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Coping With Urges

May 12, 2014 - 16 comments
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COPING WITH URGES

By: Robert Westermeyer, Ph.D.

Habits and urges go hand in hand. In fact, many people in the throes of an addictive behavior problem, whether it is overeating, drug use or alcohol abuse, claim that they derive no pleasure from their habit--that it is nothing but the relentless craving that fuels ongoing addictive behavior. What is usually most difficult for people when changing a bad habit is coping with the sometimes relentless urges. The initial days of a habit kicking plan can be exhausting as urges dominate thinking and interfere with daily routine. Many people give up change efforts because they feel that there is no way they can function without their habit as the urges interfere too much with quality of life.

It is important to remember that urges, in and of themselves, are normal. We experience craving in varying degrees every day. And because your habit has been important to you for a long time, it may be unreasonable to expect urges to vanish completely. What is hoped is that you will come to experience urges with less frequency and that when they are experienced you will be able to react in a way that avoids relapse.

The "three Ds" can be helpful in coping with urges and craving, 'whether these urges are related to alcohol or drug use, overeating, tobacco use or any habit you are attempting to change. The Ds stand for Decatastrophizing, Disputing expectancies and Distracting.

Decatastrophizing

Especially early on in your change efforts, craving can seem excruciating. Your daily routine has been altered by the elimination of an important part of life and now you can't get your mind off it. Everything you see reminds you of your habit. If you smoke, every room you enter may bring to mind the image of> a cigarette and associated pleasure. The inability to satisfy the urge can lead to frustration and inner statements like, "I can't stand this!" or "There is no way I will be able to live without giving in. I'll just go crazy!" Statements like this can be overwhelming. So much so that people often give up efforts.

As is the case with anxiety, catastrophic thoughts can lead to a great deal of arousal which can, in turn, make things seem worse than they are. If you believe that you are completely out or control, your emotions will follow. What is important to remember is that urges are normal and typically decline in intensity as you continue implementing change. To combat catastrophic reactions to urges it is important to remind yourself of times in the past when you have successfully changed habits (think now, we all have done so at least once or twice!). Do you still experience urges? If so, are they as intense as during the initial phase of your change efforts? Probably not, right? Furthermore, think about other people you have known who have undergone significant change. Do they seem haunted by urges such that they cannot function? If not, who is to say that you cannot accomplish that also?

Try to take some of the power away from a black and white adjective like "horrible" or "unbearable." Belief in horrible extremes only makes you feel worse. Just how unbearable is your urge right now? To accurately answer this you may need to conjure images of what other types of suffering reported as unbearable are like. Is this as unbearable as getting stabbed in the stomach? Or better still, what have you endured which was worse than your current urge? Was that unbearable? lf so, does it folIow that your urge is less than unbearable and perhaps only "very uncomfortable."

Disputing Expectancies

Craving is, in essence, the activation of expectancies. Beck and his colleagues (Cognitive Therapy of Substance Abuse, 1993, Guilford Publications) believe that there are three beliefs associated with the acute decision to engage in substance abuse." They are Anticipatory, such as "I'm gonna be Mr. Wonderful after one line." Relief Oriented, such as "I won't have to think about work if I drink this bottle of wine." and Facilitative or Permissive, such as, " I've been good all week, I'm entitled to an evening high." Though Beck and his colleagues presented these fundamental beliefs in reference to substance abuse problems, it is this author's contention that these beliefs can function in any habit urge.

Since we rarely think about distant consequences when craving, bring them to mind deliberately. Bring to mind the negative emotions which may be
experienced at a later time due to engaging in your habit. Urges are "myopic" in that they can only see advantages. You must shed some light on your craving in order to effectively control it. Ask yourself questions like:
* How will I feel later if I give in to my urges?"

* What consequences might I suffer if I give in?"

* Will the negatives outweigh the positives in the long run if I give in?"

Another way to cope with urges is to imagine that someone very close to you is voicing the very urge you are experiencing. How would you go about convincing them not to give in. Sometimes distancing ourselves from our urges is imperative before you can subject them to any scrutiny.

Your ability to conjure vivid images can be used in your favor when you experience craving. In the presence of a strong urge, try to imagine a very negative outcome. The more negatively graphic the better. The more true to your life the better. For example, if you have a problem with alcohol and experience a strong urge to walk down to the convenience store and buy a bottle of Vodka, imagine the worst hangover possible. Imagine vomiting all morning. Better still, imagine someone very important dropping by, someone you really want to impress, and seeing you in that condition. It is amazing how powerful our own imagination can be in fueling and impeding behavior. Use it to your advantage in your habit change efforts!

Distracting

Some urges are so relentless that talking back to them is insufficient. You still can't get your mind off your habit. Good old fashioned distraction is sometimes the only medicine that can pull your thoughts away. Distraction can be cognitive, in the form of some mental exercises, or behavioral, in the form of activity. Certainly the latter is going to be the most effective, in that urges tend to occur in environments which are the same or similar to those in which the habit occurred in the past. If you are trying to quit smoking, and you have previously smoked in your office all day, being in your office is going to elicit a strong drive to light up. Certainly if possible, taking your work into a conference room, or taking a break and walking outside will often be enough to decrease the urge to a manageable level. You must evaluate your schedule and determine which situations evoke the most intense craving and create as much flexibility as possible so that you can "escape" if necessary--especially in the initial days of your change efforts.

Cognitive distraction can be very powerful. Certainly imagery has been used as a means of helping stressed people learn to relax. You too can use imagery to take your mind off an urge which is dominating consciousness. Conjuring a pleasant place like a beach or on a raft in a lake can help you not only take your mind off the urge but relax as well.

However, "relaxing" images are not helpful for everyone. Some find that if they relax when craving they will only want it more. This makes sense as we have discussed that many habits are associated with relaxation and pleasure, and evoking these feelings in places previously associated with your habit can strengthen urges tremendously. I recommend that you find some mental task that will be very difficult to finish but which is interesting and consuming that you can activate in response to an urge. I like to refer to these as Mental Tapes. Some examples of tapes which have been helpful are:

* Writing the perfect epic novel or screenplay.

*Planning the perfect vacation.

*Creating the ideal money-making business.

*Interpreting a dream from the night before.

*Picking an acquaintance and trying to "figure them out."

Certainly what you choose will depend on your interests, but the key is to make it something that will be easy and perhaps interesting and fun to do. Choosing to think about all the mistakes you've made this year and how you could have done things differently is not going to prove a good distraction tape as it won't be enjoyable. In fact it may increase the power of your urge, especially if stress has precipitated your habit in the past.

It is sometimes best to try one urge control technique at a time so that you don't get overwhelmed. These techniques work, but they also require a great deal of mental energy and conscious effort. The aim here is not to make change excruciating or extraordinarily taxing, but to provide you with some tools which you can add to your armory at a your own pace.

The Minnesota Model

Apr 20, 2014 - 3 comments
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Imagine for a moment that it is 1949, and that someone you love is alcoholic. As you struggle with this fact, you quickly learn about three prospects for this person's future: One is commitment to a locked ward in a mental hospital, sharing facilities with people diagnosed as schizophrenic. Another is that alcoholism will lead to crime, which could mean years in prison. And third is a slow sinking into poverty and helplessness -- perhaps life on "skid row."

In all three cases, your loved one's condition will be denied, ignored, or denounced as evidence of moral weakness.

The year 1949 is significant because it marked Hazelden's beginning. What started then as a guest house for alcoholic men has flowered into the prevailing method of treating addiction: the Minnesota Model. More importantly, this historic innovation offered alcoholics a new alternative to jail, mental wards, or homelessness.

It's easy to forget that the Minnesota Model represents a social reform movement. The model played a major role in transforming treatment wards from snake pits into places where alcoholics and addicts could retain their dignity.

Hazelden began with the idea of creating a humane, therapeutic community for alcoholics and addicts. Once this idea was ridiculed; today it is seen as commonplace. The story of how this change has evolved is in large part the story of the Minnesota Model.

The model began humbly. During Hazelden's first year of operation in Center City, Minn., the average daily patient count was seven and the staff numbered three. The treatment program was equally bare-boned, resting on a few expectations of patients: Behave responsibly, attend lectures on the Twelve Steps of Alcoholics Anonymous, talk with the other patients, make your bed, and stay sober.

It would be easy to dismiss such a program. Yet behind these simple rules was a wealth of clinical wisdom. All five rules focused on overcoming a common trait of alcoholics--something the founders of AA described as "self-will run riot." People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden's founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other. The aim was to help alcoholics shift from a life of isolation to a life of dialogue.

This led to a heartening discovery, one that's become a cornerstone of the Minnesota Model: Alcoholics and addicts can help each other.

Throughout the 1950's, Hazelden built on this foundation by adopting some working principles developed at another Minnesota institution, Willmar State Hospital. Among them were these:

    Alcoholism exists. This condition is not merely a symptom of some other underlying disorder. It deserves to be treated as a primary condition.
    Alcoholism is a disease. Attempts to chide, shame, or scold an alcoholic into abstinence are essentially useless. Instead, we can view alcoholism as an involuntary disability--a disease--and treat it as such.
    Alcoholism is a multiphasic illness. This statement echoes an idea from AA--that alcoholics suffer from a disease affecting them physically, mentally and spiritually. Therefore treatment for alcoholism will be more effective when it takes all three aspects into account.

These principles set the stage for a model that expanded greatly during the 1960s, one that has been emulated worldwide and has merged the talents of people in many disciplines: addiction counselors, physicians, psychologists, social workers, clergy, and other therapists. These people found themselves working on teams, often for the first time. And what united them was the notion of treating the whole person--body, mind and spirit.

A Relapse Prevention Plan: The Tools of Recovery

Apr 09, 2014 - 10 comments
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The Stages of Relapse

Relapse is a process, it's not an event. In order to understand relapse prevention you have to understand the stages of relapse. Relapse starts weeks or even months before the event of physical relapse. In this page you will learn how to use specific relapse prevention techniques for each stage of relapse. There are three stages of relapse.(1)

    Emotional relapse
    Mental relapse
    Physical relapse

Emotional Relapse

In emotional relapse, you're not thinking about using. But your emotions and behaviors are setting you up for a possible relapse in the future.

The signs of emotional relapse are:

    Anxiety
    Intolerance
    Anger
    Defensiveness
    Mood swings
    Isolation
    Not asking for help
    Not going to meetings
    Poor eating habits
    Poor sleep habits

The signs of emotional relapse are also the symptoms of post-acute withdrawal. If you understand post-acute withdrawal it's easier to avoid relapse, because the early stage of relapse is easiest to pull back from. In the later stages the pull of relapse gets stronger and the sequence of events moves faster.
Early Relapse Prevention

Relapse prevention at this stage means recognizing that you're in emotional relapse and changing your behavior. Recognize that you're isolating and remind yourself to ask for help. Recognize that you're anxious and practice relaxation techniques. Recognize that your sleep and eating habits are slipping and practice self-care.

If you don't change your behavior at this stage and you live too long in the stage of emotional relapse you'll become exhausted, and when you're exhausted you will want to escape, which will move you into mental relapse.

Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of yourself. Think about why you use. You use drugs or alcohol to escape, relax, or reward yourself. Therefore you relapse when you don't take care of yourself and create situations that are mentally and emotionally draining that make you want to escape.

For example, if you don't take care of yourself and eat poorly or have poor sleep habits, you'll feel exhausted and want to escape. If you don't let go of your resentments and fears through some form of relaxation, they will build to the point where you'll feel uncomfortable in your own skin. If you don't ask for help, you'll feel isolated. If any of those situations continues for too long, you will begin to think about using. But if you practice self-care, you can avoid those feelings from growing and avoid relapse. (Reference: www.AddictionsAndRecovery.org)
Mental Relapse

In mental relapse there's a war going on in your mind. Part of you wants to use, but part of you doesn't. In the early phase of mental relapse you're just idly thinking about using. But in the later phase you're definitely thinking about using.

The signs of mental relapse are:

    Thinking about people, places, and things you used with
    Glamorizing your past use
    Lying
    Hanging out with old using friends
    Fantasizing about using
    Thinking about relapsing
    Planning your relapse around other people's schedules

It gets harder to make the right choices as the pull of addiction gets stronger.
Techniques for Dealing with Mental Urges

Play the tape through. When you think about using, the fantasy is that you'll be able to control your use this time. You'll just have one drink. But play the tape through. One drink usually leads to more drinks. You'll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and you'll get caught in the same vicious cycle. When you play that tape through to its logical conclusion, using doesn't seem so appealing.

A common mental urge is that you can get away with using, because no one will know if you relapse. Perhaps your spouse is away for the weekend, or you're away on a trip. That's when your addiction will try to convince you that you don't have a big problem, and that you're really doing your recovery to please your spouse or your work. Play the tape through. Remind yourself of the negative consequences you've already suffered, and the potential consequences that lie around the corner if you relapse again. If you could control your use, you would have done it by now.

Tell someone that you're having urges to use. Call a friend, a support, or someone in recovery. Share with them what you're going through. The magic of sharing is that the minute you start to talk about what you're thinking and feeling, your urges begin to disappear. They don't seem quite as big and you don't feel as alone.

Distract yourself. When you think about using, do something to occupy yourself. Call a friend. Go to a meeting. Get up and go for a walk. If you just sit there with your urge and don't do anything, you're giving your mental relapse room to grow.

Wait for 30 minutes. Most urges usually last for less than 15 to 30 minutes. When you're in an urge, it feels like an eternity. But if you can keep yourself busy and do the things you're supposed to do, it'll quickly be gone.

Do your recovery one day at a time. Don't think about whether you can stay abstinent forever. That's a paralyzing thought. It's overwhelming even for people who've been in recovery for a long time.

One day at a time, means you should match your goals to your emotional strength. When you feel strong and you're motivated to not use, then tell yourself that you won't use for the next week or the next month. But when you're struggling and having lots of urges, and those times will happen often, tell yourself that you won't use for today or for the next 30 minutes. Do your recovery in bite-sized chunks and don't sabotage yourself by thinking too far ahead.

Make relaxation part of your recovery. Relaxation is an important part of relapse prevention, because when you're tense you tend to do what’s familiar and wrong, instead of what's new and right. When you're tense you tend to repeat the same mistakes you made before. When you're relaxed you are more open to change. (Reference: www.AddictionsAndRecovery.org)

Physical Relapse

Once you start thinking about relapse, if you don't use some of the techniques mentioned above, it doesn't take long to go from there to physical relapse. Driving to the liquor store. Driving to your dealer.

It's hard to stop the process of relapse at that point. That's not where you should focus your efforts in recovery. That's achieving abstinence through brute force. But it is not recovery. If you recognize the early warning signs of relapse, and understand the symptoms of post-acute withdrawal, you'll be able to catch yourself before it's too late.

Addiction: Classical Conditioning

Apr 08, 2014 - 5 comments
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Excerpt from Harvard Mental Health Letter

Classical Conditioning

Operant conditioning accounts for repeated use when a drug is available. Classical or Pavlovian conditioning is said to explain the relapses that often occur after long periods of abstinence. When a neutral stimulus or cue is consistently associated with a stimulus that causes an unconditioned response (food or an addictive drug, for example), the neutral stimulus eventually brings about a conditioning response on its own. A person is more likely to return to using a drug when exposed to cues that have been reliably associated with its use or its effects in the past. Many types of external and internal cues or conditioned stimuli may cause an addict to relapse: the sight of the bar where he used to drink, a needle of the type used for injection, even the onset of a mood in which she was accustomed to taking the drug.

Classical conditioning also helps to determine patterns of tolerance and withdrawal symptoms. Tolerance originally develops because the brain because adapted to the new chemical environment created by the drug and no longer responds to it with the same intensity. Presumably neurotransmitters are depleted, or the number or sensitivity of nerve receptors for the drug decreases. This homeostatic or compensatory reaction is the body's way of returning to a relatively normal state. Almost all addictive drugs produce some tolerance and a person or animal that is tolerant to one drug will also be tolerant to others in the same class--sedative, stimulant, or opioid.

Withdrawal symptoms are another form of compensatory response. Drugs that produce a certain intense withdrawal syndrome, especially sedatives and opioids, are sometimes said to cause physical dependence. But the physical intensity of the withdrawal reaction is rarely one of the most important reasons why a person goes on using a drug. Many researchers believe that the brain mechanisms producing these reactions are unrelated to the reward system. People who take large doses of morphine for the relief of pain in a hospital, even when they suffer a withdrawal reaction afterward, are unlikely to look for opiates on the street.

Simple unconditioned compensatory responses to the immediate presence or absence of a drug are not the only source of tolerance and withdrawal symptoms. By way of classical conditioning environmental cues can stimulate similar responses long after drug use has stopped and the chemical is no longer exerting direct effects on the body and brain. An addict may start to develop mild withdrawal symptoms on returning to the old neighborhood or simply anticipating an injection. Formally addicted rats are most likely to survive a high dose of heroin or cocaine if they are kept in the cage where they were originally addicted, apparently because the familiar environment excites a compensatory tolerance. If the experimenter substitutes a placebo for the drug in that environment, the conditioned tolerance will eventually by eliminated (extinguished).

Patterns of conditioned tolerance and withdrawal are much more complicated than any straightforward automatic response to an internal state of the body or brain. A rat that presses a level to inject heroin will develop more tolerance and more severe abstinence symptoms than another rat that is simply attached to the same machinery and absorbs the drug passively. Rabbits develop tolerance to the effect of alcohol on motor activity and coordination faster if they take it before rather than after they are required to work for food. Rats become tolerant to the appetite reducing effects of amphetamine more quickly if they are given plenty of sweetened milk at the same time. The presence of food or the need to work apparently provides the cue for a compensatory reaction.

The language of behavioral conditioning does have words for desires, urges, and cravings, or even for purpose of intention. Behaviorists regard these concepts as scientifically valueless, because they refer to subjective states that are not consistently or clearly associate with distinct physical symptoms or patterns of drug use. In fact, addicts usually do not say they relapse because of cravings or urge; instead they talk about moods and situations that provoke drug use. But there is another way to think about craving. Repetition of any activity tends to make it automatic, a uniform response to a uniform stimulus. Urgings and cravings can be seen as the result of complicated nonautomatic processes that are activated in the brain either to oppose the automatic process or to overcome an obstacle to it (such as unavailability of the drug). In other words, craving is a sign that the addict is either trying to obtain a drug that is temporarily unavailable or trying to resist the temptation to use a drug that is available. This view of craving is compatible with the DSM-III-R definition, which describes unsuccessful attempts to stop as one of the symptoms of drug dependence.