warning signs might be:
Stopping medications on one’s own or against the advice of medical professionals
Hanging around old drinking haunts and drug using friends – slippery places
Isolating – not attending meetings – not using the telephone for support
Keeping alcohol, drugs, and paraphernalia around the house for any reason
Obsessive thinking about using drugs or drinking
Failing to follow ones treatment plan – quitting therapy – skipping doctors appointments
Feeling overconfident – that you no longer need support
Relationship difficulties – ongoing serious conflicts – a spouse who still uses
Setting unrealistic goals – perfectionism – being too hard on ourselves
Changes in eating and sleeping patterns, personal hygiene, or energy levels
Feeling overwhelmed – confused – useless – stressed out
Constant boredom – irritability – lack of routine and structure in life
Sudden changes in psychiatric symptoms
Dwelling on resentments and past hurts – anger – unresolved conflicts
Avoidance – refusing to deal with personal issues and other problems of daily living
Engaging in obsessive behaviors – workaholism – gambling – sexual excess and acting out
Major life changes – loss – grief – trauma – painful emotions – winning the lottery
Ignoring relapse warning signs and triggers
Almost everyone in recovery has times when compelling thoughts of drinking or using drugs resurface. In early recovery, drinking or drugging dreams are not uncommon. It helps to remind ourselves that the reality of drinking and using has caused many problems in our lives. That no matter how bad things get, the benefits of staying abstinent will far outweigh any short term relief that might be found in drugs or alcohol. Recovery takes time. Eventually the cravings, relapse dreams, and uncertainties of early recovery fade. When we are committed to dual recovery we slowly but surely develop a new confidence in our new way of life without drugs and alcohol.
Staying clean and sober and managing ones psychiatric symptoms constructively is an ongoing process. Abstinence and dealing positively with a dual disorder go hand in hand. DRA members build a personal inventory of recovery tools that help them meet these goals by staying involved in the process of dual recovery. An individual is in dual recovery when they are actively following a program that focuses on the recovery needs for both their chemical dependency and their psychiatric illness. People in dual recovery make sure to use some of their recovery tools each and every day. Their personal recovery tool kit serves as the best protection against a relapse.
By identifying things that put us at risk for relapse and using the various recovery tools on an ongoing basis, we try to prevent a relapse before it happens. We can periodically review our relapse prevention plans with our doctors, treatment professionals and sponsors and modify them as needed.
By becoming familiar with our triggers and warning signs, utilizing the various recovery tools, and having a practical plan of action, we greatly minimize the tendency to lapse back into our addictions. If and when lapses do happen, we do not judge or blame--we are not bad people. We seek progress not perfection. We simply learn what we can from the situation and move on with our program of dual recovery. Sharing our relapse experience with our sponsor, group, and helping professionals is an important way to figure out what went wrong. Our experience may also help others in recover --------------------------------------------------------------------------------
Preventing Relapse Main Page
A few common tools that sustain recovery and help in times of crisis are:
Journaling our progress in recovery
Meetings, attending DRA and other 12 Step support meetings
The telephone, reaching out
Prayer and meditation seeking guidance
Reading recovery books and literature
A plan of action, a written list of things to do when sudden cravings strike or symptoms increase
Additional forms and lists that can help us to build a personal relapse prevention plan
Relaxation techniques
Service work, helping others
The Steps, the basis of our recovery
Talking to sponsors, caring advisors, and recovering friends
Recovery slogans
First Things First
This Too Shall Pass
One Day At A Time
Easy Does It
H.A.L.T.
Keep It Simple
Live And Let Live
The Serenity Prayer
Today I will do one thing
More Slogans
™
Dual Recovery Anonymous
World Services Central Office
P.O. Box 8107, Prairie Village, Kansas, 66208
Toll Free 1-877-883-2332
Member
Thread Starter
Join Date: Oct 2004
Location: The Field of Dreams
Posts: 7,249
Delevoping A Relapse Prevention Program
How To Develop A RP Plan
By Terence T. Gorski
GORSKI-CENAPS Web Publications
(www.tgorski.com; www.cenaps.com; www.relapse.org)
May 28, 2003
Terry Gorski and other members of the GORSKI-CENAPS Team are available to train & consult on areas related to recovery & relapse prevention
People who relapse aren't suddenly taken drunk. Most experience progressive warning signs that reactivate denial and cause so much pain that self-medication with alcohol or drugs seems like a good idea. This is not a conscious process. These warning signs develop automatically and unconsciously. Since most recovering people have never been taught how to identify and manage relapse warning signs, they don't notice them until the pain becomes too severe to ignore.
There are nine steps in learning to recognize and stop the early warning signs of relapse.
Step 1: Stabilization:
Relapse prevention planning probably won't work unless the relapser is sober and in control of themselves. Detoxification and a few good days of sobriety are needed in order to make relapse prevention planning work. Remember that many patients who relapse are toxic. Even though sober they have difficulty thinking clearly, remembering things and managing their feelings and emotions. These symptoms get worse when the person is under high stress or is isolated from people to talk to about the problems of staying sober. To surface intense therapy issues with someone who has a toxic brain can increase rather than decrease the risk of relapse. In early abstinence go slow and focus on basics. The key question is "What do you need to do to not drink today?"
Step 2: Assessment:
The assessment process is designed to identify the recurrent pattern of problems that caused past relapses and resolve the pain associated with those problems. This is accomplished by reconstructing the presenting problems, the life history, the alcohol and drug use history and the recovery relapse history.
By reconstructing the presenting problems the here and now issues that pose an immediate threat to sobriety can be identified and crisis plans developed to resolve those issues.
The life history explores each developmental life period including childhood, grammar school, high school, college, military, adult work history, adult friendship history, and adult intimate relationship history. Reviewing the life history can surface painful unresolved memories. It's important to go slow and talk about the feelings that accompany these memories.
Once the life history is reviewed, a detailed alcohol and drug use history is reconstructed. This is be done by reviewing each life period and asking four questions: (1) How much alcohol or drugs did you use? (2) How often did you use it? (3) What did you want alcohol and drug use to accomplish? and (4) What were the real consequences, positive and negative, of your use? In other words, did the booze and drugs do for you what you wanted it to do during each period of your life?
Finally, the recovery and relapse history is reconstructed. Starting with the first serious attempt at sobriety each period of abstinence and chemical use is carefully explored. The major goal is to find out what happened during each period of abstinence that set the stage for relapse. This is often difficult because most relapsers are preoccupied with their drinking and drugging and resist thinking or talking about what happened during periods of abstinence.
Comprehensive assessments have shown that most relapsers get sober, encounter the same recurring pattern of problems, and use those problems to justify the next relapse. As one person put it "It is not one thing after the other, it is the same thing over and over again!"
A 23 year old relapser named Jake reported drinking about a six pack of beer every Friday and Saturday night during high school. He did it in order to feel like he was part of the group, relax and have fun. at that stage in his addiction the beer did exactly what he wanted it to do.
That all changed when Jake left school and went to work as a salesman. He had to perform in a high pressure environment and felt stressed. The other salesmen were competitive and no matter what he did they wouldn't let him belong. He began drinking bourbon every night to deal with the stress. He wanted to feel relaxed so he could cope better at work. He consistently drank too much and woke up with terrible hangovers that caused new problems with his job.
Every time Jake would attempt to stop drinking he would feel isolated and alone and become overwhelmed by the stress of his job. Even when with others at Twelve Step Meetings he felt like he didn't belong and couldn't fit in. As the stress grew he began to think "If this is sobriety who needs it?" Each relapse was related with his inability to deal with job related pressures.
By comparing the life history, the alcohol and drug use history, and the recovery relapse history Jake could see in a dramatic way the recurrent problems that caused him to relapse. The two major issues were (1) the need to drink in order to feel like he belonged and (2) the need to drink in order to cope with stress.
It wasn't surprising that Jake discovered that during every past period of abstinence he became isolated, lonely and depressed. The longer he stayed sober the worse it got. The stress built up until he felt that if he didn't take a drink to relax he would go crazy or collapse.
Step 3: Relapse Education:
Relapsers need to learn about the relapse process and how to manage it. It's not a bad idea to get their family and Twelve Step Sponsors involved. The education needs to reinforce four major messages: First, relapse is a normal and natural part of recovery from chemical dependence. There is nothing to be ashamed or embarrassed about. Second, people are not suddenly taken drunk. There a progressive patterns of warning signs that set them up to use again. These warning signs can be identified and recognized while sober. Third, once identified recovering people can learn to manage the relapse warning signs while sober. And Fourth, there is hope. A new counseling procedure called relapse prevention therapy can teach recovering people how to recognize and manage warning signs so a return to chemical use becomes unnecessary.
When Jake entered relapse prevention therapy he felt demoralized and hopeless. That began to change when he heard his first lecture that described the typical warning signs that precede relapse to chemical use. He felt like someone had read his mail. "Since someone understand what causes me to get drunk," he thought, "perhaps they know what to do in order to stay sober.
Step 4: Warning Sign Identification:
Relapsers need to identify the problems that caused relapse. The goal is to write a list of personal warning signs that lead them from stable recovery back to chemical use.
There is seldom just one warning sign. Usually a series of warning signs build one on the other to create relapse. It's the cumulative affect that wears them down. The final warning sign is simply the straw that breaks the camel's back. Unfortunately many of relapsers think it's the last warning sign that did it. As a result they don't look for the earlier and more subtle warning signs that set the stage for the final disaster.
When Jake first came into relapse prevention therapy he thought that he was crazy. "I can't understand it," he told his counselor, "Everything was going fine and suddenly, for no reason at all I started to overreact to things. I'd get confused, make stupid mistakes and then not know what to do to fix it. I got so stressed out that I got drunk over it."
Jake, like most relapsers, didn't know what his early relapse warning signs were and as a result didn't recognize the problems until it was too late. A number of procedures are used to help recovering people identify the early warning signs relapse.
Most people start by reviewing and discussing The Phases And Warning Signs Of Relapse (available from Independence Press, PO Box HE, Independence MO 64055, 1-800-767-8181). This warning sign list describes the typical sequence of problems that lead from stable recovery to alcohol and drug use. By reading and discussing these warning signs relapsers develop a new way of thinking about the things that happened during past periods of abstinence that set them up to use. They learn new words with which to describe their past experiences.
After reading the warning signs they develop an initial warning sign list by selecting five of the warning signs that they can identify with. These warning signs become a starting point for warning sign analysis. Since most relapsers don't know what their warning signs are they need to be guided through a process that will uncover them. The relapser is asked to take each of the five warning signs and tell a story about a time when they experienced that warning sign in the past while sober. They tell these stories both to their therapist and to their therapy group. The goal is to look for hidden warning signs that are reflected in the story.
Jake, for example, identified with the warning sign "Tendency toward loneliness." He told a story about a time when he was sober and all alone in the house because his wife had left with the children. "I felt so lonely and abandoned, he said. I couldn't understand why she would walk out just because we had a fight. She should be able to handle it better than she does."
The group began asking questions and it turned out that Jake had frequent arguments with his wife that were caused by his grouchiness because of problems on the job. It turned out that these family arguments were a critical warning sign that occurred before most relapses. Jake had never considered his marriage to be a problem, and as a result never thought of getting marriage counseling.
Jake had now identified three warning signs: (1) the need to drink in order to feel like he belonged, (2) the need to drink in order to cope with stress, and (3) the need to drink in order to cope with marital problems. In order to be effectively managed each of these warning would need to be further clarified.
I then had Jake to write these three warning signs using a standard format and identify the irrational thoughts, unmanageable feelings and self defeating behavior that accompanied each. He wrote:
(1) I know I am in trouble with my recovery when I feeling lonely and unable to fit in with other people; When this happens I tend to think that I am no good and nobody could ever care about me. When this happens I tend to feel lonely, angry and afraid. When this happens I have an urge to hide myself away so I don't have to talk with anyone.
(2) I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress; When this happens I tend to think that I need to try harder in order to get things under control or else I will be a failure. When this happens I tend to feel humiliated and embarrassed. When this happens I drive myself to keep working even thought I know I need to rest.
(3) I know I am in trouble with my recovery when I irrationally angry at my wife. When this happens I tend to think that I'm a terrible person for treating her that way, but a part of me believes she deserves it. When this I happens I tend to feel angry and ashamed. When this happens forget that the incident ever happened, put it behind us and get on with our marriage.
With this detailed description of the relapse warning signs Jake was ready to move on to the fifth step of relapse prevention planning, warning sign management.
Understanding the warning signs is not enough. We need to learn how to manage them without resorting to alcohol or drug use. This means learning nonchemical problem solving strategies that help us to identify high risk situations and develop coping strategies. In this way relapsers can diffuse irrational thinking, manage painful feelings, and stop the self-defeating behaviors before they lead to alcohol or drug use.
This is done by taking each relapse warning sign and developing a general coping strategy. Jake, for example developed the following management strategy for dealing with his job related stress.
Warning Sign: I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress.
General Coping Strategy: I will learn how to say no to taking on extra projects, limit my work to 45 hours per week, and learn how to use relaxation exercises and meditation to unwind.
The next step is to identify ways to cope with the irrational thoughts, unmanageable feelings, and self-defeating behaviors that accompany each warning sign. Jake developed the following coping strategies:
Irrational Thought: I need to try harder in order to get things under control or else I will be a failure.
Rational Thought: I am burned out because I am trying to hard. I need to time to rest or I will start making more mistakes.
Unmanageable Feelings: Humiliation and embarrassment.
Feeling Management Strategy: Talk about my feelings with others. Remind myself that there is no reason to embarrassed. I am a fallible human being and all people get tired.
Self-defeating Behavior: Driving myself to keep working even thought I know I need to rest.
Constructive Behavior: Take a break and relax. Ask someone to review the project and see if they can help me to solve the problem.
Now Jake is ready to move unto the sixth step of recovery planning. A recovery plan is a schedule of activities that puts relapsers into regular contact with people who will help them to avoid alcohol and drug use. They must stay sober by working the twelve step program and attending relapse prevention support groups that teach them to recognize and manage relapse warning signs. This is why I call relapse prevention planning a "Twelve Step Plus" approach to recovery.
Jake needed to build something into his recovery program to help him deal with job related stress. He decided to enter into counseling with a counselor who specialized in stress management, understood chemical dependency and had a background as an employee assistance counselor. By doing this Jake was forced to regular discuss his problems at work and review how he was coping with them. By identifying job related problems early, he could prevent getting overwhelmed by small problems that became overwhelming.
The seventh step is inventory training. Most relapsers find it helpful to get in the habit of doing a morning and evening inventory. The goal of the morning inventory is to prepare to recognize and manage warning signs. The goal of the evening inventory is to review progress and problems. This allows relapsers to stay anticipate high risk situations and monitor for relapse warning signs. Relapsers need to take inventory work seriously because most warning signs are deeply entrenched habits that are hard to change and tend to automatically come back whenever certain problems or stresses occur. If we aren't alert we may not notice them until it's too late.
The eighth step is family involvement. A supportive family can make the difference between recovery and relapse. We need to encourage our family members to get involved in Alanon so they can recover from codependency. With this foundation of shared recovery we can beginning talking with our families about past relapses, the warning signs that led up to them, and how the relapse hurt the family. Most importantly we can work together to avoid future relapse.
If we had heart disease we would want our family to be prepared for an emergency. Chemical dependency is a disease just like heart disease. Our families' needs to know about the early warning signs that lead to relapse. They must be prepared to take fast and decisive action if we return to chemical use. We can work out in advance, when we are in a sober state of mind, the steps they should take if we return to chemical use. Our very life could depend upon it.
The final step is follow-up. Our warning signs will change as we progress in recovery. Each stage of recovery has unique warning signs. Our ability to deal with the warning signs of one stage of recovery doesn't guarantee that we will recognize or know how to manage the warning signs of the next stage. Our relapse prevention plan needs to be updated regularly; monthly for the first three months, quarterly for the first two years, and annually thereafter.
Originally Published In: Alcoholism & Addiction Magazine: Relapse - Issues and Answers: Column 3: How To Develop A Relapse Prevention Plan: By Terence T. Gorski, September 25, 1989; 708-799-5000, www.cenaps.com.
CENREF ART003
About the Author
Terence T. Gorski is internationally recognized for his contributions to Relapse Prevention Therapy. The scope of his work, however, extends far beyond this. A skilled cognitive behavioral therapist with extensive training in experiential therapies, Gorski has broad-based experience and expertise in the chemical dependency, behavioral health, and criminal justice fields.
By Terence T. Gorski
GORSKI-CENAPS Web Publications
(www.tgorski.com; www.cenaps.com; www.relapse.org)
May 28, 2003
Terry Gorski and other members of the GORSKI-CENAPS Team are available to train & consult on areas related to recovery & relapse prevention
People who relapse aren't suddenly taken drunk. Most experience progressive warning signs that reactivate denial and cause so much pain that self-medication with alcohol or drugs seems like a good idea. This is not a conscious process. These warning signs develop automatically and unconsciously. Since most recovering people have never been taught how to identify and manage relapse warning signs, they don't notice them until the pain becomes too severe to ignore.
There are nine steps in learning to recognize and stop the early warning signs of relapse.
Step 1: Stabilization:
Relapse prevention planning probably won't work unless the relapser is sober and in control of themselves. Detoxification and a few good days of sobriety are needed in order to make relapse prevention planning work. Remember that many patients who relapse are toxic. Even though sober they have difficulty thinking clearly, remembering things and managing their feelings and emotions. These symptoms get worse when the person is under high stress or is isolated from people to talk to about the problems of staying sober. To surface intense therapy issues with someone who has a toxic brain can increase rather than decrease the risk of relapse. In early abstinence go slow and focus on basics. The key question is "What do you need to do to not drink today?"
Step 2: Assessment:
The assessment process is designed to identify the recurrent pattern of problems that caused past relapses and resolve the pain associated with those problems. This is accomplished by reconstructing the presenting problems, the life history, the alcohol and drug use history and the recovery relapse history.
By reconstructing the presenting problems the here and now issues that pose an immediate threat to sobriety can be identified and crisis plans developed to resolve those issues.
The life history explores each developmental life period including childhood, grammar school, high school, college, military, adult work history, adult friendship history, and adult intimate relationship history. Reviewing the life history can surface painful unresolved memories. It's important to go slow and talk about the feelings that accompany these memories.
Once the life history is reviewed, a detailed alcohol and drug use history is reconstructed. This is be done by reviewing each life period and asking four questions: (1) How much alcohol or drugs did you use? (2) How often did you use it? (3) What did you want alcohol and drug use to accomplish? and (4) What were the real consequences, positive and negative, of your use? In other words, did the booze and drugs do for you what you wanted it to do during each period of your life?
Finally, the recovery and relapse history is reconstructed. Starting with the first serious attempt at sobriety each period of abstinence and chemical use is carefully explored. The major goal is to find out what happened during each period of abstinence that set the stage for relapse. This is often difficult because most relapsers are preoccupied with their drinking and drugging and resist thinking or talking about what happened during periods of abstinence.
Comprehensive assessments have shown that most relapsers get sober, encounter the same recurring pattern of problems, and use those problems to justify the next relapse. As one person put it "It is not one thing after the other, it is the same thing over and over again!"
A 23 year old relapser named Jake reported drinking about a six pack of beer every Friday and Saturday night during high school. He did it in order to feel like he was part of the group, relax and have fun. at that stage in his addiction the beer did exactly what he wanted it to do.
That all changed when Jake left school and went to work as a salesman. He had to perform in a high pressure environment and felt stressed. The other salesmen were competitive and no matter what he did they wouldn't let him belong. He began drinking bourbon every night to deal with the stress. He wanted to feel relaxed so he could cope better at work. He consistently drank too much and woke up with terrible hangovers that caused new problems with his job.
Every time Jake would attempt to stop drinking he would feel isolated and alone and become overwhelmed by the stress of his job. Even when with others at Twelve Step Meetings he felt like he didn't belong and couldn't fit in. As the stress grew he began to think "If this is sobriety who needs it?" Each relapse was related with his inability to deal with job related pressures.
By comparing the life history, the alcohol and drug use history, and the recovery relapse history Jake could see in a dramatic way the recurrent problems that caused him to relapse. The two major issues were (1) the need to drink in order to feel like he belonged and (2) the need to drink in order to cope with stress.
It wasn't surprising that Jake discovered that during every past period of abstinence he became isolated, lonely and depressed. The longer he stayed sober the worse it got. The stress built up until he felt that if he didn't take a drink to relax he would go crazy or collapse.
Step 3: Relapse Education:
Relapsers need to learn about the relapse process and how to manage it. It's not a bad idea to get their family and Twelve Step Sponsors involved. The education needs to reinforce four major messages: First, relapse is a normal and natural part of recovery from chemical dependence. There is nothing to be ashamed or embarrassed about. Second, people are not suddenly taken drunk. There a progressive patterns of warning signs that set them up to use again. These warning signs can be identified and recognized while sober. Third, once identified recovering people can learn to manage the relapse warning signs while sober. And Fourth, there is hope. A new counseling procedure called relapse prevention therapy can teach recovering people how to recognize and manage warning signs so a return to chemical use becomes unnecessary.
When Jake entered relapse prevention therapy he felt demoralized and hopeless. That began to change when he heard his first lecture that described the typical warning signs that precede relapse to chemical use. He felt like someone had read his mail. "Since someone understand what causes me to get drunk," he thought, "perhaps they know what to do in order to stay sober.
Step 4: Warning Sign Identification:
Relapsers need to identify the problems that caused relapse. The goal is to write a list of personal warning signs that lead them from stable recovery back to chemical use.
There is seldom just one warning sign. Usually a series of warning signs build one on the other to create relapse. It's the cumulative affect that wears them down. The final warning sign is simply the straw that breaks the camel's back. Unfortunately many of relapsers think it's the last warning sign that did it. As a result they don't look for the earlier and more subtle warning signs that set the stage for the final disaster.
When Jake first came into relapse prevention therapy he thought that he was crazy. "I can't understand it," he told his counselor, "Everything was going fine and suddenly, for no reason at all I started to overreact to things. I'd get confused, make stupid mistakes and then not know what to do to fix it. I got so stressed out that I got drunk over it."
Jake, like most relapsers, didn't know what his early relapse warning signs were and as a result didn't recognize the problems until it was too late. A number of procedures are used to help recovering people identify the early warning signs relapse.
Most people start by reviewing and discussing The Phases And Warning Signs Of Relapse (available from Independence Press, PO Box HE, Independence MO 64055, 1-800-767-8181). This warning sign list describes the typical sequence of problems that lead from stable recovery to alcohol and drug use. By reading and discussing these warning signs relapsers develop a new way of thinking about the things that happened during past periods of abstinence that set them up to use. They learn new words with which to describe their past experiences.
After reading the warning signs they develop an initial warning sign list by selecting five of the warning signs that they can identify with. These warning signs become a starting point for warning sign analysis. Since most relapsers don't know what their warning signs are they need to be guided through a process that will uncover them. The relapser is asked to take each of the five warning signs and tell a story about a time when they experienced that warning sign in the past while sober. They tell these stories both to their therapist and to their therapy group. The goal is to look for hidden warning signs that are reflected in the story.
Jake, for example, identified with the warning sign "Tendency toward loneliness." He told a story about a time when he was sober and all alone in the house because his wife had left with the children. "I felt so lonely and abandoned, he said. I couldn't understand why she would walk out just because we had a fight. She should be able to handle it better than she does."
The group began asking questions and it turned out that Jake had frequent arguments with his wife that were caused by his grouchiness because of problems on the job. It turned out that these family arguments were a critical warning sign that occurred before most relapses. Jake had never considered his marriage to be a problem, and as a result never thought of getting marriage counseling.
Jake had now identified three warning signs: (1) the need to drink in order to feel like he belonged, (2) the need to drink in order to cope with stress, and (3) the need to drink in order to cope with marital problems. In order to be effectively managed each of these warning would need to be further clarified.
I then had Jake to write these three warning signs using a standard format and identify the irrational thoughts, unmanageable feelings and self defeating behavior that accompanied each. He wrote:
(1) I know I am in trouble with my recovery when I feeling lonely and unable to fit in with other people; When this happens I tend to think that I am no good and nobody could ever care about me. When this happens I tend to feel lonely, angry and afraid. When this happens I have an urge to hide myself away so I don't have to talk with anyone.
(2) I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress; When this happens I tend to think that I need to try harder in order to get things under control or else I will be a failure. When this happens I tend to feel humiliated and embarrassed. When this happens I drive myself to keep working even thought I know I need to rest.
(3) I know I am in trouble with my recovery when I irrationally angry at my wife. When this happens I tend to think that I'm a terrible person for treating her that way, but a part of me believes she deserves it. When this I happens I tend to feel angry and ashamed. When this happens forget that the incident ever happened, put it behind us and get on with our marriage.
With this detailed description of the relapse warning signs Jake was ready to move on to the fifth step of relapse prevention planning, warning sign management.
Understanding the warning signs is not enough. We need to learn how to manage them without resorting to alcohol or drug use. This means learning nonchemical problem solving strategies that help us to identify high risk situations and develop coping strategies. In this way relapsers can diffuse irrational thinking, manage painful feelings, and stop the self-defeating behaviors before they lead to alcohol or drug use.
This is done by taking each relapse warning sign and developing a general coping strategy. Jake, for example developed the following management strategy for dealing with his job related stress.
Warning Sign: I know I am in trouble with my recovery when I feel unable to cope with high levels of job-related stress.
General Coping Strategy: I will learn how to say no to taking on extra projects, limit my work to 45 hours per week, and learn how to use relaxation exercises and meditation to unwind.
The next step is to identify ways to cope with the irrational thoughts, unmanageable feelings, and self-defeating behaviors that accompany each warning sign. Jake developed the following coping strategies:
Irrational Thought: I need to try harder in order to get things under control or else I will be a failure.
Rational Thought: I am burned out because I am trying to hard. I need to time to rest or I will start making more mistakes.
Unmanageable Feelings: Humiliation and embarrassment.
Feeling Management Strategy: Talk about my feelings with others. Remind myself that there is no reason to embarrassed. I am a fallible human being and all people get tired.
Self-defeating Behavior: Driving myself to keep working even thought I know I need to rest.
Constructive Behavior: Take a break and relax. Ask someone to review the project and see if they can help me to solve the problem.
Now Jake is ready to move unto the sixth step of recovery planning. A recovery plan is a schedule of activities that puts relapsers into regular contact with people who will help them to avoid alcohol and drug use. They must stay sober by working the twelve step program and attending relapse prevention support groups that teach them to recognize and manage relapse warning signs. This is why I call relapse prevention planning a "Twelve Step Plus" approach to recovery.
Jake needed to build something into his recovery program to help him deal with job related stress. He decided to enter into counseling with a counselor who specialized in stress management, understood chemical dependency and had a background as an employee assistance counselor. By doing this Jake was forced to regular discuss his problems at work and review how he was coping with them. By identifying job related problems early, he could prevent getting overwhelmed by small problems that became overwhelming.
The seventh step is inventory training. Most relapsers find it helpful to get in the habit of doing a morning and evening inventory. The goal of the morning inventory is to prepare to recognize and manage warning signs. The goal of the evening inventory is to review progress and problems. This allows relapsers to stay anticipate high risk situations and monitor for relapse warning signs. Relapsers need to take inventory work seriously because most warning signs are deeply entrenched habits that are hard to change and tend to automatically come back whenever certain problems or stresses occur. If we aren't alert we may not notice them until it's too late.
The eighth step is family involvement. A supportive family can make the difference between recovery and relapse. We need to encourage our family members to get involved in Alanon so they can recover from codependency. With this foundation of shared recovery we can beginning talking with our families about past relapses, the warning signs that led up to them, and how the relapse hurt the family. Most importantly we can work together to avoid future relapse.
If we had heart disease we would want our family to be prepared for an emergency. Chemical dependency is a disease just like heart disease. Our families' needs to know about the early warning signs that lead to relapse. They must be prepared to take fast and decisive action if we return to chemical use. We can work out in advance, when we are in a sober state of mind, the steps they should take if we return to chemical use. Our very life could depend upon it.
The final step is follow-up. Our warning signs will change as we progress in recovery. Each stage of recovery has unique warning signs. Our ability to deal with the warning signs of one stage of recovery doesn't guarantee that we will recognize or know how to manage the warning signs of the next stage. Our relapse prevention plan needs to be updated regularly; monthly for the first three months, quarterly for the first two years, and annually thereafter.
Originally Published In: Alcoholism & Addiction Magazine: Relapse - Issues and Answers: Column 3: How To Develop A Relapse Prevention Plan: By Terence T. Gorski, September 25, 1989; 708-799-5000, www.cenaps.com.
CENREF ART003
About the Author
Terence T. Gorski is internationally recognized for his contributions to Relapse Prevention Therapy. The scope of his work, however, extends far beyond this. A skilled cognitive behavioral therapist with extensive training in experiential therapies, Gorski has broad-based experience and expertise in the chemical dependency, behavioral health, and criminal justice fields.
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Managing Difficult Behavior
MANAGING DIFFICULT BEHAVIOR
Preventing unwanted behavior. Is it really within our powers?
Just as it is hard to start a new habit, it is hard to stop an old one. In fact, some behaviors are thought to be unpreventable, i.e. beyond our ability to control with "willpower" or self-help techniques. Many feel this way about drinking alcohol; some do about eating, smoking, and even procrastination. When we add an awareness that genetic, metabolic, physiological, unconscious, and environmental factors as well as underlying emotions affect our reaction to drinking, food, smoking, coffee, soft drinks, sugar, etc., it shakes our faith (rightly so) in self-control. There is evidence, for instance, that alcoholics chemically process alcohol differently from nonalcoholics (Heilman, film). Alcoholism is called a "disease," implying that it is an unstoppable physical disorder, treatable only by physicians or a Higher Power? For an extensive discussion and references, see the Addiction section and Stanton Peele's books (Peele & Brodsky, 1991). For the specific steps to take when preventing relapse, go to Relapse Prevention.
Experienced people in Alcoholics Anonymous (AA), Overeaters Anonymous (OA), and Emotions Anonymous (EA) say the first step towards recovery is to admit you are powerless over alcohol, food, emotions, or whatever. Then, their 12-step program basically says, (l) abstain (totally in the case of alcohol) by asking for help from friends (in AA or OA or EA who have been in the same situation) and from a Higher Power, (2) admit your "defects of character" and the wrongs you've done, and (3) make amends. AA is often considered the best available treatment for alcoholism, so use it if you need it. Interestingly, AA has a reputation for being successful in spite of little or no outcome research. Unfortunately, AA opposes research (members aren't supposed to disclose what happens at AA meetings) and doesn't directly teach self-control methods. It is known that many people go to AA only a few times and others backslide after hundreds of AA sessions. One study of 90 addicts found that they had, on average, attended 586 AA sessions before relapsing (Chiauzzi, 1989). That is an amazing amount of "treatment" to be followed by failure. So, AA is not a perfect miracle cure. If AA added more self-control beliefs and procedures, especially relapse prevention, to its program, it might be more effective. Only research can tell us. See more references concerning alcoholism at the end of the chapter.
There is also evidence that overweight people adjust their metabolism as they reduce their intake of food so that they tend to stay about the same weight, called their "biological destiny" (Bennett & Gurin, l98?). If that is the case, losing weight may be very hard to do if you have a genetic tendency to be heavy or to crave sweets, etc. It is believed that weight loss efforts work best the first time you try to diet; thereafter, the body loses weight more slowly but gains it back much more rapidly. Also, over-weight people produce more insulin than thin people when they see food and that increases hunger pangs. Heavy people respond more to external cues--smells, sight of dessert, etc. All this (plus the emotions pushing us to eat) makes it hard to lose weight. As most people know, our metabolism is a function of our activity level, so losing weight without exercise is especially hard to do.
No matter what the physiological and emotional processes are and how difficult it is to reduce drinking or overeating, the addict still has the problem of how to stop a harmful habit. Should he/she get professional medical help, psychological help, give up trying to do the impossible alone and turn to God, join a self-help group, take antabuse or diet pills, go to a Mental Health Center or an addiction treatment center, talk to friends, read and try to help him/herself or what? My answer again is, "Try all kinds of treatment until something works."
Is it harder for some people to overcome bad habits than others? Since this is like the question "Do I see blue the same as you do?" we will never know but old habits are hard for everybody to stop. How hard? There is very contradictory evidence. Some treatment programs claim a 90% success rate (during the treatment phase). In general, relapse after treatment of addictive behavior is very high, 50% to 90% (Brownell, Marlatt, Lichtenstein & Wilson, 1986). Two thirds to 3/4's of drug and alcohol abusers relapse within three months after treatment (Chiazzi, 1989). In one study, less than 10% of treated alcoholics abstained for two years (Armor, Polich, & Stambul, 1978). Researchers of weight loss projects also report disappointing results: few stay in treatment, and 80% of those that do, gain any weight loss back within a year. Smokers frequently quit, then relapse. Clients who stay in these treatment programs for various problems are successful (why else would they stay?), but thus far no program enables a high percentage of clients to maintain their gains. So, it is hopeful (we can change) but the final long-term results of today's "programs," even the expensive ones, are not good enough. On the other hand, note that about half of all former problem-drinkers have quit drinking "on their own" (no help from a MD or AA or any treatment). You are not powerless! But I'd recommend getting all the outside help you can, as well as self-helping.
Similarly, Stanley Schachter (1982) reported some interesting but controversial findings: almost 2/3's (63%) of people who tried to lose weight or stop smoking on their own (without professional help) were successful! And they kept it off for years! This implied that self-help was better than professionally run treatment programs. Subsequent studies (Cohen, et al, 1989) showed this was not true; self-quitters (smokers) did no better or no worse than clients in a stop smoking clinic. But over the years, we try to help ourselves a lot more often than we use professional programs. Thus, 85% of those trying to stop are on their own and only 15% join a stop-smoking program. About 1/3 of all smokers have tried to stop within the last year; most failed. Of those trying to stop sometime (or many times) between 1976 and 1986, 48% of the self-helpers and 24% of the treatment clients were successful. Altogether 40 million Americans have stopped smoking, so it is possible. 90% of the successful ones were on their own and most of them had tried again and again. 70-75 million are still smoking. There is no evidence that successful quitters used different behavior-change methods than the relapsers; they just motivated themselves more and kept on trying (maybe until they found an approach that worked for them). There is hope. Again, I'll remind you: self-administered programs (listening to a tape, reading a manual, watching a videotape) have been just as effective as therapist-administered programs (Scogin, Bynum, Stephens, & Calhoon, 1990). The keys seems to be learning to be motivated and maintaining your gains.
Relapse prevention for addictions
Marlatt and Parks (1982) and Marlatt and Gordon (1985) zero in on a crucial point--the relapse. This is the point, usually after successfully stopping smoking, drinking, avoiding studying, overeating, etc., at which you give up your controlled behavior and fall back into the old behavior. (Untrained or unread self-helpers fail about 80% of the time, usually more near the start than after succeeding. But that is called a failure, not a relapse.) A slight slip is called a "lapse;" total, continuous, complete backsliding is called a "relapse." Why do between 50% and 90% of program successes eventually relapse? Probably because we don't focus enough on maintaining our gains, but research is starting to show us how to avoid relapsing.
First, Marlatt and others (Prochaska, Norcross & DiClemente, 1994) studied the circumstances in which people relapsed, called high-risk situations. About 35% of the relapses occurred during periods of negative emotions, such as depression, anger, stress, or boredom. An additional 16% relapsed while having the same kind of feelings but in a social situation--a conflict or argument with a spouse, relative, friend, or co-worker. A health crisis in the family is a common cause. Here again we find an important relationship between behavior and emotions. About 20% relapsed under social pressure, either being with people doing what you don't want to do (smoking a cigarette, using drugs, eating) or being verbally pressured to participate ("Come on, John, have a beer with us"). About 10% of the backsliders felt the forbidden urge or temptation when all alone. None of this is a surprise but it can help us search for the conditions that might reduce our self-control. We all have our "weak times." Old temptations may return months or years later.
Prochaske, et al, found that certain mental mistakes lead to relapse: (1) over-confidence ("I've got this drinking problem beat for sure"), (2) self-testing ("I'll keep a bottle...some candy...some cigarettes hidden in my desk just to prove I'm cured"), (3) self-blaming ("My smoking made my kids sick and caused by husband to start smoking again"). In short, some confidence is needed, but don't get too much of it, don't get cocky! By denying the risks and rationalizing one's risk-taking behavior, in effect the relapsing alcoholic sets him/herself up for another failure (which he/she doesn't feel responsible for). These cognitions must be attended to... and challenged by the addict.
Secondly, Marlatt and his colleagues recommend several methods for avoiding relapses. Learn to recognize your own high-risk situations by (a) considering the data above and in the following paragraphs, (b) self-monitoring (see chapter 11) what's going on when we are tempted or slip a little or relapse, (c) self-testing in fantasy how well you would handle several high-risk situations (imagine how would you respond if a good friend encouraged you to try cocaine?), and (d) observing your lapse and relapse fantasies or temptations, i.e. imagine how you might relapse. After identifying your dangerous situations, you can avoid some and learn to cope with others. Certainly take credit for avoiding the risky situations.
But, also admit that getting into high-risk situations are a result of a series of decisions you have made (without much awareness?), seldom is it an accident or someone else's fault. No alcoholic gets seated at a table in a bar with drinking buddies (nor a philander with a tempting, attractive person) without making many choices leading to that high-risk environment. Identify those decisions or choice points; they are your means of staying out of trouble in the future. Monitor your thoughts carefully. Vigilantly guard against longing for "a cold beer on a hot day," "the taste of just one cigarette," "another night out in a topless bar with the boys," etc. Don't be seduced again. Remember the bad consequences of your old habit and the good aspects of you new lifestyle.
Chiauzzi (1989) identified several specific trouble spots that lead addicts back into abusing. Be especially careful if you have any of these personality traits: (a) compulsiveness --perfectionistic, unemotional, over-controlled--because they come unglued when they backslide, (b) dependency--indecisive, clinging--because they go back to drugs when others abandon them, (c) passive-aggressiveness --resistive, procrastinating, blaming--because they drive others away and then can't handle their own anger, (d) self-centeredness --egotistical, pushy--because they don't admit their problems, and (e) rebelliousness --impulsive, antisocial--because they resent anyone offering help.
Another ominous sign is replacing the old addiction with another addiction, e.g. compulsive alcoholics become workaholics, dependent eaters smoother someone, sex addicts turn to alcohol, smokers to food, etc. As John Bradshaw says, "They are still sick." The second addiction generates new problems. A third pitfall, according to Chiauzzi, is that 30% of relapsers believe all they have to do is abstain or attend AA. They disregard gaining self-awareness, self-help skills, intimacy, advancement at work, a philosophy of life, etc. They also forget to avoid bars, physical problems, loss of sleep, etc. Constant awareness of all these warning signs helps avoid relapse.
Self-help groups, like AA or Weight Loss groups or Assertiveness Training groups, help you stay on track. Ask friends to help: steer me away from temptations, challenge my over-confidence, support my new behaviors and interests, be sure I can say "no" clearly, come quickly to my rescue when I falter, and remember maintenance is forever.
Practice coping with the unavoidable high-risk situations. Think about what you could say and do when faced with the temptation. Get advice and watch others. Role play with friends the situation repeatedly until you are sure you can handle it (chapter 13). Learn a set of self-instructions that will guide you through the dangerous period (chapter 11). You might even test your coping skills in the actual high-risk-of-relapse situations: A smoker could interact with other smokers without smoking; John could go play sports or to the bars to see if he can return to his studies within one hour, a dieter could go out with friends having pizza and just have a light salad, etc.
Learn to make decisions carefully and stick with them (chapter 13). Marlatt points out that not only are the long-range effects overlooked (e.g. John's neglect of his future career) but the lure of the fantasized immediate result is intensified during the first several days of avoiding a strong habit. Examples: "If I could just have a smoke, I'd feel more relaxed" or "If I go out for a drink, I would get over this loneliness and might run into a hot woman." Sometimes the relapse specialists enable the client under controlled conditions to test out their expectations, i.e. have a cigarette or go to a bar and find out the results are not as fantastic as supposed (exactly when this is a wise approach is not known yet--see Brownell, et al, 1986). This is too risky to do on your own. The grass looks greener on the other side of the fence, but it is just as hard to mow!
Sometimes the therapist gives an abstaining-but-tempted drinker a cold beer and after he/she enjoys the wonderfully soothing release of inner tension that the drinker feels can only come from a beer, tells him/her that it is Near-Beer. This is an eye opening experience. In cases where abstaining isn't possible (such as food), and especially where the client just "can't stand the restrictions any more," Marlatt has tried "controlled cheating," i.e. scheduling a big binge for one meal a week. It helps some food addicts (but probably not drinkers, smokers, spenders, gamblers, etc.) stay under control.
Prepare in advance for a lapse (to avoid a relapse). Attempt to limit the loss of control and reduce the feeling that you are a hopeless total failure. Instead, if you slip, just admit that you have made a mistake. (a) Make an agreement to limit the slip (to one smoke, one dessert, one hour of TV, one drink) and/or call a helper when you have lost control. (b) Prepare and carry a "reminder card " that says something like this, "Slips do occur. They make us feel guilty, that's normal. But don't let these feelings of failure snowball right now into feelings of hopeless despair so that you continue to (smoke, eat, drink, procrastinate). One slip doesn't make a total failure. Stay calm. Learn from this experience. Learn your weaknesses and how to overcome them. Remember why you are abstaining. Recommit yourself. At this time, do this: get out of the situation (leave the bar, go back to studying, throw away the remaining cigarettes, cake, drugs, etc.). If necessary call a friend at number ____. Exercise or atone for a wrong or do something good. You'll feel better." (c) Later, practice handling the high-risk situation with a supportive friend. And, when alone, imagine handling similar situations well.
Any addicted person needs to reorganize his/her life. The needs driving the compulsion can be meet in better ways. The habit-breaker needs more satisfaction out of life, probably requiring a balance of some immediate pleasures and long-term, meaningful goals. Often, a more detached view of the urges and craving (not "ain't I awful" and "I'm a failure") is helpful; it helps the urges fade away. Marlatt and many other researchers (e.g. Brownell, et al.) recommend learning a broad range of self-help skills, much like what is offered by this book. This includes personal problem solving skills, learning to get a balance between "shoulds" and "wants" in your life, getting exercise and some positive addiction (described by Glasser above), behavior control techniques, increased self-awareness (realizing our rationalizations and denial), and encouragement from friends or a self-help group to vigilantly guard against unwanted choices and actions.
Not all relapse prevention programs have been successful but the majority have been (Irvin, Bowers, Dunn & Wang, 1999). Relapse prevention works best with drugs, only fair with alcohol, and poorly, thus far, with smoking. If you do backslide, relapse prevention helps you recover from lapses (but the training may increase lapses). Some behaviors are very hard to maintain. Many people make the same New Year's resolutions for several years before they find the right "treatment plan." Smokers typically make 3, 4 or more attempts to stop before succeeding. Prochaska, DiClemente, & Norcross (1992) found that relapsers don't necessarily go back to "square one," sometimes they learn from their mistakes, think of a better approach, and build up their courage to try again. Try hard to avoid relapsing but if you do, don't give up. This is one of the "hot" areas in self-control, much research is being done.
Controlling simple habits
Nate Azrin and Greg Nunn (1977) offer Habit Control in a Day. It is a clinically tested method for stopping nail-biting, hair-pulling, tics, stuttering, thumb sucking, and other nervous habits. They obtained 90% reduction in the habit the first day and 95% reduction within the first week and 99% within a month (assuming you keep working on the problem as prescribed).
The method is simple: learn to substitute an acceptable but incompatible action in place of the bad habit. To do this you must observe the bad habit in minute detail. The substitute behavior should (1) interfere with the habit but not with other normal activities, (2) be unnoticeable by others but something you are very aware of, and (3) be a response you can easily do for 3 minutes or so.
Examples of behaviors useful in opposing bad habits are: grasping an object, like a pencil, or lightly clenching your fist. Either could be substituted for nail biting or hair pulling. Likewise, filing your nails or brushing your hair would also be incompatible with nail biting or hair pulling. Also, isometric contraction of muscles opposing the ticking muscles is another example. Consciously breathing in and out slowly and evenly is inconsistent with coughing or clearing your throat; drinking water is incompatible with the same habits.
Next, practice the new response 5-10 minutes every day for at least a week. In addition, mentally rehearse how and when you can use the new response. Once mastered, the new response must be used for three minutes every time (a) you catch yourself doing the old habit, (b) you feel the urge to do the old habit, (c) you enter a situation where the old habit frequently occurred, and (d) you realize you are doing another habit that often precedes the bad habit. Examples of the latter would be face touching that almost always precedes nail biting or hair pulling, touching the finger nail before biting it, and feeling your face before picking it. More careful self-observation is needed to discover the situations, activities, and people in (c), and the associated habits in (d).
Azrin and Dunn's procedures also include relaxing in the habit-producing situations, daily practice of replacing the old habit with the new response in the four circumstances described above, asking friends for feedback, showing off your improvements (especially in situations you have been avoiding), and, of course, keeping daily records of progress.
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Preventing unwanted behavior. Is it really within our powers?
Just as it is hard to start a new habit, it is hard to stop an old one. In fact, some behaviors are thought to be unpreventable, i.e. beyond our ability to control with "willpower" or self-help techniques. Many feel this way about drinking alcohol; some do about eating, smoking, and even procrastination. When we add an awareness that genetic, metabolic, physiological, unconscious, and environmental factors as well as underlying emotions affect our reaction to drinking, food, smoking, coffee, soft drinks, sugar, etc., it shakes our faith (rightly so) in self-control. There is evidence, for instance, that alcoholics chemically process alcohol differently from nonalcoholics (Heilman, film). Alcoholism is called a "disease," implying that it is an unstoppable physical disorder, treatable only by physicians or a Higher Power? For an extensive discussion and references, see the Addiction section and Stanton Peele's books (Peele & Brodsky, 1991). For the specific steps to take when preventing relapse, go to Relapse Prevention.
Experienced people in Alcoholics Anonymous (AA), Overeaters Anonymous (OA), and Emotions Anonymous (EA) say the first step towards recovery is to admit you are powerless over alcohol, food, emotions, or whatever. Then, their 12-step program basically says, (l) abstain (totally in the case of alcohol) by asking for help from friends (in AA or OA or EA who have been in the same situation) and from a Higher Power, (2) admit your "defects of character" and the wrongs you've done, and (3) make amends. AA is often considered the best available treatment for alcoholism, so use it if you need it. Interestingly, AA has a reputation for being successful in spite of little or no outcome research. Unfortunately, AA opposes research (members aren't supposed to disclose what happens at AA meetings) and doesn't directly teach self-control methods. It is known that many people go to AA only a few times and others backslide after hundreds of AA sessions. One study of 90 addicts found that they had, on average, attended 586 AA sessions before relapsing (Chiauzzi, 1989). That is an amazing amount of "treatment" to be followed by failure. So, AA is not a perfect miracle cure. If AA added more self-control beliefs and procedures, especially relapse prevention, to its program, it might be more effective. Only research can tell us. See more references concerning alcoholism at the end of the chapter.
There is also evidence that overweight people adjust their metabolism as they reduce their intake of food so that they tend to stay about the same weight, called their "biological destiny" (Bennett & Gurin, l98?). If that is the case, losing weight may be very hard to do if you have a genetic tendency to be heavy or to crave sweets, etc. It is believed that weight loss efforts work best the first time you try to diet; thereafter, the body loses weight more slowly but gains it back much more rapidly. Also, over-weight people produce more insulin than thin people when they see food and that increases hunger pangs. Heavy people respond more to external cues--smells, sight of dessert, etc. All this (plus the emotions pushing us to eat) makes it hard to lose weight. As most people know, our metabolism is a function of our activity level, so losing weight without exercise is especially hard to do.
No matter what the physiological and emotional processes are and how difficult it is to reduce drinking or overeating, the addict still has the problem of how to stop a harmful habit. Should he/she get professional medical help, psychological help, give up trying to do the impossible alone and turn to God, join a self-help group, take antabuse or diet pills, go to a Mental Health Center or an addiction treatment center, talk to friends, read and try to help him/herself or what? My answer again is, "Try all kinds of treatment until something works."
Is it harder for some people to overcome bad habits than others? Since this is like the question "Do I see blue the same as you do?" we will never know but old habits are hard for everybody to stop. How hard? There is very contradictory evidence. Some treatment programs claim a 90% success rate (during the treatment phase). In general, relapse after treatment of addictive behavior is very high, 50% to 90% (Brownell, Marlatt, Lichtenstein & Wilson, 1986). Two thirds to 3/4's of drug and alcohol abusers relapse within three months after treatment (Chiazzi, 1989). In one study, less than 10% of treated alcoholics abstained for two years (Armor, Polich, & Stambul, 1978). Researchers of weight loss projects also report disappointing results: few stay in treatment, and 80% of those that do, gain any weight loss back within a year. Smokers frequently quit, then relapse. Clients who stay in these treatment programs for various problems are successful (why else would they stay?), but thus far no program enables a high percentage of clients to maintain their gains. So, it is hopeful (we can change) but the final long-term results of today's "programs," even the expensive ones, are not good enough. On the other hand, note that about half of all former problem-drinkers have quit drinking "on their own" (no help from a MD or AA or any treatment). You are not powerless! But I'd recommend getting all the outside help you can, as well as self-helping.
Similarly, Stanley Schachter (1982) reported some interesting but controversial findings: almost 2/3's (63%) of people who tried to lose weight or stop smoking on their own (without professional help) were successful! And they kept it off for years! This implied that self-help was better than professionally run treatment programs. Subsequent studies (Cohen, et al, 1989) showed this was not true; self-quitters (smokers) did no better or no worse than clients in a stop smoking clinic. But over the years, we try to help ourselves a lot more often than we use professional programs. Thus, 85% of those trying to stop are on their own and only 15% join a stop-smoking program. About 1/3 of all smokers have tried to stop within the last year; most failed. Of those trying to stop sometime (or many times) between 1976 and 1986, 48% of the self-helpers and 24% of the treatment clients were successful. Altogether 40 million Americans have stopped smoking, so it is possible. 90% of the successful ones were on their own and most of them had tried again and again. 70-75 million are still smoking. There is no evidence that successful quitters used different behavior-change methods than the relapsers; they just motivated themselves more and kept on trying (maybe until they found an approach that worked for them). There is hope. Again, I'll remind you: self-administered programs (listening to a tape, reading a manual, watching a videotape) have been just as effective as therapist-administered programs (Scogin, Bynum, Stephens, & Calhoon, 1990). The keys seems to be learning to be motivated and maintaining your gains.
Relapse prevention for addictions
Marlatt and Parks (1982) and Marlatt and Gordon (1985) zero in on a crucial point--the relapse. This is the point, usually after successfully stopping smoking, drinking, avoiding studying, overeating, etc., at which you give up your controlled behavior and fall back into the old behavior. (Untrained or unread self-helpers fail about 80% of the time, usually more near the start than after succeeding. But that is called a failure, not a relapse.) A slight slip is called a "lapse;" total, continuous, complete backsliding is called a "relapse." Why do between 50% and 90% of program successes eventually relapse? Probably because we don't focus enough on maintaining our gains, but research is starting to show us how to avoid relapsing.
First, Marlatt and others (Prochaska, Norcross & DiClemente, 1994) studied the circumstances in which people relapsed, called high-risk situations. About 35% of the relapses occurred during periods of negative emotions, such as depression, anger, stress, or boredom. An additional 16% relapsed while having the same kind of feelings but in a social situation--a conflict or argument with a spouse, relative, friend, or co-worker. A health crisis in the family is a common cause. Here again we find an important relationship between behavior and emotions. About 20% relapsed under social pressure, either being with people doing what you don't want to do (smoking a cigarette, using drugs, eating) or being verbally pressured to participate ("Come on, John, have a beer with us"). About 10% of the backsliders felt the forbidden urge or temptation when all alone. None of this is a surprise but it can help us search for the conditions that might reduce our self-control. We all have our "weak times." Old temptations may return months or years later.
Prochaske, et al, found that certain mental mistakes lead to relapse: (1) over-confidence ("I've got this drinking problem beat for sure"), (2) self-testing ("I'll keep a bottle...some candy...some cigarettes hidden in my desk just to prove I'm cured"), (3) self-blaming ("My smoking made my kids sick and caused by husband to start smoking again"). In short, some confidence is needed, but don't get too much of it, don't get cocky! By denying the risks and rationalizing one's risk-taking behavior, in effect the relapsing alcoholic sets him/herself up for another failure (which he/she doesn't feel responsible for). These cognitions must be attended to... and challenged by the addict.
Secondly, Marlatt and his colleagues recommend several methods for avoiding relapses. Learn to recognize your own high-risk situations by (a) considering the data above and in the following paragraphs, (b) self-monitoring (see chapter 11) what's going on when we are tempted or slip a little or relapse, (c) self-testing in fantasy how well you would handle several high-risk situations (imagine how would you respond if a good friend encouraged you to try cocaine?), and (d) observing your lapse and relapse fantasies or temptations, i.e. imagine how you might relapse. After identifying your dangerous situations, you can avoid some and learn to cope with others. Certainly take credit for avoiding the risky situations.
But, also admit that getting into high-risk situations are a result of a series of decisions you have made (without much awareness?), seldom is it an accident or someone else's fault. No alcoholic gets seated at a table in a bar with drinking buddies (nor a philander with a tempting, attractive person) without making many choices leading to that high-risk environment. Identify those decisions or choice points; they are your means of staying out of trouble in the future. Monitor your thoughts carefully. Vigilantly guard against longing for "a cold beer on a hot day," "the taste of just one cigarette," "another night out in a topless bar with the boys," etc. Don't be seduced again. Remember the bad consequences of your old habit and the good aspects of you new lifestyle.
Chiauzzi (1989) identified several specific trouble spots that lead addicts back into abusing. Be especially careful if you have any of these personality traits: (a) compulsiveness --perfectionistic, unemotional, over-controlled--because they come unglued when they backslide, (b) dependency--indecisive, clinging--because they go back to drugs when others abandon them, (c) passive-aggressiveness --resistive, procrastinating, blaming--because they drive others away and then can't handle their own anger, (d) self-centeredness --egotistical, pushy--because they don't admit their problems, and (e) rebelliousness --impulsive, antisocial--because they resent anyone offering help.
Another ominous sign is replacing the old addiction with another addiction, e.g. compulsive alcoholics become workaholics, dependent eaters smoother someone, sex addicts turn to alcohol, smokers to food, etc. As John Bradshaw says, "They are still sick." The second addiction generates new problems. A third pitfall, according to Chiauzzi, is that 30% of relapsers believe all they have to do is abstain or attend AA. They disregard gaining self-awareness, self-help skills, intimacy, advancement at work, a philosophy of life, etc. They also forget to avoid bars, physical problems, loss of sleep, etc. Constant awareness of all these warning signs helps avoid relapse.
Self-help groups, like AA or Weight Loss groups or Assertiveness Training groups, help you stay on track. Ask friends to help: steer me away from temptations, challenge my over-confidence, support my new behaviors and interests, be sure I can say "no" clearly, come quickly to my rescue when I falter, and remember maintenance is forever.
Practice coping with the unavoidable high-risk situations. Think about what you could say and do when faced with the temptation. Get advice and watch others. Role play with friends the situation repeatedly until you are sure you can handle it (chapter 13). Learn a set of self-instructions that will guide you through the dangerous period (chapter 11). You might even test your coping skills in the actual high-risk-of-relapse situations: A smoker could interact with other smokers without smoking; John could go play sports or to the bars to see if he can return to his studies within one hour, a dieter could go out with friends having pizza and just have a light salad, etc.
Learn to make decisions carefully and stick with them (chapter 13). Marlatt points out that not only are the long-range effects overlooked (e.g. John's neglect of his future career) but the lure of the fantasized immediate result is intensified during the first several days of avoiding a strong habit. Examples: "If I could just have a smoke, I'd feel more relaxed" or "If I go out for a drink, I would get over this loneliness and might run into a hot woman." Sometimes the relapse specialists enable the client under controlled conditions to test out their expectations, i.e. have a cigarette or go to a bar and find out the results are not as fantastic as supposed (exactly when this is a wise approach is not known yet--see Brownell, et al, 1986). This is too risky to do on your own. The grass looks greener on the other side of the fence, but it is just as hard to mow!
Sometimes the therapist gives an abstaining-but-tempted drinker a cold beer and after he/she enjoys the wonderfully soothing release of inner tension that the drinker feels can only come from a beer, tells him/her that it is Near-Beer. This is an eye opening experience. In cases where abstaining isn't possible (such as food), and especially where the client just "can't stand the restrictions any more," Marlatt has tried "controlled cheating," i.e. scheduling a big binge for one meal a week. It helps some food addicts (but probably not drinkers, smokers, spenders, gamblers, etc.) stay under control.
Prepare in advance for a lapse (to avoid a relapse). Attempt to limit the loss of control and reduce the feeling that you are a hopeless total failure. Instead, if you slip, just admit that you have made a mistake. (a) Make an agreement to limit the slip (to one smoke, one dessert, one hour of TV, one drink) and/or call a helper when you have lost control. (b) Prepare and carry a "reminder card " that says something like this, "Slips do occur. They make us feel guilty, that's normal. But don't let these feelings of failure snowball right now into feelings of hopeless despair so that you continue to (smoke, eat, drink, procrastinate). One slip doesn't make a total failure. Stay calm. Learn from this experience. Learn your weaknesses and how to overcome them. Remember why you are abstaining. Recommit yourself. At this time, do this: get out of the situation (leave the bar, go back to studying, throw away the remaining cigarettes, cake, drugs, etc.). If necessary call a friend at number ____. Exercise or atone for a wrong or do something good. You'll feel better." (c) Later, practice handling the high-risk situation with a supportive friend. And, when alone, imagine handling similar situations well.
Any addicted person needs to reorganize his/her life. The needs driving the compulsion can be meet in better ways. The habit-breaker needs more satisfaction out of life, probably requiring a balance of some immediate pleasures and long-term, meaningful goals. Often, a more detached view of the urges and craving (not "ain't I awful" and "I'm a failure") is helpful; it helps the urges fade away. Marlatt and many other researchers (e.g. Brownell, et al.) recommend learning a broad range of self-help skills, much like what is offered by this book. This includes personal problem solving skills, learning to get a balance between "shoulds" and "wants" in your life, getting exercise and some positive addiction (described by Glasser above), behavior control techniques, increased self-awareness (realizing our rationalizations and denial), and encouragement from friends or a self-help group to vigilantly guard against unwanted choices and actions.
Not all relapse prevention programs have been successful but the majority have been (Irvin, Bowers, Dunn & Wang, 1999). Relapse prevention works best with drugs, only fair with alcohol, and poorly, thus far, with smoking. If you do backslide, relapse prevention helps you recover from lapses (but the training may increase lapses). Some behaviors are very hard to maintain. Many people make the same New Year's resolutions for several years before they find the right "treatment plan." Smokers typically make 3, 4 or more attempts to stop before succeeding. Prochaska, DiClemente, & Norcross (1992) found that relapsers don't necessarily go back to "square one," sometimes they learn from their mistakes, think of a better approach, and build up their courage to try again. Try hard to avoid relapsing but if you do, don't give up. This is one of the "hot" areas in self-control, much research is being done.
Controlling simple habits
Nate Azrin and Greg Nunn (1977) offer Habit Control in a Day. It is a clinically tested method for stopping nail-biting, hair-pulling, tics, stuttering, thumb sucking, and other nervous habits. They obtained 90% reduction in the habit the first day and 95% reduction within the first week and 99% within a month (assuming you keep working on the problem as prescribed).
The method is simple: learn to substitute an acceptable but incompatible action in place of the bad habit. To do this you must observe the bad habit in minute detail. The substitute behavior should (1) interfere with the habit but not with other normal activities, (2) be unnoticeable by others but something you are very aware of, and (3) be a response you can easily do for 3 minutes or so.
Examples of behaviors useful in opposing bad habits are: grasping an object, like a pencil, or lightly clenching your fist. Either could be substituted for nail biting or hair pulling. Likewise, filing your nails or brushing your hair would also be incompatible with nail biting or hair pulling. Also, isometric contraction of muscles opposing the ticking muscles is another example. Consciously breathing in and out slowly and evenly is inconsistent with coughing or clearing your throat; drinking water is incompatible with the same habits.
Next, practice the new response 5-10 minutes every day for at least a week. In addition, mentally rehearse how and when you can use the new response. Once mastered, the new response must be used for three minutes every time (a) you catch yourself doing the old habit, (b) you feel the urge to do the old habit, (c) you enter a situation where the old habit frequently occurred, and (d) you realize you are doing another habit that often precedes the bad habit. Examples of the latter would be face touching that almost always precedes nail biting or hair pulling, touching the finger nail before biting it, and feeling your face before picking it. More careful self-observation is needed to discover the situations, activities, and people in (c), and the associated habits in (d).
Azrin and Dunn's procedures also include relaxing in the habit-producing situations, daily practice of replacing the old habit with the new response in the four circumstances described above, asking friends for feedback, showing off your improvements (especially in situations you have been avoiding), and, of course, keeping daily records of progress.
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The Study of Paths
The Study of Paths
Perversely, some people follow a path that they know will produce more costs than benefits, because following the path of greatest advantage sets up a conflict. On one side there is the autonomous behavior that leads to immediate gratification. Against this is pitted the person’s decision to move in the direction of greatest advantage. The conflict plays out in real time: choices are made, outcomes are experienced, and so the course of one's life is defined.
Following the path of greatest advantage is not a trivial task; one must over-ride two attributes of the soul that favor relapse despite good intentions:
The Problem of Immediate Gratification [the PIG]: Motivation to approach or avoid is much more sensitive to the immediacy than to the magnitude of the payoff. The PIG causes people to choose a small reward now at the expense of a much a larger but delayed reward. Another version of the PIG is to avoid a small punishment now and get the punishment later. See The PIG
The Karma of Practice: The more well worn a path, the easier it is to follow - habit strengthens with exercise. The stronger the habit the easier it becomes to perform, and the more conscious effort is required to interrupt. With sufficient practice a behavioral sequence becomes autonomous, in that it is not intentionally chosen, but plays out all by itself. The consequence of repeatedly performing a behavior sequence is that it becomes autonomous - The Karma of Practice
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Commitment
The path of greatest advantage begins with the decision to over-ride the PIG and the karma of bad habits. Note that the word: "decide" is derived from the root "cide" as in sui-cide, homi-cide, insecti-cide and means: to kill. When, for example, an alcoholic makes the decision to quit drinking it is understood that [s]he means to kill, for once and for all, the option to drink alcohol, and thereby lock out drinking in the future.
Nearby stimuli influence motivation much more than distant stimuli [see Myopia]: bad mood or luck now can have a greater influence on behavior than a commitment made last month. In some situations the alcoholic wants to drink, in others [s]he wants to quit drinking forever. Commitment is required precisely because motivation is fluid, and changes with local conditions.
The decision to act marks the transition from fluid motivation to frozen commitment. Incentive use will no longer be controlled by local conditions, but by the commitment one makes at this moment of decision.
A commitment is a promise to perform in a specified way at a future time. The ability to deliver on this promise - despite the pull of local conditions - can be strengthened or weakened. Making a commitment is like making a wager - a bet that you will do what you committed to do. Winning the bet increases will power - the power to adhere to future commitments. Failing to adhere to the commitment loses the bet, and with it some amount of future will-power.1 Addiction is the consequence of losing this bet too many times.
Don't Be Reasonable!
When you make a commitment you are giving odds - one loss overcomes many victories. You must do exactly what you committed to do. A well formed commitment is developed with the no-exceptions requirement in mind, and so requires a clear specification. It may be stated as an "I will" intention, e.g., "I will remain clean and sober in all circumstances - no exceptions." Note: coding the intention as a negative, e.g., "I will not drink alcohol" is poor form [see The Imp of the Perverse].
Motivation changes with local conditions. In the beginning, addicted individuals are highly motivated to adhere to their decision to change. Naturally, they expect to always feel this way [see The Soul Illusion], but they will not.
As the crisis that motivated the commitment recedes into the past and one becomes involved in the continuous stream of events that play out in real time, the commitment decays. Local motivation becomes more a function of local circumstances than the distant commitment. The PIG which at first supported the commitment - when the addict wanted immediate gratification of the desire to be free of the addition - must be over-ridden when the addict is faced with immediate temptation. The motivation to maintain abstinence is greater during the contrite state following an unfortunate drinking episode, than during a high-risk situation some months later.
Motivation is an abstract construct, but action changes the world. Will [s]he lapse or adhere to the commitment during that high-risk situation? Whatever happens at the moment becomes part of the performer's biography. What had been merely a possibility is promoted to a reality; the alternative options vanish into oblivion.2 Once performed, overt action becomes part of world history, and can not be undone.
And so the decision to kill off a rewarding incentive sets up a conflict that plays out over time. On one side there is the autonomous behavior that leads to immediate gratification.3 Against this is pitted your rational decision to move in the direction of greatest advantage. The ability to follow the path of greatest advantage despite habit and the PIG is itself the result of following a path of self discovery.
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Selecting a Path
Good outcome requires that the rules you commit to now - when you are in your right mind - will influence your behavior in the future despite the influence of local stressors and temptations. Most people with addictive disorders repeatedly fail to adhere to their voluntary commitments despite their intentions to avoid the errors that led to lapses in the past. The critical question is: Do you have the power to make a decision now that will remain effective to guide your actions in the future? Relapse Prevention is the consequence of following a good path for a long time. With this in mind, an important early task is to select a path that is well matched to your personal attributes and environmental realties.
Three paths to independence are described on this web site. If you have not done so already, you will soon have to select one of them and begin the journey. The summaries and exercises presented on the pages below will help you get started.
Historical Review
Warning Signs
Stages of Change
Reminder Card
Prediction and Free Will
1. Ainslie, George, Specious reward: A behavioral theory of impulsiveness and impulse control. Psychological Bulletin. 1975 Jul Vol 82(4) 463-496
2. Frankl, Victor E. Basic concepts of logotherapy. Confinia Psychiatrica. 1961 4 99-109
3. Tiffany, Stephen T. A cognitive model of drug urges and drug-use behavior: Role of automatic and nonautomatic processes. Psychological Review. 1990 Apr Vol 97(2) 147-168
We don't receive wisdom; we must discover it for ourselves after a journey that no one can take for us, nor spare us.
- Marcel Proust
Concerning all acts of initiative and creation, there is one elemental truth - the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, the Providence moves, too.
- Goethe
Integrity has no need of rules.
- A. Camus
In theory, there is no difference between theory and practice. But, in practice, there is.
- Jan van de Snepscheut
A path is only a path, and there is no affront, to oneself or to others, in dropping it if that is what your heart tells you. Look at every path closely and deliberately. Try it as many times as you think necessary. Then ask yourself alone, one question. Does this path have a heart? If it does, the path is good; if it doesn't it is of no use.
- Carlos Castaneda
...to choose the path of greatest advantage rather than yield in the direction of least resistance.
- G. B. Shaw
Perversely, some people follow a path that they know will produce more costs than benefits, because following the path of greatest advantage sets up a conflict. On one side there is the autonomous behavior that leads to immediate gratification. Against this is pitted the person’s decision to move in the direction of greatest advantage. The conflict plays out in real time: choices are made, outcomes are experienced, and so the course of one's life is defined.
Following the path of greatest advantage is not a trivial task; one must over-ride two attributes of the soul that favor relapse despite good intentions:
The Problem of Immediate Gratification [the PIG]: Motivation to approach or avoid is much more sensitive to the immediacy than to the magnitude of the payoff. The PIG causes people to choose a small reward now at the expense of a much a larger but delayed reward. Another version of the PIG is to avoid a small punishment now and get the punishment later. See The PIG
The Karma of Practice: The more well worn a path, the easier it is to follow - habit strengthens with exercise. The stronger the habit the easier it becomes to perform, and the more conscious effort is required to interrupt. With sufficient practice a behavioral sequence becomes autonomous, in that it is not intentionally chosen, but plays out all by itself. The consequence of repeatedly performing a behavior sequence is that it becomes autonomous - The Karma of Practice
--------------------------------------------------------------------------------
Commitment
The path of greatest advantage begins with the decision to over-ride the PIG and the karma of bad habits. Note that the word: "decide" is derived from the root "cide" as in sui-cide, homi-cide, insecti-cide and means: to kill. When, for example, an alcoholic makes the decision to quit drinking it is understood that [s]he means to kill, for once and for all, the option to drink alcohol, and thereby lock out drinking in the future.
Nearby stimuli influence motivation much more than distant stimuli [see Myopia]: bad mood or luck now can have a greater influence on behavior than a commitment made last month. In some situations the alcoholic wants to drink, in others [s]he wants to quit drinking forever. Commitment is required precisely because motivation is fluid, and changes with local conditions.
The decision to act marks the transition from fluid motivation to frozen commitment. Incentive use will no longer be controlled by local conditions, but by the commitment one makes at this moment of decision.
A commitment is a promise to perform in a specified way at a future time. The ability to deliver on this promise - despite the pull of local conditions - can be strengthened or weakened. Making a commitment is like making a wager - a bet that you will do what you committed to do. Winning the bet increases will power - the power to adhere to future commitments. Failing to adhere to the commitment loses the bet, and with it some amount of future will-power.1 Addiction is the consequence of losing this bet too many times.
Don't Be Reasonable!
When you make a commitment you are giving odds - one loss overcomes many victories. You must do exactly what you committed to do. A well formed commitment is developed with the no-exceptions requirement in mind, and so requires a clear specification. It may be stated as an "I will" intention, e.g., "I will remain clean and sober in all circumstances - no exceptions." Note: coding the intention as a negative, e.g., "I will not drink alcohol" is poor form [see The Imp of the Perverse].
Motivation changes with local conditions. In the beginning, addicted individuals are highly motivated to adhere to their decision to change. Naturally, they expect to always feel this way [see The Soul Illusion], but they will not.
As the crisis that motivated the commitment recedes into the past and one becomes involved in the continuous stream of events that play out in real time, the commitment decays. Local motivation becomes more a function of local circumstances than the distant commitment. The PIG which at first supported the commitment - when the addict wanted immediate gratification of the desire to be free of the addition - must be over-ridden when the addict is faced with immediate temptation. The motivation to maintain abstinence is greater during the contrite state following an unfortunate drinking episode, than during a high-risk situation some months later.
Motivation is an abstract construct, but action changes the world. Will [s]he lapse or adhere to the commitment during that high-risk situation? Whatever happens at the moment becomes part of the performer's biography. What had been merely a possibility is promoted to a reality; the alternative options vanish into oblivion.2 Once performed, overt action becomes part of world history, and can not be undone.
And so the decision to kill off a rewarding incentive sets up a conflict that plays out over time. On one side there is the autonomous behavior that leads to immediate gratification.3 Against this is pitted your rational decision to move in the direction of greatest advantage. The ability to follow the path of greatest advantage despite habit and the PIG is itself the result of following a path of self discovery.
--------------------------------------------------------------------------------
Selecting a Path
Good outcome requires that the rules you commit to now - when you are in your right mind - will influence your behavior in the future despite the influence of local stressors and temptations. Most people with addictive disorders repeatedly fail to adhere to their voluntary commitments despite their intentions to avoid the errors that led to lapses in the past. The critical question is: Do you have the power to make a decision now that will remain effective to guide your actions in the future? Relapse Prevention is the consequence of following a good path for a long time. With this in mind, an important early task is to select a path that is well matched to your personal attributes and environmental realties.
Three paths to independence are described on this web site. If you have not done so already, you will soon have to select one of them and begin the journey. The summaries and exercises presented on the pages below will help you get started.
Historical Review
Warning Signs
Stages of Change
Reminder Card
Prediction and Free Will
1. Ainslie, George, Specious reward: A behavioral theory of impulsiveness and impulse control. Psychological Bulletin. 1975 Jul Vol 82(4) 463-496
2. Frankl, Victor E. Basic concepts of logotherapy. Confinia Psychiatrica. 1961 4 99-109
3. Tiffany, Stephen T. A cognitive model of drug urges and drug-use behavior: Role of automatic and nonautomatic processes. Psychological Review. 1990 Apr Vol 97(2) 147-168
We don't receive wisdom; we must discover it for ourselves after a journey that no one can take for us, nor spare us.
- Marcel Proust
Concerning all acts of initiative and creation, there is one elemental truth - the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, the Providence moves, too.
- Goethe
Integrity has no need of rules.
- A. Camus
In theory, there is no difference between theory and practice. But, in practice, there is.
- Jan van de Snepscheut
A path is only a path, and there is no affront, to oneself or to others, in dropping it if that is what your heart tells you. Look at every path closely and deliberately. Try it as many times as you think necessary. Then ask yourself alone, one question. Does this path have a heart? If it does, the path is good; if it doesn't it is of no use.
- Carlos Castaneda
...to choose the path of greatest advantage rather than yield in the direction of least resistance.
- G. B. Shaw
Member
Thread Starter
Join Date: Oct 2004
Location: The Field of Dreams
Posts: 7,249
Warning Signs
Warning Signals
--------------------------------------------------------------------------------
Will you yield in the direction of least resistance the next time you have the chance?
In most cases relapses occur not because the person was overpowered by unbearable forces, but because the first lapse did not seem like a really bad idea at the time.
Escaping addiction appears straightforward enough. At first, the addicted person clearly understands that the addiction is a bad deal and has vowed to change, and fully expects to energetically resist lapsing at future high risk times. Sadly, by the time [s]he encounters the high-risk situation everything has changed.
Motivation is not fixed. What was strongly abhorrent at one moment may be strongly attractive at another [see The Soul Illusion]. Changes in appraisal may occur so fast and so subtly that traps which are obvious to you now, will be invisible at the critical moment. To guide your own path, you must recognize diverting influences before it is too late!
Since hindsight is better than foresight, study your history - look for warning signals - events that have preceded previous relapses such as certain cognitive events. Listed below are some of the classic warning signals.
--------------------------------------------------------------------------------
Cognitive Events
Goal Oriented - Permitting a lapse will help achieve some goal.
Example: "The addictive behavior will help me relax and perform well in this social situation."
Anticipatory - Attention to the immediate pleasurable aspects of the lapse, while ignoring its delayed painful consequences [often accompanied by minimization].
Example: "It would feel so good."
Minimization - Underrating the negative consequences of a lapse; ignoring the painful lessons of past lapses.
Example: "I'll just have a little, it won’t cause a problem."
Why questions - Posing a "why" or "why not" question with the tacit understanding that if you can’t answer it at the moment you have license to lapse.
Example: "Life sucks anyway, so why not?"
Reactance - Counter-regulatory motivation in reaction to restriction of a freedom.
Example: "Other people enjoy this incentive, why can’t I? I’ll do what I want!"
--------------------------------------------------------------------------------
The Egyptian River
Denial is the stealthiest of them all. The chain of events that leads to relapse often begins and unfolds all by itself - autonomously - without rationalization or justification [see The Study of Paths].
You will be in greatest danger of falling into "Da Nile" whenever your cognitive resources are unavailable. The mnemonic HALT refers to some situations which tax cognitive resources and thereby make one vulnerable: Hungry, Angry, Lonely, or Tired. If you fail to recognize these first tier warning signals, you will be approaching the final links of the relapse chain.
Last Lines of Defense
"Look at me!" - If the incentive captures your attention, you must recapture it without delay. Any thought or image of the incentive - or people, places and things associated with it - reduces the psychological distance between you and the first lapse. Attending to the incentive is always a warning signal - consider:
Apparently Irrelevant Decisions - Attraction to activities that are seemingly unrelated to the addictive behavior, but decrease the distance between you and the incentive.
Thinking about circumstances in which it might be OK to use the incentive.
Debating with yourself about lapsing.
Imagining how it would feel to re-experience the addictive incentive. {Note: Dreams about the incentive are not warning signals, and may in fact promote long-term recovery}.
The door is open – At first there was no question about adhering to the commitment. But at some point the door to the first lapse has become open. While there has been no conscious decision to renege on the "no exceptions" commitment, something has changed. If you allow the door to remain open, you will surely lapse. You must close the door immediately and firmly. This is your last chance to rescue victory from the jaws of defeat.
Redirecting attention to the original commitment may not seem heroic at the time, which is why mindful behavior is so exceptional. Engaging in an effortful coping tactic during the ordinary experience of real time may seem forced, weird, or unspontaneous. Of course it is. The default path - the one that seems natural - is lapsing. To escape addition you must over-ride these autonomous tendencies and wear in a path that produces more pleasure and less pain.
--------------------------------------------------------------------------------
"It is the enemy whom you do not recognize who is the most dangerous"
- Fernando Rojas
If you want the future to be different from the past, study the past
- Spinoza
"Hell is discovering the truth - too late"
- John Locke
That which deceives us and does us harm also undeceives us and does us good.
- J. Roux
Even thinking about wickedness is already the beginning of wickedness.
- Confucius
The safest road to hell is the gradual one - The gentle slope, soft under foot, without sudden turnings, without milestones, without sign posts.
- C. S. Lewis
--------------------------------------------------------------------------------
Will you yield in the direction of least resistance the next time you have the chance?
In most cases relapses occur not because the person was overpowered by unbearable forces, but because the first lapse did not seem like a really bad idea at the time.
Escaping addiction appears straightforward enough. At first, the addicted person clearly understands that the addiction is a bad deal and has vowed to change, and fully expects to energetically resist lapsing at future high risk times. Sadly, by the time [s]he encounters the high-risk situation everything has changed.
Motivation is not fixed. What was strongly abhorrent at one moment may be strongly attractive at another [see The Soul Illusion]. Changes in appraisal may occur so fast and so subtly that traps which are obvious to you now, will be invisible at the critical moment. To guide your own path, you must recognize diverting influences before it is too late!
Since hindsight is better than foresight, study your history - look for warning signals - events that have preceded previous relapses such as certain cognitive events. Listed below are some of the classic warning signals.
--------------------------------------------------------------------------------
Cognitive Events
Goal Oriented - Permitting a lapse will help achieve some goal.
Example: "The addictive behavior will help me relax and perform well in this social situation."
Anticipatory - Attention to the immediate pleasurable aspects of the lapse, while ignoring its delayed painful consequences [often accompanied by minimization].
Example: "It would feel so good."
Minimization - Underrating the negative consequences of a lapse; ignoring the painful lessons of past lapses.
Example: "I'll just have a little, it won’t cause a problem."
Why questions - Posing a "why" or "why not" question with the tacit understanding that if you can’t answer it at the moment you have license to lapse.
Example: "Life sucks anyway, so why not?"
Reactance - Counter-regulatory motivation in reaction to restriction of a freedom.
Example: "Other people enjoy this incentive, why can’t I? I’ll do what I want!"
--------------------------------------------------------------------------------
The Egyptian River
Denial is the stealthiest of them all. The chain of events that leads to relapse often begins and unfolds all by itself - autonomously - without rationalization or justification [see The Study of Paths].
You will be in greatest danger of falling into "Da Nile" whenever your cognitive resources are unavailable. The mnemonic HALT refers to some situations which tax cognitive resources and thereby make one vulnerable: Hungry, Angry, Lonely, or Tired. If you fail to recognize these first tier warning signals, you will be approaching the final links of the relapse chain.
Last Lines of Defense
"Look at me!" - If the incentive captures your attention, you must recapture it without delay. Any thought or image of the incentive - or people, places and things associated with it - reduces the psychological distance between you and the first lapse. Attending to the incentive is always a warning signal - consider:
Apparently Irrelevant Decisions - Attraction to activities that are seemingly unrelated to the addictive behavior, but decrease the distance between you and the incentive.
Thinking about circumstances in which it might be OK to use the incentive.
Debating with yourself about lapsing.
Imagining how it would feel to re-experience the addictive incentive. {Note: Dreams about the incentive are not warning signals, and may in fact promote long-term recovery}.
The door is open – At first there was no question about adhering to the commitment. But at some point the door to the first lapse has become open. While there has been no conscious decision to renege on the "no exceptions" commitment, something has changed. If you allow the door to remain open, you will surely lapse. You must close the door immediately and firmly. This is your last chance to rescue victory from the jaws of defeat.
Redirecting attention to the original commitment may not seem heroic at the time, which is why mindful behavior is so exceptional. Engaging in an effortful coping tactic during the ordinary experience of real time may seem forced, weird, or unspontaneous. Of course it is. The default path - the one that seems natural - is lapsing. To escape addition you must over-ride these autonomous tendencies and wear in a path that produces more pleasure and less pain.
--------------------------------------------------------------------------------
"It is the enemy whom you do not recognize who is the most dangerous"
- Fernando Rojas
If you want the future to be different from the past, study the past
- Spinoza
"Hell is discovering the truth - too late"
- John Locke
That which deceives us and does us harm also undeceives us and does us good.
- J. Roux
Even thinking about wickedness is already the beginning of wickedness.
- Confucius
The safest road to hell is the gradual one - The gentle slope, soft under foot, without sudden turnings, without milestones, without sign posts.
- C. S. Lewis
Member
Thread Starter
Join Date: Oct 2004
Location: The Field of Dreams
Posts: 7,249
StagesOf Change
Stages of Change
There has been considerable research on the natural history of attempts to improve one's lot - e.g., quit smoking, lose weight, control drinking, etc. There is a predictable sequence of stages along the passage of change1:
Pre-contemplation = there is no intention to change behavior in the foreseeable future. The individual is unaware or under-aware of the problem. "It isn't that they can't see the solution. Its that they can't see the problem."
Individuals in this stage who presents for treatment are often doing so because of pressure from others - spouse, employer, etc. They may demonstrate change as long as the pressure is one, but once the pressure is off, they quickly return to their old ways.
Contemplation = stage at which person is aware that a problem exists and is seriously thinking about changing, but has not yet made a serious commitment to take action.
Planning = a preparatory stage in which the individual uses rational planning processes to develop a plan most likely to lead to the desired outcome.
Action = the stage in which the individual modifies behavior, experiences or environment in order to overcome the problem.
Some people, including professionals, equate action with change. Thus they overlook the requisite work that prepares people for action, and the important effort that is necessary to maintain the changes following action.
Relapse Prevention = stage at which the person work to prevent relapse and consolidate gains attained during the action stage.
Relapse prevention is the continuation not the absence of change. When relapse prevention fails, the individual - at some point in the future - will go through this cycle again. Hopefully for the last time. Outcome research shows that most people who achieved good long-term outcome did so only after several times through the stages,
--------------------------------------------------------------------------------
Proscriptive and Prescriptive Implications
of Stage of Change
Proscriptive:
Do not rely on change processes appropriate for the contemplation stage [e.g., consciousness raising] when you are in fact in the action stage. For example, trying to modify behaviors by becoming more aware of why you should change. Insight alone does not bring about behavior change.
Do not rely on change process appropriate for the action stage [e.g., selective attention] without the deep motivational shift provided by the contemplation stage - Action without insight produces short term change
Prescriptive:
Our treatment program is available in CD-ROM and Ebook formats. Each program follows the stage of change model, and navigational tools are included to help the user develop a path that best matches his or her circumstance.
Stage I - Trance formation of motivation - The first part of the kit includes tools that facilitate a focus on the costs and benefits of the different paths available to you. Here your task is to select the path that provides the greatest advantage considering you tastes and principles. Several trance forming audio files are included to quiet the mind, and to evoke experiences that can help you become aware of what you really want, and which path is in your own best interests.
From contemplation can emerge a deep motivational shift in which it becomes clear that benefits of change far outweigh the costs of change. At that point you will be ready to make a commitment - that is, promise to follow your path of greatest advantage - even in the face of local stressors or temptations.
Do not make commitments about changing behavior lightly. Be aware that you will have to behave as intended until the new behaviors become habitual. This can take a long time - generally three weeks to three months before life gets easier.
Stage 2 - Planning - The text describes how our bio-psycho-social systems tend to work. Experientially, each of us perceive our self from our own biased perspective, resulting in interesting philosophical paradoxes. Things are not always as they seem, and some individuals repeatedly follow a path that leads to pain because they continue to be taken in by illusions of self-reference. When you come to appreciate the illusions that maintain self-destructive traps you become less vulnerable to them.
To help you develop your plan, specific strategies and tactics are described along with examples. A wide range of cognitive, behavioral, and spiritual methods of influencing life's course are presented. Included are presentations designed to elicit experiential phenomena associated with deep motivational change.
You already know at a conscious level what is in your own best interests. The irreversible change we are seeking requires that the unconscious - experiential processing system - is in harmony with your conscious conclusions. Some of the text and many of the trance forming audio files are dedicated to eliciting an intentional change at the unconscious, biological level.
However, the most reliable method of producing change at a biological level is to invoke the Law of Practice, which holds that behaviors that are exercised get stronger and hence easier to perform. So after using your cognitive abilities to select your path of greatest advantage, your task is not done. You are responsible for training the beast you live in to perform as you intend.
The trance forming audio files will be helpful to most, and magical for some, but whatever your response to them, you remain responsible for intentionally producing the intended behavior until it becomes your default path. A recommended structure for training the body is outlined in detail in the kit.
Stage 3 - Action - The transition from intention to action is where most self-help efforts fail. People do in fact commit to following a plan, and do follow it - for a while. Unfortunately, the long-term outcome for most is relapse. Rigid and flexible strategies to overcome dependence are appraised. Recommended is a paradoxical middle way to improving the correlation between intention and outcome.
Stage 4 Relapse Prevention - Periodic online consultations are recommended to keep the soul focused and reminded.
--------------------------------------------------------------------------------
For more information about our kits, please visit PARTS' Store
--------------------------------------------------------------------------------
Footnotes:
1. Prochaska, J, DiClemente, Carlo & Norcross, J - In search of how people change: Applications to addictive behavior. American Psychologist, 1992, 47 1102-1114
.
There has been considerable research on the natural history of attempts to improve one's lot - e.g., quit smoking, lose weight, control drinking, etc. There is a predictable sequence of stages along the passage of change1:
Pre-contemplation = there is no intention to change behavior in the foreseeable future. The individual is unaware or under-aware of the problem. "It isn't that they can't see the solution. Its that they can't see the problem."
Individuals in this stage who presents for treatment are often doing so because of pressure from others - spouse, employer, etc. They may demonstrate change as long as the pressure is one, but once the pressure is off, they quickly return to their old ways.
Contemplation = stage at which person is aware that a problem exists and is seriously thinking about changing, but has not yet made a serious commitment to take action.
Planning = a preparatory stage in which the individual uses rational planning processes to develop a plan most likely to lead to the desired outcome.
Action = the stage in which the individual modifies behavior, experiences or environment in order to overcome the problem.
Some people, including professionals, equate action with change. Thus they overlook the requisite work that prepares people for action, and the important effort that is necessary to maintain the changes following action.
Relapse Prevention = stage at which the person work to prevent relapse and consolidate gains attained during the action stage.
Relapse prevention is the continuation not the absence of change. When relapse prevention fails, the individual - at some point in the future - will go through this cycle again. Hopefully for the last time. Outcome research shows that most people who achieved good long-term outcome did so only after several times through the stages,
--------------------------------------------------------------------------------
Proscriptive and Prescriptive Implications
of Stage of Change
Proscriptive:
Do not rely on change processes appropriate for the contemplation stage [e.g., consciousness raising] when you are in fact in the action stage. For example, trying to modify behaviors by becoming more aware of why you should change. Insight alone does not bring about behavior change.
Do not rely on change process appropriate for the action stage [e.g., selective attention] without the deep motivational shift provided by the contemplation stage - Action without insight produces short term change
Prescriptive:
Our treatment program is available in CD-ROM and Ebook formats. Each program follows the stage of change model, and navigational tools are included to help the user develop a path that best matches his or her circumstance.
Stage I - Trance formation of motivation - The first part of the kit includes tools that facilitate a focus on the costs and benefits of the different paths available to you. Here your task is to select the path that provides the greatest advantage considering you tastes and principles. Several trance forming audio files are included to quiet the mind, and to evoke experiences that can help you become aware of what you really want, and which path is in your own best interests.
From contemplation can emerge a deep motivational shift in which it becomes clear that benefits of change far outweigh the costs of change. At that point you will be ready to make a commitment - that is, promise to follow your path of greatest advantage - even in the face of local stressors or temptations.
Do not make commitments about changing behavior lightly. Be aware that you will have to behave as intended until the new behaviors become habitual. This can take a long time - generally three weeks to three months before life gets easier.
Stage 2 - Planning - The text describes how our bio-psycho-social systems tend to work. Experientially, each of us perceive our self from our own biased perspective, resulting in interesting philosophical paradoxes. Things are not always as they seem, and some individuals repeatedly follow a path that leads to pain because they continue to be taken in by illusions of self-reference. When you come to appreciate the illusions that maintain self-destructive traps you become less vulnerable to them.
To help you develop your plan, specific strategies and tactics are described along with examples. A wide range of cognitive, behavioral, and spiritual methods of influencing life's course are presented. Included are presentations designed to elicit experiential phenomena associated with deep motivational change.
You already know at a conscious level what is in your own best interests. The irreversible change we are seeking requires that the unconscious - experiential processing system - is in harmony with your conscious conclusions. Some of the text and many of the trance forming audio files are dedicated to eliciting an intentional change at the unconscious, biological level.
However, the most reliable method of producing change at a biological level is to invoke the Law of Practice, which holds that behaviors that are exercised get stronger and hence easier to perform. So after using your cognitive abilities to select your path of greatest advantage, your task is not done. You are responsible for training the beast you live in to perform as you intend.
The trance forming audio files will be helpful to most, and magical for some, but whatever your response to them, you remain responsible for intentionally producing the intended behavior until it becomes your default path. A recommended structure for training the body is outlined in detail in the kit.
Stage 3 - Action - The transition from intention to action is where most self-help efforts fail. People do in fact commit to following a plan, and do follow it - for a while. Unfortunately, the long-term outcome for most is relapse. Rigid and flexible strategies to overcome dependence are appraised. Recommended is a paradoxical middle way to improving the correlation between intention and outcome.
Stage 4 Relapse Prevention - Periodic online consultations are recommended to keep the soul focused and reminded.
--------------------------------------------------------------------------------
For more information about our kits, please visit PARTS' Store
--------------------------------------------------------------------------------
Footnotes:
1. Prochaska, J, DiClemente, Carlo & Norcross, J - In search of how people change: Applications to addictive behavior. American Psychologist, 1992, 47 1102-1114
.
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