Here’s most of an email I recently received:
> Subject: why does the addiction resurface when we least expect?
> Marc,
>
> I really enjoyed your memoir. In so many ways I feel I can relate….
>
> So… Here’s my question…
>
> Why, after being sober for 7-months, did my craving for alcohol become
> that much more intense? Gave up alcohol in August 2013… Started
> drinking again in February 2014… It’s like….. thought I was on my
> way toward a happy peaceful sober life, and then, BAM! Drinking more
> and in ways that I see are perhaps more self-destructive?
>
>
> What’s up with me?
Here’s most of my reply:
Hi _____, Thanks for your note. I find it thought provoking, and really very moving, partly because I had similar experiences when I was taking drugs. Also, your note goaded me into writing this long-overdue post.
This is what happened to me: In 1979 or so, after several years of struggling to abstain and remain abstinent, I finally quit “successfully” for a few months, and then BAM! — I fell back in. Just as you describe. I had quit taking any and all opiates in late December, at the same time as extricating myself from an extremely painful marriage — many strings, much guilt — and making binding promises to myself. Now I was living in my own apartment, I’d given up trying to influence my wife’s state of mind, I was getting good grades in my first year (of graduate psychology), and I was thoroughly delighted to be “unhooked” physically and, so it seemed, psychologically.
Then I went to a party at someone’s home in April, about four months later. I went to the bathroom to pee, and while standing in front of the sink I impulsively opened the medicine chest. And there, staring me in the face, was a large-size bottle of Tussionex — about 1/4 used up, so…. ideal for taking a few sizable gulps without anyone being the wiser. (Tussionex is a cough medicine whose main ingredient is hydrocodone.) Soon after that night, I began using again regularly, and breaking into medical offices again regularly. I guess I was so upset with myself for ending my fast that…well you know how that one goes. Then, one night, three months after that, I climbed out of the basement window of an enormous medical centre, my pockets stuffed with drugs and needles, and walked directly into the waiting arms of several officers of the law. Ironically, I was working as a psychology intern at the time. In other words, I was supposed to be one of the healthy ones. Six weeks later I was given a suspended sentence. But far worse than that, I was kicked out of graduate school, essentially black-listed from all psych departments in Canada, at least for a few years, and I ended up washing windows and house painting to make ends meet.
So what goes on when we are sailing, in the clear for months, and then BAM! — we suddenly find ourselves in the throes of our addiction, as bad or worse than ever?
I figure the two most important brain changes that go with addiction are (1) the rewiring of the striatum, from ventral (nucleus accumbens) to dorsal striatum, and (2) the rewiring of prefrontal areas responsible for self-control, decision making, and so forth. The striatal change takes drug-seeking from an impulse to a compulsion, so that the behaviours we engage in to get/take substances or engage in other addictive acts become at least partly automatic. This is an example of classical (Pavlovian, i.e., stimulus-response, i.e., S-R) conditioning. Stimulus now leads directly to response. The prefrontal change blunts our capacity to think flexibly and switch goals as needed, so that addictive goal-seeking is no longer harnessed by cognitive control.
If those two brain changes are central to addiction, then ongoing brain changes in both systems — essentially in the opposite direction — are probably central to recovery. We recover some cognitive control, and those prefrontal networks become more efficient once more, but slowly, and mostly because we work on it like hell. We practice cognitive control daily, and thereby awaken the synapses that got too sleepy. In fact, a study I recently reviewed on my blog shows that we grow extra synapses in cognitive control areas after several months of abstinence. These function like a suit of armour that protects us from addictive impulses….until the automatic S-R response finally weakens.
But here’s the problem: On any given occasion, the cognitive control network is slower to power up than the impulsive/compulsive network, and this is especially true while the cognitive control network is still being “tuned up” (so to speak) during the recovery phase. So the synapses in the striatum and its close neighbour, the amygdala, get activated extremely rapidly by drug cues — even during recovery — compared to the prefrontal control networks. Approximately one-fifth to half a second faster (my speculation based on EEG findings). So these “control” networks (which Kahneman refers to as System 2) are not only intrinscally slower to begin with, they’re even slower (and more deliberate) than usual because they’ve gotten rusty with disuse.
So when I opened that medicine chest, my slow deliberative control mechanisms did not have a chance to act BEFORE the rapid, automatic, Pavlovian-style response took effect — as soon as I saw that bottle. Stimulus = Tussionex. Response = Grab and drink. Reflective self-control doesn’t even power up until half a second after the sight of the bottle. And that’s another important point: action tendencies break off and have a life of their own. My whole brain was already set into a response mode (triggered by the stimulus) that was extremely hard to interrupt once it got started. All those striatal synapses were already singing in choral unison: “fuck it”, “just do it”, “I have to get this inside me”, “do it now before anyone (including myself) can stop me”. Those synapses were still functioning as a coherent, efficient network — the net result of all those yeas of addiction.
I don’t know if this explanation works for you. You mention increased craving. But that could be a sort of byproduct. I’d say that many people slip because they’ve let down their guard, they’ve stopped concentrating very hard on beating back those action tendencies (and maybe even imagined they could experiment a bit) — simply because they’ve been sober long enough to believe they’re out of danger — at a time when they actually 
need extra effort while cognitive control networks are just beginning to blossom again. They figure they’re safe. They open up medicine chests on a whim, or sip a glass of bubbly at an office party. And, as you say, BAM! Down you go again. And this ride really is more self-destructive than the last, because you are terribly angry at yourself for letting it happen. What an ideal time for a self-destructive feast!
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Marc & The 7 Month-er. How very odd, and fortuitous that I should wake up and read this. The last 6 days or more, perhaps, I have been in a very frightening place. An odd sort of depression or lack of motivation, more empty thoughts than usual. And an increase of thinking about using opiates. I cannot seem to push myself to read or do book work or other fortification activities against my addiction. I feel I am on a cliff or a wire waiting for a snap of wind to push me off. I see this yet i feel powerless to do anything about it. And today is 7 months for me exactly.My brain or mind feels a mix of fatigue and laziness interlaced with slight malaise. I do not have any reason or answer as to why. I am just trying to push through it. But I feel I am doing so without a map. Seems there are at least 3 people who got tripped up at 7 months so I am going to take it as a small sample experiencing something normal. Thanks for posting this.
Al
Al, See my response below, following JLK’s response to you. I think he has a point.
Marc,
This is very interesting.
What you wrote here is very much like the “disease model”: the re-wirings of the brain that cause drug-seeking from an impulse to a compulsion, and loss (or damage) of cognitive self-control.
Also, at end, you wrote:
“I’d say that many people slip because they’ve let down their guard, they’ve stopped concentrating very hard on beating back those action tendencies (and maybe even imagined they could experiment a bit) — simply because they’ve been sober long enough to believe they’re out of danger — at a time when they actually need extra effort while cognitive control networks are just beginning to blossom again. They figure they’re safe….”
This is very much like something I brought up under a previous post.
Marc’s depiction need not necessarily reflect the “disease model” (unless having those S-R memories that precipitate drug relapse is considered a disease, which some argue is the case). What is particularly interesting, in my viewpoint, is how PERSISTENT drug-associated memories are. I don’t know that they ever go away, and we have to be vigilant to always exercise the neural pathways that lead us to make the choice NOT to take drugs. While I don’t necessarily agree with relegating one’s self to the identity of always being an “addict” or “alcoholic” (per 12 step programs); it does seem useful to always be reminded of the need to maintain vigilance. I wonder, do other recovery programs emphasize the need to persistently engage in cognitive control exercises that steer us away from engaging in S-R, “relapse to drug use” responses, without putting the marker of “lifetime addict” on the patient? How might these programs go about encouraging maintaining vigilance against possible drug-relapse triggers?
Hi Liz. Yes, this is exactly the point. Can we think about persistent vigilance and cued self-reminders without seeing ourselves — or being seen by others — as having a disease and/or being classified as “addicts” (or something just as creepy) for life? I don’t see why not…
I have to constantly be vigilant about driving within the speed limit here in the Netherlands, where they’re quite strict and give you whopping tickets. And I have to remain vigilant about not making thoughtless comments about politics or religion, especially in certain contexts, because they tend to provoke useless arguments. In fact there are a whole lot of “guideposts” I provide myself for getting through the day, given that I’m basically a somewhat impulsive person with sometimes questionable social judgement. But I don’t need to wear a sign or check myself in somewhere or get my urine tested….
I guess what I’m trying to convey in neural terms is that strong attractions beget strong habits which require more persistent controls — and both the attraction and the control networks are frequently under construction, like the busy streets of a big city, at least when it comes to addiction/recovery. Well, when streets are under construction, you often have to stop day-dreaming and pay attention to your driving for a change. That’s all…
By the way, “vigilance” and “mindfulness” are not entirely opposites. They may have a lot in common. Though the latter has a much nicer flavor. And, neurally speaking, the alternative (to both) is the default-mode network, which is more active in NONmeditators according to the literature. I posted on that a while back.
All of which is to say, it’s not only not abnormal but it can be quite positive and productive to pay attention to what you’re doing!
You’re right, Jenny. It does sound like I’ve gone over to the disease model. Well, I haven’t, but I don’t want to bee doctrinaire about these things either, and sometimes addiction really does seem like (and needs to be treated as) a disease.
The point of overlap is that developmental changes in goal settings, sensitization, and action tendencies certainly become crystallized over time. If you want to call that a disease, go ahead. But the fact that these changes can and do reverse, once they stop being reinforced, and often through an effort of will, convinces me that there is no actual disease process at work.
Hi Maec
It is have to bifurcate where I agree and disagree.
As you know I am an AA (not 12 step) believer and participator. (See last 10 written arguments). And somehow through a combination of experience and instinct ….not a lot of brain science available back then…. they KNEW about this dynamic of addiction at some level. Unfortunately Al does not.
In my own experience, after a particularly nasty battle over car keys (sound familiar?) with one of my beloved daughters after embarrassing the shit out of hew with my behavior at a wedding in Cape Cod, I decided to quit for 6 months and, in my ignorance thought that would reduce the cravings.
Unfortunately I had not heard Marc’s physical explanation, or, more importantly to the layman, founder’s aphorism that “it always gets worse, never better”. In other words once you have crossed that “invisible line’ into full-blown addiction, unless you continue absolute abstinence you are screwed in 99% of the cases (there is an exception to everything).
After started drinking again I swear it was worse; I seemed to have flipped over from “problem drinker to “Type One” alky. Big difference…zero control …Even as President of a large lumber distribution company, I would load up on kerosene (figurative jet-fuel) EVERY day starting about 2:15 for some reason and count down the minutes until 4.30 when I could leave without too much the employees noticing…yeah sure..they all knew.
Another story: I was sitting in an AA meeting room and I see this guy arriving and he sits next to me. I knew there was something wrong but couldn’t put me finger on it. Then the guy told me; he had been sober for 19 YEARS,, had some personal problems, started drinking and within 30 DAYS was back in Rehab.
Get used to it you have a lifetime of sobriety ahead but don’t worry it gets MUCH easier after 2-3 years.Fortunately for me forewarned if forearmed so I white knuckled those goddam compulsive cravings early on.
Marc’s medicine chest adventures: you will probably get angry but I will venture to say that, like me, the old medicine chest trick is a result of addiction. I used to do it then when I began recovering (after 2 year or so I never looked gain. Dunno why. So there is one upside to abstinence. In other words stealing drugs out of med cabinets is justa for of addictive manifestation that actually will go away (eventually).
JLK
PS I have almost 11 years sober to give Al a benchmark. (I almost had a drink last week……whew! Closest I’ve been in years!
,
Hi, What is it that I do not understand? Please clarify.
Al
Hi Al
The answer is in the aphorism….. Always gets worse, never better. This means that no matter how long you abstain, the alcoholism remains..it does not “drain” but somehow remains in your system psychology or physically? Either way it remains. Not only that it worsens. If not you are probably not an addict. A few months is not a long time to be sober. I know people with 40 years sober that are afraid of what would happen if they had a drink of alcohol.
You may not agree but it sounds like you have already experienced what I am talking about.
I hope that is clear enough
JLK
JLK has a point, Al. If you are sitting there waiting for the cravings to evaporate, you’re probably in for a rough time. Where he and I disagree is in a different time frame: For me, and for many others, the cravings do lessen with time. In fact I think this is what you refer to, JLK, when you say you never looked again after two years. But 7 months is probably not enough time to expect such changes. Well, in your case, clearly not.
On the other hand, I don’t like JLK’s assertions that if your addiction didn’t progress exactly the way he (or the book) says it should have, then you’re probably not an addict. As if you have to follow the formula to earn this esteemed title?!
What I was trying to say in my post is that these systems do recover but in different ways and at different rates. For many of us, the ingrained automatic response to drugs or booze can take a very very long time to change, and it may not ever change completely…..and yet these responses are quick to rise to the surface on any given occasion, because we’re dealing with a rapid, intuitive, and rather dumb (neurally speaking) system.
So….indeed, “white knuckling” it is probably the best possible solution for some time to come.
It’s an “over-learned” behavior, like talking, driving, playing a musical instrument, karate, swimming etc. The amount of time, intensity, alignment with other brain systems, etc are all going to contribute to the strength of the connections that result, and have to weaken and be restructured. I had been doing it so long, it felt like it just happened. I didn’t have any “triggers”. I was the entire gun. And it took a long time to weaken the connections, redirect the behavior, and rewire.
Hey all
Sorry about the shitty syntax. I am beat this AM and can’t type as well as usual which is pretty goddam bad.
JLK
No problem. I muddled my way through.
Back to the Pavlovian S-R characterization. One thing that helped me with late stage lapses, was to think of them as extinction burst outliers— my brainstem’s last ditch attempt to blindside me into using again while it still had some juice. Then I was expecting them, like being wary of an adversary’s surprise attack. recognize them and engage my thinking brain, before it got too far. It wasn’t perfect, but another failsafe measure to add to my armory.
Excellent explanation and strategy Matt. I have somewhat the same tactic. It works for me too.
Matt, that’s a great way to put it. Indeed, the “juice” in these systems can take a long time to drain. It may never drain all the way. (think striatal / amygdaloid active synapses) Which, I know, sounds like pus or something — a very “diseasey” way of putting it.
So, to switch metaphors, I still get tempted to get into stupid arguments with my ex-wife, via email, though I’ve been super-good lately — brilliantly in control. But I maintain that the argument habit is nothing like a disease…. It’s just….a habit….based on longstanding changes to my brain brought about by strong emotions in the past. And my build-up of control is nothing like taking insulin to counter a disease. It’s just, as you say, engaging the thinking parts of the brain, on cue, when potential problems appear on the horizon. Not a bad general strategy for living in a rather unpredictable and sometimes dangerous world.
Sort of like the ‘drug diversion’ programs in the courts, excepting diverting strong errant emotions so Big Cortex can take back control…
Something like that. The brain is so damn complicated it’s hard to say “where” anything happens.
Marc, that reminds me of your thoughts on OCD and addiction. I think anyone who swings that way to any degree doesn’t want their routine disrupted. If you’re dependent or addicted, then obviously stopping is going to disrupt that daily routine. If you’re not, well, using is going to disrupt it in just as jarring of a way.
Hi Persephone! Good point. Any behavioural habit corresponds with the reprogramming of the dorsal striatum, at which point the stimulus “calls up” a particular response automatically. But we are much more complicated than Pavlov’s dog. The problem with addiction, OCD, and other forms of automatic habits is that they sit at the center of an emotional universe (the other parts of your brain) which has already adapted to them. Changing the habit means forcing all those other systems to become more flexible so that a new habit can be “programmed” in the striatum, which takes time. That’s not easy. Especially because the first stage is to just to stop the routine, with nothing to replace it. Yet. Essentially the command is: do nothing. That’s where the existential void rears its ugly head.
Yes, and that was my trap with the Tussionex. I had at least some “injured person routine”, then suddenly I had a cough and quite high fever. Total disruption. Back to normal health-wise (as much as one in my situation can be) and I wanted the routine back. To be honest, the disruption of routine of knowing I had to leave town for almost a month for physical injuries was far worse than the Tussionex.
It’s interesting that you mention the idea of programming, because that is exactly what I am having to begin to do now, only with the physical. The point, from my MDs and PTs, is to tap back into the muscle memory I had before compensating around injuries for this many months. It has also been brought up that I need to redesign these neural patterns (their words, not mine) to stop interpreting pain the way the injuries caused me to.
So this isn’t just laying down new habits or behaviors, it goes also into how the brain responds to pain, how the nervous system interprets small stimuli and blows them up into CNS overload, and how the muscles must be retrained to fire normally after being disrupted for a period of time. Which is really much the same as a substance abuse rehabilitation, when you get right down to it.
Interesting as usual. I have been reading recently about Marlatt’s abstinence violation effect (AVE) which occurs when the person views their substance use or “lapse” as a violation of their commitment to absolute abstinence. This is best encapsulated by the 12-step phrase “1 too many, 1000 not enough”. The internal dialogue is something like; “I cannot stop, I am a failure, I cannot stay clean. I may as well/I can only continue using”.
In my treatment setting we try and combat this by welcoming cravings and seeing them as part of the recovery process – Marlatt uses the term “urge surfing”. At the Mind & Life conference the Dalai Lama spoke about the embracing of craving as well.
I have found that by acknowledging cravings and the accompanying feelings, rather than resisting them, many of my patients feel more comfortable and less inclined to respond automatically to them – I would be interested to see some research on this, although there has been some research by Yuan-Tang and others that seemed to marked improvement in ACC and PFC activity in smokers, although the n was very small.
Sarah Bowen has also looked at this in her work.
Personally I have found the acknowledgement of lapses as part of a process and a learning opportunity to be very helpful.
Just some thoughts.
Hi Shaun,
I quit drinking 8 months ago (and 1 week). The “embracing” is exactly what I do myself, although thous os the first time I’ve heard others describe it. Cravings and urges are to be expected and, in my mind, embraced. They are challenges and and tests and are designed to re-wire my brain. Yes, they can be uncomfortable and disconcerting at times, however, every test that comes my way I embrace it and crush it and take a little piece back that I gave away before. I welcome them and the sooner I get them over with the better. I approached it this way from very early on when I quit and I feel I continue to re-wire mind and mental capacity to deal with it. I’m 50 and drank excessively for a very long time (teenage years). I also remind myself I’m really glad to be done with it.
Good to hear that’s working for you Dave.
I agree. Fear and self-denigration are not recipes for moving forward. They keep one stuck in the addiction, and in the presupposition of something that hasn’t happened yet. What do they say in AA? FEAR= False Evidence Appearing Real
Yes, Sarah Bowen took over that whole approach when Marlatt died. And urge surfing is a big part of her program — Mindfulness based relapse prevention.
Judson Brewer seems to lead the research into using mindfulness/meditation to help smokers quit. Here’s a quote from the last line of the abstract of one of their papers:
“These findings suggest that MT may be effective as a treatment for smoking cessation and that informal mindfulness practice predicts a decoupling of the association between craving and smoking.”
(Mindfulness training for smoking cessation: Moderation of the relationship
between craving and cigarette use. Hani M. Elwafi, Katie Witkiewitz, Sarah Mallik, Thomas A. Thornhill IV, Judson A. Brewer)
MT = mindfulness training. These guys are finding that the craving still occurs but simply does not trigger smoking behaviour as frequently, once participants start meditating, even informally.
Makes perfect sense: Know thine enemy, you can’t stop/change something if you don’t know what it is, etc…
Oh, as an interesting aside, there is currently some research looking at using Imaginal Exposure to help combat cravings. This CBT technique requires that the substance user scripts a typical using/trigger experience. They record this in great detail. They then imagine an alternative to the using, a situation where they choose a better option. This is worked through with an individual therapist in a structured way.
I think this will have some interesting results, and once they are out and published, I hope to incorporate this into our treatment programs.
Yes Shaun. This sounded interesting to me as well, but how it is structured and tailored to the individual is unclear and could have high backfire potential for some. I’m interested to hear the results as well.
Will keep all posted. The results are blinded so I am champing at the bit!
Isn’t there some way to speed up the process of rejuvenating the neuronal controls, pharmacologically and/or behaviorally? Recovery groups are one, but they are a slow process. My intuition and experience tell me that strenuous exercise works (by accelerating the return of the body’s natural dopamine system?) and meditation another (allowing one to better pay attention to thoughts and feelings, among other physiological effects). Has anybody come up with anything else? …besides fulfilling hobbies or experiences, which are personalized and can take a while, too. They are great for filling in all the space and time that opens up after we stop using, but also a long process…
Exercise and meditation, for sure. We keep hearing about these two from all sorts of sources. The other big one for me is this thing I’ve called intertemporal dialogue (following George Ainslie) or simply self-trust. I can feel my mood and my mind click into a different mode — in which self-care is no longer an obligation but a preference — when I connect the present “me” (often anxious and uncertain) with a larger “me” that runs through time, from past, to future — it’s a sense of self-understanding and self-valuing that makes it less attractive to find immediate rewards or relief.
The ability to like who you’ve been, what you’ve become, and to start where you are…?
Yes, “like” comes along. But when I do it I sometimes start off almost blind. Okay, this is where I’ve been, and this might be where I’m going, and hey, I’m not such a bad guy after all. Then comes the “like” — and even some of those warm tendrils of self-love that are almost indescribable. I really can’t explain it well. It just feels like I’m taking care of myself because I can and because I want to, not because I’m supposed to.
I like this statement Marc. Yes, most people don’t do things because they suppose to, but because they “want to” and “can”… “Want” is a big factor.
Marc, that is a beautifully succinct version of how I feel most of the time about this.
To 7 monther and Al,
Sorry to hear that you’re struggling. These will help:
1- Don’t use or stop using
2- Call someone
3-go to an AA/NA meeting
Please keep us posted.
Best wishes,
Nick
Nicolas,
1, I have not used. 2. I dragged my lazy hazy ass and brain to 2 NA meetings. it seems to help when I am reminded of how horrible people’s stories are. 3. I called a chap from the meetings and talked for about an hour.
5. I went to my drug counselor yesterday as well. I still feel like there is something I should be doing. Not knowing what I colored a flag of Nevada for my kid’s project for school, I counted a bin of crystal beads and went to bed early to the sound of eckhart Tolle’s droll voice talking about a mish mash of meditative musings. I realize my recovery, or state of not using opiods is all over a map that I do not seem to possess. I really feel I am in the wilderness. With a huge suitcase of items that may or may not be useful in this camping expedition. Like the land of the lost, waiting for Chaka to pop his head out any minute. Waiting for that sudden flash of intuition or aha moment. Thanks for your encouragement.
Al
Al,
Thanks. The slogans helped me a lot in the beginning: keep it simple. Easy does it. One step at a time. They helped slow down and sort out the jumble.
Best,
Nicolas
To Al and others
Another grenade: You are all MOSTLY aware of the dynamic of addiction but again MOST of you over do it with big Psych words and thoughts from books that you have read or studies you have undertaken..
There is only one way and I am 100% convinced of this. Since in most cases it takes 2-5 YEARS to get thru the first stage of recovery (I took a poll once) where you can feel comfortable without drugs or alcohol I cringe when I read about guys like Al who obviously have the best of intentions and a good human being, but limiting talking to a sponsor or even an experienced survivor, to “2 or 3 conversations made me feel better.”(Obviously not a Hemingway sentence) Hey if 2 or 3 make you feel better how about 4-5 times/week EVERY week.
Recovery should include a constant vigilance which means EVERY day however you want to do it. I like AA because of the ready-made structure…we now have 600 meetings a week in my city. The best guess is a 20% success rate But the one thing the failures have in common is that they did NOT do the work. The work is hard it takes time and it is basic. Until we find that silver bullet over-intellectualizing takes you nowhere because it is a substitute for the work.
If you break it down you will find that it is an esoteric version of guesswork.
All we know for sure right now is that the only way out is absolute abstinence. If you quit for a few weeks/months then start again you find yourself in the worst trap of all and that is bingeing.
I am constantly accused of being over-esoteric when I talk because I get tired of saying the same old shit..believe it or not,…because on this page I am probably the simplest talker. But I am also one of the more successful people in kicking the habit. (11 years and counting day-by-day) There is a reason for that. I am capable of writing esoterically but I avoid it because I lose my way in doing the only thing that counts; as one of our late members used to say “whatever happens don’t drink”. Simple. Effective.He was able to stay sober after losing two children and fighting cancer for 17 years.
JLK
I am going to close this irritating piece with the prayer we use in every meeting (and I use many times each day).It was originally used in a sermon by the great philosopher/theologian, Reinhold Niehbuhr, to wit:
“God grant me the serenity.
to accept the things I cannot change
The courage to change the things I can
And the wisdom to know the difference”
I know this is not the exact original but was slightly changed in the60′ to fit its purpose in the 1960’s but it’s close enough.
BTW I am an agnostic, but I find comfort in the prayer..
BTW 2 I am not saying that research is useless, on the contrary it is absolutely necessary but for now we only have one way out.
JLK
Total abstinence is not the only way…but with a demanding, craving brain, it’s just so much easier. At the end of the day, we still have to embrace, examine and learn from our urges, cravings, and addictive behavior.
HiMatt
I would love to find another way out. I believe I have tried every possible way…drinking what you don’t like alternating non alcoholic drinks, etc but nothing worked until I quit, period and a long time ago.
I must admit there are still times even since 2003 that I would kill for a drink…not very often but frustrating just the same
JLK ,
JLK—
I’d have to agree. I love having my brain back, and it seems to appreciate it, too. And the abstinence route has worked for me, you and millions of others. But that doesn’t mean it’s the only way. We have only to look at the history of science to appreciate that…
Hi Matt
You seem to be well versed in this particular discipline but have yet to be specific on what the alternatives are. A book was written in the 70’s whose name escapes me as I read it many years ago and made the mistake of LENDING the book to someone who never returned it. You known how that goes.
Anyway this book was a landmark in the early study of alcohol addiction and laid out the 4 phases of problem drinking
1) Problem drinkers (check)
2) Phase One alcoholism (when I quit)
3) Phase2 alcoholism where drinking becomes a life disturbing problem (loss of family job money etc
4) Phase 3 where serious life-threatening diseases set in such as OBS (wetbrain as we call it) and pancreatitis. At this point it is pretty much too late and alcoholism evolves into a deadly disease/
The reason I say this is I have a suspicion that your “cures” outside of abstinence may be related to those who have not crossed that “invisible line” Phase One and remain “problem drinkers”. I was a “problem drinker” between the ages of 15 (my first arrest) and when I quit at 55. I could keep myself under control until (it seemed) all of a sudden I lost control in very embarrassing situations. I would go to an important business meeting telling myself all the way to the location “you’re not going to get drunk”, you’re not going to get drunk” yadda yadda. you know what happened next…within 2 hours I was hammered.
I traveled to Europe a lot and being a Platinum flyer I always received upgrades where the vino was free and flowed like water. And you know what free booze is to an alcoholic. I would get so drunk on the Frankfurt-Atlanta leg I would be literally bouncing off the walls on my way to the lounge.
My first wife was/is a heavy drinker and she did NOT want me to quit. So she came up with all these alternatives one of which was called “Moderate Drinkers Anonymous”. What a joke…the founder killed a mother and daughter in a car crash then blew a 1.5, That was the turning point. I knew I was screwed. So after 1 a year or so of hand wringing about quitting for life I finally took the plunge.
Since then I personally have not seen an alternative that has any credibility. (no mice please). So if you could help me out here I would love to hear about it. I would LOVE to enjoy a glass of wine from time to time.
Best Rgds
JLK
JLK
I’m sorry if I touched a nerve and was so unclear. Not my intention at all. I was not talking about Moderation Management, or any of the other programs that purport to help people continue drinking. They don’t prevent the consequences. What I meant to convey was this: to say there is only ONE way for anything of this nature is potentially problematic and narrows the range of possibilities for individuals who may be reading this.
For me, and possibly for you, abstinence is the only way. I personally can’t imagine ever taking a drink again, nor would I even want to. I don’t feel the loss I did in early recovery. I quit at 56 and remember being so impaired that I was evaluated for “wet brain” type encephalopathy by the attending neurologist at a major hospital. By some miracle, I recovered. And my loving and patient wife of more than 2 decades didn’t leave me. A fact that baffles me to this day.
In SMART Recovery (an abstinence oriented group) the primacy of abstinence is taken off the table so people can discover a plan that works for them as individuals with any type of “addictive” behavior. Which for the vast majority of people includes abstinence. There is a tiny group of people who attend SMART or other groups who have decided they do not want to quit drinking. And they design some complicated plan of rules and limits, and stopgaps; they continue to check in with the group to report their progress. I personally would rather use all that time and energy for something more productive than moderating my use of intoxicants. I can say that now.
I was encouraging us to be open to the possibilities, because the “cure” for the range of individuals with this problem may come from a place you’d least expect. The combination of learned behaviors and conditions that may contribute to this problematic habit, are daunting and seemingly limitless. The hypervigilance and hand wringing that comes with “forever” is allayed for many, by breaking abstinence into achievable chunks. In SMART, it’s often a year. In others, it’s one day at a time
Write your name and phone number in your books. Sometimes they actually turn up again when you’d least expect it.
To Matt & Persephone
First Matt …I feel such a kinship since we have had the same experiences with the exception of a much later MRSA bout. I am still convinced that my alcoholism results from a combination of “problem drinking” (Mr Lampshade) and daily 30mg doses of Lexapro. Otherwise it is almost unexplainable. My whole family was the same….party people BUT they all tailed off their drinking as they aged except yours truly. A little story I have I believe proves it.
As many know I was an International businessman until retirement in 2006. Now I “retired by owning 2 companies to manage my investments in real estate etc. (I bought at the right time). In about 2000 I was sitting in Business Class next to an Austrian guy flying from Atlanta to Vienna. The guy was #2 at Vienna Airport (complete with their beloved DOKTOR title on his card).
Anyway he was an alky and consumed 9 glasses of wine on the flight over (I counted). I remember being amazed and disgusted as I usually quit after 2 or 3. wo years later I was THAT GUY, routinely hoovering 8 or 9 glasses. It came on too fast to not have additional causes.
I mention this as a warning as I am sure there are some on this page that use Lexapro.
Persephone: Don’t worry the “cravings” are rare but often enough to remind me to be on my guard. The closest I came was 2 months ago. whew! I a gnats rear end from wrecking 11 years of work. But it’s a lesson for us all.
Rgds
JLK
PS You can contact me or read my (boring) Econ articles even see my pic. Marc thought I was grizzled-looking until I sent him some pics from a wedding where I was dancing with my 2 daughters.
JLK
Ditto. And here is another twist on how our stories diverge. I have heard of the paradoxical effects of SSRIs, SNRIs some with similar catastrophic results. And I took them for many years without any noticeable benefit. Then, a very astute psych nurse practitioner, discovered a first degree relative of mine had gotten some benefit from a NDRI— that targeted dopamine, not serotonin. It had an immediate positive effect and gave me the leg up I needed to finally get sober. And want to be.
Everybody needs something different to hasten their recovery— even if that difference is conformity to a method of proven effectiveness. There are many paths to recovery. The trick is maintaining motivation to keep trying till you find something that works. Never give up. And the adage”squeaky wheel gets the grease” is of particular relevance here. No one else can help if you never let them know something’s wrong.
Guys, I have enjoyed following your dialogue. But JLK, will I ever hear you acknowledge that there really are different routes for different people?
I know you collapse this challenge into a formula: that if you can get by with moderate or occasional drinking then you never crossed the line into “true” addiction. I find this unsatisfying. It’s simply a post-hoc definition, inferring the intensity of the problem only by the ways and means (and success) people find for dealing with it. A definition like that doesn’t do much for me. Even though it may accurately describe the path for many people….definitions should come before outcomes, not after.
Anyway, I’m going to do another post…any minute….partly inspired by this dialogue.
Your said that sooooo much prettier then I was going to . I have been waiting to respond , waiting until I could do it with a civil tongue ( or fingers )
I understand this “Post-hoc definition” , the real problem here is the translation of whats written . JLK is an A.A guy , not “in too” the 12 steps , that is his decision and good luck with that . It’s a little like sitting in a library for 7 years chatting about books you have never read and expecting a masters degree when your done . Speaking of books , Chapter 3 of the Big book of Alcoholic Anonymous , “More about Alcoholism” reads : “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.”
This is a 1940 way of saying “We don’t know what the f*cks wrong with you but have a nice day .
It took four years to sober up 100 people in Akron , N.Y and Cleveland generaly known as the first 100 , Bill W and the first 100 are credited with writing the “Big Book” as it is known . The real great part is they were trying to explain the same “Phenomenon” of change as we are here .
JLK, I respect that that is your path. I just cannot imagine life with constant vigilance against addiction. I am very sorry that that is what you have to (or feel you have to) deal with on a daily basis. Or not, if it works for you, it just seems like torture.
Hi Per
You get used to it. It’s not torture. The trick is to know when to be super-vigilant and when not.
JLK
And I think the acronym in the program, H.A.L.T— hungry, angry, lonely, tired— represents most states that sap one’s willpower, resolve and ability to self monitor. It’s important to stay satiated, happy, involved and tranquil to keep a leg up on the situation as much as possible. Never any guarantees due to neurophysiology and the capricious nature of the mind, but monitoring these internal states helps a lot of people catch themselves about to lapse…
Hi Matt
Hate to say this but hat is one of the more important acronyms/aphorisms in AA.
Rgds
JLK
I know it’s AA. I should have specified the program better because that was my point. We all get around to saying the same things in different ways. HALT enumerates the weakened or volatile states we have to be aware of and deliberately remedy. Notice they don’t have an acronym for the remedy or the desired remedial state…
The emphasis is on proscription, not discovering, implementing, and supporting plans that work for individual situations and predicaments. One of the biggest encumbrances to achieving and maintaining sobriety I see is loneliness. And being in a room full of 100 other alcoholics can feel like the loneliest place in the world. There is something missing that needs to be filled in, and when it doesn’t happen eventually, many people don’t make it. It’s a central issue that always seems to be skirting the periphery…..
Hi Matt
Yourlast note kinda blew me away. You are the first person I have ever heard say that. When people complain of loneliness it is virtually always about the alocoholic state.
After spending years in the throes of alcoholic isolation all they feel is relief at being in a roomful of people that can actually understand what it FEELS LIKE to be an alcoholic replete with social,economic and familial isolation.
JLK
I did pick up on one thing you said that might help. I hate big meetings and a hundred is a big meeting. I prefer 10-15 as it seems like you can really get/become a lot more intimate with your fellows, That’s what becoming a “friend of Bill’s” is all about.
So try a few smaller ones and it miht help.
Thanks, JLK. I agree. I have found smaller meetings that I like, some SMART, some AA, some hybrid…
The substance use does exacerbate loneliness and drives people to isolate more, but in many cases it’s a chicken- or-the-egg problem. This has been a problem in identifying people with dual diagnosis— having a co-occurring mental health issue along with the substance use. It’s frequently assumed the alcohol or substance is causing the underlying condition when it actually is a misguided form of self-medication. And when withdrawal from the substance is complete the condition persists…
Thanks for your concern, JLK. That’s the thing that’s supportive and healing in meetings..
I quite agree. Loneliness is a huge problem in addiction. Loneliness is often what gets you there to begin with. Then the addiction isolates you further, as Matt cogently describes, from everyone/everything ….except IT! I understand that AA works in large part by providing care, understanding, and support — and yes, that seems absolutely critical for filling the void that only the substance seemed able to fill until then.
Whatever philosophical beefs I have with AA, I see this as a brilliant and deeply human solution to the horrendous self-isolation that comes with addiction.
One note on HALT (which isn’t only AA at all), if I may: the first letter. If blood sugar drops too low, or you’re prone to hypoglycemia, you CAN go on auto-pilot, so to speak, and stop making decent decisions. It makes perfect sense for everyone trying to make a sound decision in general, not just someone addicted or formerly addicted. No one makes good decisions in any of the letters of that acronym.
Yep. All the letters represent physical/emotional states than drain the willpower reserves, and if you get blindsided by some unforeseen stressor or trauma, conditions might be right for relapse.
Matt–sorry, wouldn’t let me reply to your comment. My broader point was that each word in HALT is a state that renders our decision making a bit more out of our control, and not just with substances.
Any of those states can cause bad decision making, from going ahead and making a purchase that is a bit too extravagant to leaving writing weird emails to plenty of rather innocent, but not sound, decisions in life.
I have to admit, as someone who cannot drink alcohol (medical condition), I really feel for those who struggle with that problem. Alcohol is everywhere. I spent a few years post-DX struggling with having to feel just out of place not being able to drink. I can’t imagine if I had been able to drink, liked it and craved it, leading to that step of making drunkenness a reality. I really respect those who manage their alcoholism and are able to not relapse, or at least not regularly. Powerful people, and deserving of much respect, IMHO.
Well, I’m glad it’s not torture to you. It’s a bit too focused on the self for me. I am glad it works for some, I just find it (as you might remember) a form of being developmentally stuck, or rather (as I think now, after reading more of Marc’s work) developing in a way I didn’t prefer to develop–but I don’t have cravings. And I cannot drink alcohol, which is EVERYWHERE. If I were in the situation you seem to be in, I would likely be a bit more vigilant myself.
Preachin’ to the choir, P. Couldn’t agree more….
That’s where mindfulness, self-knowledge, self-awareness come in…
I have found it helpful, when dealing with cravings, to mentally focus on and remind myself of all the bad stuff related to using. How did I feel right before stopping? E.g., I felt physically and mentally shitty, dull, depressed, dependent. It was horrible. We tend to forget the bad and only remember what felt good. Sometimes it helps to have physical reminders such as signs posted around your home, or objects that help us to remember the bad. I agree with all who’ve said, fighting the ongoing cravings is an ongoing battle (and I’m on maintenance buprenorphine!). All the tricks that are necessary to help should be used. It’s definitely being constantly mindful and/or vigilant, and using whatever helps us to be so.
For me, all those “bad”s condensed into a sense of aversion, even disgust, so powerful that it beat out the sense of attraction each cravings arose. It was amazing for me: to think about opiates and feel a “yuccch” that came on stronger and faster then the “aaahhh”.
Yes, your brain reframes the “cue” as a noxious, repulsive stimulus. The “euphoric recall” is recognized as a decoy to suck you back down the trail of inevitable negative consequences, and it gets assigned an appropriately negative attribution. I intuitively feel this represents a weak link in learning that differentiates two patterns in addiction and recovery— the group that can stop itself after exposure to an intoxicant (or behavior), and the group that can’t stop after just one. The movie “The French Connection” always struck me as a grand metaphor for this phenomenon.
Hiya Marc
Sorry not been in touch. This post really resonates with the book I’m reading by Daniel Kahneman. It’s called thinking fast and slow and he describes us as having two thinking systems, A and B, in our brains. A is all about reflex thinking, intuition, rule of thumb, kind of stuff and is designed to help us to survive by making quick decisions based on minimal amounts of information. It’s how our brains are tricked by optical illusions and probably behind many of the mistakes we make as human beings. System B is our more analytical part that evaluates and processes information enabling us to think things through and consider the consequences of our actions. The problem is that we get stuck and dependant on system A thinking and system B becomes lazy so does not butt in as it should do.
You see it everywhere, especially in professional circles where decisions need to be made quickly often on very minimal amounts of information. These often become diagnosis and prescribed treatments with professional pride and contempt prior to investigation not allowing system B to kick in.
Unfortunately it’s also predominant in recovery circles as well with this different sort of addict ideology being a great example. Strangely I made contact with an old mate the other day. I genuinely thought he was dead having not seen him since 1998. We used to use together, same stuff in the same way involving the same chaos. Much the same as myself he used for over 30 years, mainly injecting heroin and cocaine at a rate of over £1000 weekly. Six years ago he decided he had had enough and just stopped. He had never been on a script, never been in detox or rehab and never been anywhere near a treatment service. All on his own he has been totally abstinent for over six years, got a little fruit and vegetable store and fixes motorcycles. Kind of flies in the face of all this “real addict and only one way” mentality, doesn’t it?
I love this story, Peter, as I told you. And I’ve already passed it on to students and colleagues. To me, it’s the single best argument against the disease model of addiction.
People pit “choice” against “disease” as the explanatory model for addiction. But they don’t realize how incredibly complex, irrational, volatile, biased, and context-dependent choice actually is. Choice comes in fragments, in moments, and often it’s shear luck to catch one of those moments and use it to catapult you out of a lengthy addiction. Will-power is NOT the right label to attach to the “choice” concept. Will-power is a kind of resource that may rise and fall, like the level of water in a reservoir, over weeks, months and years. It can help. But choice is really a momentary thing…..and the trick is to catch it and use it.
And every person’s “choice” mechanism has a mutable hierarchical structure that changes as we move from experience to experience in life….
…and THAT is complicated..
One last note to all. While admitting AA is not the be all-end all The common threat throughout this really cool discussion is that virtually ALL of the talking points are either AA-based or an integral part of the program.
One has to remember that AA was created with the lowest common denominator (educationally/intelligence etc) in mind. Big or esoteric psych words are not used (as I found out to my grief early on) but you drill down a short ways and it becomes the same message in all ways that I have seen on this page.
But you have to go to hundreds of meetings to really get that part.
JLK
I think you have to go to as many meetings till you hear what you need to. As they say in the program it takes as long s it takes. In AA as in everything else in recovery, there is no “one-size-fits-all”….
Marc, I had a recent similar experience. I’m injured, btw, flying out for surgery in the morning, so painkillers will be unavoidable. In fact, I have a whole bottle right here.
Anyway, I got a virus with a cough a few weeks ago, and as coughs and abdominal injuries don’t go terribly well together, they gave me tussionex. I had a high fever, the stuff is rather strong, before i knew it it was gone. But then I couldn’t even get off the couch once it was gone! I was horrified! But somehow, whatever got set off with the cough syrup (maybe tied to being that sick, the high fever, or just that once upon a time tussionex set off MANY an addictive period) just didn’t kick in with the pain pills, and they’re both hydrocodone. My pharmacist (yes, I went into minor withdrawal after 6 days of tussionex, I’m the world’s worst “addict”) told me to wean off using the pills, and I found that 1/2 a vike in the morning was adequate. 1/4 to 1/2 at night. Then nothing.
So why does it hit, then suddenly disappear? I know I have to have them Thursday, I’m having two surgical procedures done. Who knows, maybe I won’t need them. Is it that I am simply NOT willing to go around acting like I know I act on the things? Or that I know I go into withdrawal at the drop of a hat and don’t want to recover from surgery AND opiates? I could have run through 60 vicoprofen since that tussionex incident a few weeks back, but I didn’t. I got terrified that I would, but I didn’t. I guess that perhaps I’m sufficiently healed that the cognitive control you write of is still stronger than the impulsive response. It was certainly in place for me to be able to wean with a giant bottle there, despite being scared half to death of both travel and surgery and knowing that a slightly higher dose would in fact remove those fears. But only to bring them back quadrupled when the dose wore off/I ran out/any of those addictive scenarios.
All I really know is that surgery or not (and it took 6 mos. of diagnosis and a painful procedure to even get me to accept a prescription), I’m not willing to go back to that place again. But I also just don’t enjoy the high any longer. I do for a few minutes, even an hour, then I just feel mildly physically ill. Or maybe I’m just really, really terrible at being a drug addict and had to hang up my hat?
Either way, quite funny that you wrote this right after I had a bout of Tussionex fever.
Persephone… You’ve just described an army of factors (competing armies, perhaps, although you emphasize the good guys) that weigh in and tip the scales either in the direction of impulsive action or control. Cognitive control — of course that’s what we call the concatenation of all those factors. But cognitive control is just a summary, an outcome, and it needs a lot of components working together. It has to fight against ego depletion and delay discounting for one thing. Not an easy battle. And yet, the various factors you describe, envisioning yourself in a way that repels you, enjoying the feeling less or not at all, practice, support, comparison of likely outcomes….these are really distinct factors, aren’t they? They reinforce one another — thank goodness — and when that happens frequently, reliably, predictably, then you’ve won the battle. And you give it a name. And you learn to love it. But like the allies in World War 2, it took a lot of cooperation to get there.
Well, Marc, I need to keep my head. I’ve been on pain pills to a very low degree since surgery Weds. but I find that taking less spread out over longer periods touch the pain better than overtaking. I’m still on what I had left, haven’t had to fill the new script yet. But sheesh, my hip was torn by a fake chiropractor (turned out to have had an inactive license for SIX years) doing an adjustment no one is supposed to do, and had to have surgery for that and the 7 muscles that got torn due to that. I need to keep my head. I need to be able to heal. And keep interviewing lawyers, etc. This week will throw me into withdrawals, I’m aware of that, but I have enough to wean myself down. This isn’t a World War, this is Kill Bill. I need to be well and able to stand and fight. I DO need all of the armies, and every part of my being is desperately aware of this fact.
And there’s the sure-fire sign that I’ve taken an opiate (one, mind you), over-sharing on the web! Woohoo! (Sorry, I’m in a lot of pain more than being drugged up, I can’t concentrate for anything right now. I’m not asking for anyone to cut me slack, but I would appreciate knowing the explanation is out here.)
I find the “concatenation ” of factors Marc describes is unique to every individual. They interweave with varying degrees of intensity and relevance to the addictive behavior and triggering situations. When I lapse, another layer of self-defeating emotions around shame or disappointment ensues. It’s further complicated by the waxing and waning of ego depletion and delay discounting, the superordinate processes that govern my allocation of willpower and resolve. I’m too prone to overthinking it, and I need a mind-body “bitch slap” to reset my nervous system. This is where strenuous exercise really helps rebalance the crucial components in my habit loop. And I’ve rediscovered a stop gap measure from my childhood to use when it seems like all is lost. I had the experience in early sobriety of accidentally imbibing a significant amount of alcohol. Before I could beat myself into shame-based submission and giving up, I walked myself straight to the ocean and dove in— full body cold water immersion. It’s rough, but not as rough as relapse. And there is science behind it. We have a ginormous collage of cold receptors in our skin and this actually sends an overwhelming signal to the brain that releases endorphins and recalibrates one’s psycho-physical state. You can do the same thing by taking a warm shower then putting your head under the cold water. As an addict, I’m an extremist I guess, but this helps me get back on the horse. Works for early morning depression as well…
P.S. I am sorry if my comment above seemed insensitive to anyone suffering cravings, it’s not that they aren’t there sometimes. It seems to be dose specific. If I hit a certain dose, I don’t want it to end, and scared myself pretty bad that I was going to just take tons of pills. I lose reason and want to take more. Then I start shaking and feel physically ill and reason takes hold again and I just can’t do it to myself. But having been there before, I am able to recognize this as a completely different experience.
For once I am going through something that, to me, is utterly horrible and quite scary, and for once the last thing I want is to blot it out. My former addicted self wanted to blot out everything, even if it wasn’t really that bad. I need to keep my head now.
Exactly what Caroline Knapp said in her wonderful book, Drinking: A Love Story. Once she quit, she was finally able to feel….which included feeling her pain and sadness at the death of her father. And the feeling was full, warm, and real, compared to the numbness of being drunk.
Interesting! Feeling is a good thing. I had my one moment Weds. when I was about to have a double surgical procedure. They asked if I wanted versed to make me less aware before general anesthesia, and I absolutely took them up on that offer!
But yes, in general, I can relate completely. I have a good (damaged) brain, and enjoy its workings, not its deliberately imposed misfirings.
Once the striatal switch has been thrown from impulsive to compulsive, the ‘addict’ has as much choice about using as Ted Nugent has about supporting gun control. What would it take?
Nicolas, ahh, is that what that is? I suppose that is his addiction to a far heavier than necessary draw weight on his recurve bow as well?
I’ve recently read that an urge is actually more like a drive. So instead of being compulsive or impulsive, it’s actually an even deeper mechanism at work. Like hunger, thirst, the urge to use is so strong that your body tells you that if you don’t imbibe then you will die. It’s probably stronger than other drives because it will have you leaving home at times you would normally rather have a hot poker in the eye in a non-driven state. Like as a non-morning person, if I were out of cigarettes I would be on my way to get them as soon as I got up. For some reason this being a drive has less of a stigma than a compulsion. I wish my brain kept footnotes of where I glean information as I know that’s important to note here.
In SMART Recovery we plan for events which increases the likelihood that you will take your higher-functioning route when encountering a trigger. So if folks are concerned they might come across a certain situation then they can write down the response they want to have and go over it, rehearse it, so those pathways are set up before the event even occurs. I heard someone’s story where they, after a long time of abstinence, felt an overwhelming urge when their mother was in the hospital knowing there were tons of opiates in her house and “no one would know.” But of course the person using always knows when we are imbibing and we are the most important person to understand it for ourselves. Whether we are found out is not as important as what we know about ourselves. And in this case the person was found out anyway. As the “I will have just a couple.” thought did not materialize in reality. The person kept returning to get more and take more.
It’s not true that in every case the addiction becomes worse while you are abstinent. The ways it manifests in people is more like on a spectrum than an absolute set of known symptoms/behaviors. I might be in the red zone, you might be in the ultraviolet zone, etc. Then there is the plethora of co-exisitng disorders which adds an additional level of complexity. Therefore, there is no one-size-fits-all approach to recovery.
Perhaps the 7 month mark is a common time of fatigue where that long of a period of vigilance has exhausted the ability to continue white-knuckling. In SMART we emphasize focusing on what you are doing, instead of not-using, in order to move your thinking away from this. It seems to take less effort than to try to NOT have certain thoughts which seems impossible (Like right now, don’t think of a pink elephant.).
Using Freud’s horse and rider metaphor, the rider (pre-frontal cortex thinking) grows tired as the horse (baser urges, drives…) has been using its muscle to try to serve its desires. Eventually the rider fatigues. In the case of the 7 month lapse/slip, perhaps we just let our rider rest for a while and do some self-care like take a nap, get a massage, a bath, something to ease our weary minds. Whatever feels rejuvenating to you. This can take some trial and error since our way of self-soothing has probably purely been using for quite some time.