Tune in to the thoughts of any addict or alcoholic deciding to take the first drink/drug of relapse. If you do not hear the exact words in the graphic, it often will be something very similar. You will hear these fateful clichés in first-time relapsers, chronic patients, those working at recovery, and those relying solely upon “willpower.” Cocaine, alcohol, heroin, marijuana, and virtually every other known addiction—the drug of choice doesn't matter.
The thoughts listed above share at least one common quality—falsehood. For an addict, sooner or later “just one” will always hurt. The addict won't “handle it—it will handle him. And “this time” will usually be different only by the degree to which it is worse. “No one will know,” in most instances, might as well be a flashing neon sign. And if the addict does “deserve it,” it is strange recompense, indeed, to invite the personal disasters that so consistently follow that thought.
Aaron Beck, MD, the father of cognitive therapy, and colleagues describe these thoughts, so characteristic of addiction, as “permission-giving be-liefs.”1 That is certainly an accurate description of what they do. Alcoholics Anonymous (AA) calls them “plain insanity,” comparing the decision involved to jumping repeatedly in front of streetcars.2 Cognitive-behavioral therapy and AA alike prepare the addict/alcoholic to recognize these thoughts for the symptoms they are. Both would counter them with the ultimate healer—the truth.
Yet there appears to be more to these self-deceptions than mere permissiveness and lack of veracity. To understand these relapse thoughts better, one should look at what has happened over time. Start with the addicted soul who has just made a sincere decision to abstain. Ask if he/she thinks “just one” will hurt. Generally, the person is fairly clear about it. Most people who have decided to quit an addiction carry a strong sense of abstinence being an all-or-nothing game. Unfortunately, that conviction so often turns out to be fragile. Not only does that belief fade over time, but the mental voice that surges or whispers in its place affirms the direct opposite—that abstinence doesn't have to be an absolute.
All permission-giving beliefs assert or assume no loss of control and no damage. “One won't hurt” implies that the person can and will stop there. “This time will be different” alludes to the existence of other times when it did not turn out so well. “I can handle it now” also acknowledges that one could not do so in some prior reality, but is now apparently altered by the healing power of time. “No one will know” merely assumes the control to manage appearances, after the drug has again in- vaded the brain. Distinguishing between “then” and “now” slams the door on the party pooper of past experience.
It is clear that these thoughts, explicitly or implicitly, deny the very reality that the word “addiction” denotes, and that the person believing them already has demonstrated the loss of control synonymous with addiction. The sweet nothings of permission ruthlessly deny the suffering about to recommence.
The likes of Terence T. Gorski and G. Alan Marlatt, PhD, have affirmed for decades that relapse is a process.3,4 Marlatt even coined the phrase “seemingly irrelevant decisions,” a wonderfully apt description that blows the whistle on choices made even before the fatal moment when “I'll just have one.”
But just what is a “process?” Is it not a recognizable sequence in which one thing changes into something else? For many addicts/alcoholics, the hard-won belief in the necessity for abstinence mysteriously transforms (back) into a belief in control (“I can control use”). How can this be? How can one who has “learned a lesson” do an about-face and “unlearn” it?
Are alcoholics and addicts just stupid? Are they like the kid who puts his left hand in the flame this time because he knows the fire would ignite the bandages on the right? But if that's the case, why do people with stupendous memories make the exact same mistakes? MDs, PhDs, attorneys, financiers, highly trained technicians—the list goes on and on. AA itself was founded by a proctologist and a financial analyst—their first recruit was an attorney! Such people are successful because they have formidable memories. Yet they relapse and find themselves back in treatment because they have forgotten one thing: their own suffering.
Ask yourself or people who have lived through this process to think back to the day they quit. Ask them to relive the awareness of their suffering that day. Using a scale from 1 to 10, have them rate that awareness as “10.” Then invite them to roll forward mentally to the day before the first drink or drug of relapse. Using the same scale, ask them to rate the awareness of suffering on that day. You will not hear a lot of 10s. And the minority who were still “10s” will not have said, “One won't hurt” as they poisoned themselves. Those who still remembered that one are likely to have barked an expletive of defeat and abdication. Only someone who has forgotten the last relapse can resume use with the comfortable assurance that he/she is certainly not going to do that again.
Some say the alcoholic/addict is just normally human in forgetting pain. No woman would have a second child and no country would fight a second war, the argument goes, if the human brain were not hardwired to forget pain. The practical problem, then, remains how to preserve the memory of suffering caused by use vividly enough to thwart the recurring idea that return to use will not create still more suffering.
The two desperate men who founded AA in 1935, both chronic relapsers, later defined memory as one of the most powerful barriers to lasting abstinence. Several years after launching the program and their own lasting recoveries, they published Alcoholics Anonymous. In words that would be both pedantic and clinical, were they not so poignant, “Dr. Bob” and “Bill W.” spelled out the problem this way: “We are unable, at certain times, to bring into consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago.”2
Why do we forget pain? Because remembering it hurts! Forgetting the facts of one's own experience paves the way for a decision based on desire, not reality. Picture an alcoholic/addict making the decision to quit. He has just cheated on a beloved wife, loaded. He missed his son's baseball championship, drunk. It would have been worse if he had showed up at the game drunk. The book Motivational Interviewing defines “motivation” as the difference between where you are and where you want to be.5 Most addicts/alcoholics deciding to quit are suffering considerably from just such a gap.
The gap is important, but so is the suffering. An objective condition, no matter how dramatic, does not “motivate” until the person in it experiences the negative emotion that makes that particular state intolerable. It is the distressing inner emotion that motivates—it provides the energy to do the work that will make the “change.”
Feelings of guilt (over what I have done), shame (at who I think I am), and fear (of what will happen and who will see) motivate a typical decision to abstain. They also motivate something else—forgetting. What else can you do if the shame and guilt are so appalling you can barely stand to share your own skin with the other being who lives in there: your conscience? If you don't forget—rapidly, thoroughly—how can you not live in a perpetual state of shame and guilt? On the other hand, if you cannot change the humiliating facts, you can do the next best thing—forget them.
Two recurring clinical experiences brought this home for me as a psychotherapist working with addictions. Years ago, I was trained to begin each succeeding psychotherapy session by asking the client what he/she remembered from the previous session. The first time a cli-ent genuinely forgot a dramatic breakthrough, I was stunned. How could he? Had I not seen his eyes grow wide with realization, heard his tremulous voice, and watched his hot tears only a week ago? My mentor showed me that by revisiting this breakthrough, we could actually exploit this memory loss. We used it to deepen the realization that had so nearly been lost. This process is not unique to working with alcoholics/addicts.
The second clinical experience, repeated hundreds of times, is specific to alcoholism. While working in an inpatient chemical dependency program, I was developing skill with dreams. This particular program required all patients to be on disulfiram (Antabuse), a drug that causes extreme nausea if the patient consumes alcohol. The goal was to prevent the behavior for which the patients needed help, so that we would not be forced to stop helping them (It seemed like a good idea at the time.) I might wish I had a dollar for every time I heard this dream: “I was already drinking. Suddenly, I remembered I was on Antabuse. Panicking, I woke up.”
A dream, the humble theory went, is “an unwanted message from the unconscious.” It took us a long time to notice in this case that the dream always began after the patients had started drinking; only then do they remember how much hurt is about to descend upon them. No wonder the dream so often woke them up. Here's the way it folds out:
In other words, the alcoholic's old defense of forgetting won't work when he takes Antabuse. His window of opportunity to enjoy even the first drink has been boarded up. The unconscious itself seems to be warning the conscious mind to “wake up,” the defining effect of a nightmare. “Waking up” is, of course, also a common description of enlightenment.
These examples should illuminate one of the primary dilemmas of the newly sober alcoholic/addict: how to keep the memory of the suffering caused by alcohol/drugs alive, without being doomed to a life of shame, guilt, and fear. Unless something changes, to remember is agony—to forget is fatal.
A quick review of AA's structure reveals an interlocking system of practices: daily meditation about still being in recovery and remembering to use tools, to attend regular meetings to share the story of how disaster follows use, and to work with newcomers who are visible reminders of what really happens. This mnemonic system was designed by those who knew they would forget, for those who know they will forget.
Not so obvious, even to those in recovery, is how directly the 12 Steps themselves confront the dilemma of alcoholic memory. Surely, the “powerlessness” of Step 1 includes the pathetic inability to remember, much less learn from, experience. Step 3 “surrenders” all wills, including the will to remember and the will to forget. Step 4 launches a direct attack on shame and guilt with a “searching and fearless moral inventory.” After writing down the worst, sharing it (Step 5), praying about it (6 and 7), and facing the victims to “make amends” (8 and 9), most who have worked these steps report profound relief.
But from what? Evidently, the inventory/amends process consistently transforms shameful memories into assets. They become gifts that keep the individual's motivation fresh, as fresh as the now often-shared memory itself, without carrying the old load of shame. At the same time, memories shared offer hope and support (motivation) to those still overwhelmed by active use, guilt, shame, and fear.
Clearly, sustained motivation for recovery from addiction requires sustained memory. To be effective, the memory must be strong enough to counter the relentless desire that lurks in the brain of any alcoholic/addict, often unrecognized. Given that chronic internal pressure, the universal trigger for relapse is nothing less than abstinence itself. And the practical question isn't “What triggers relapse?” but “What blocks it?” Memory, motivation, and maintenance.George DuWors, MSW, LCSW, is a psychotherapist and trainer in Everett, Washington. The author of White Knuckles and Wishful Thinking, he has presented workshops across the United States, in Canada, and in the United Kingdom.