The New Quitter

 

Diane Potvin has been sober for 23 years, but is still acutely aware that she could fall off the wagon.

Mike Di Ioia lost more than 100 pounds by sticking to a rigid diet, but is haunted by memories of being sick, overweight, and afraid of dying. Diane Webber-Thrush tries to stop a modest wine-drinking habit, but a rough day at the office sends her back to the liquor store.

The dirty little secret about addictions is that relapsing is the rule, not the exception. Up to 80 percent of alcoholics treated for a drinking problem will hit the bottle again at least once. Between 60 and 90 percent of smokers light up within a year of stopping, and more than 90 percent of the gamblers who quit on their own will eventually place another bet. Even minor bad habits are hard to break: People make the same New Year's resolution for an average of five years running before they maintain the change for even six months.

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When it comes to major behavioral changes—anything from losing weight to quitting hard drugs—few people do it perfectly the first time. For most, it's a long and winding road.

Yet many people do eventually overcome their bad habits. There are more ex-smokers (48 million) than current smokers (46 million) in the United States. In the biggest American survey of alcohol use, only one-quarter of the people dependent on alcohol were still drinking heavily the following year. Another long-term study revealed that for cocaine addicts who had gone through treatment, more than half were clean five years later.

Such statistics have inspired a new psychology of addiction that puts the problem of relapse front and center. It recognizes that relapse is distressingly common—but also that it can be just a stumble on the road to recovery. In fact, if handled the right way, a relapse can actually open the door to lasting success.

The abstinence-only doctrines that once dominated the thinking about addiction have given way to a more flexible—and more forgiving—approach. Overcoming a habit is understood to be a slow and halting process that is often plagued with slipups and setbacks. This understanding is motivated in part by evidence from neuroscience that addictions change the brain in ways that can take a long time to undo. "The last 10 years have given us a picture from a lot of different areas of science that once addiction sets in, it takes on the character of a chronic illness," says Jon Morgenstern, director of substance abuse services at Columbia University Medical Center in New York City. "It's very difficult for people to maintain behavioral change. Relapse is considered a part of the condition."

By the same token, relapse is no longer seen as a catastrophe. A fall off the wagon may feel like a failure that cancels out all the hard work of quitting, but that all-or-nothing perspective doesn't square with the facts, says G. Alan Marlatt, a professor of psychology and director of the Addictive Behaviors Research Center at the University of Washington. "It's like learning to ride a bicycle. Almost everybody falls at least once." A relapse can provide useful information. The trick is to view an episode of backsliding as a chance to learn, an opportunity to develop better techniques for anticipating and avoiding or overcoming urges. This insight applies to a range of problems, from life-threatening drug addictions to compulsions like overeating.

 
Out with Black-and-White Thinking

When Marlatt started working in an alcoholism ward in the 1960s, roughly 70 percent of the clients he saw bounced in and out of hospital-based treatment programs. But addiction counselors weren't supposed to acknowledge the high rate of relapse: The thinking then was talking about that would "just give people permission to do it," Marlatt recalls. Frustrated, he began studying how successful quitters maintained their sobriety over time. "We found that many had slips or lapses, and were able to get back on the wagon again," says Marlatt. "They were learning from their mistakes, and figuring out what to do next time." He developed a recovery model that addressed the reality of relapse, identifying common triggers and concrete psychological skills that helped people get back on the straight and narrow.

One of his early insights was that black-and-white thinking can turn a minor lapse into a major one. After a small slip, many people throw in the towel. A new ex-smoker has a couple of drags of a friend's cigarette, bums another, and then buys a pack, figuring she's already negated all her progress. This "abstinence-violation effect," as Marlatt named it, is the belief that anything less than perfection is total failure. It leads the quitter to conclude he just doesn't have the willpower to succeed.

But having just one slipup does not inevitably lead to a full-blown relapse. The slide back into addiction can be reversed. Addiction psychologist Stanton Peele describes it as multiple stations of a journey. The first "stop" for a drinker might be seeing an old drinking buddy at a bar. The drinker could "get off" at that point by leaving. If he stays, he could order ginger ale. If he does have a beer, he can "get off" at the next stop by going home rather than drinking more. The idea is that there are many opportunities to avert a total relapse.

 Listening to Professor Relapse

Marlatt encourages the backslider to see lapses as errors rather than defeats. Instead of stewing in guilt, the quitter should think analytically about how it occurred, dissecting the circumstances. What was he feeling? What happened earlier that day? Who was around? "We try to make it a learning process," says Marlatt. "We say: 'Hey, you fell off the wagon. How would you handle it differently next time?'" With this mentality, a recovering addict can learn to identify the situations that are likely to push him into a relapse. He can embrace the possibility of failure and see the broader horizon of change beyond it.

This mentality can help prevent the lapse from spiraling into a full-blown crisis, says Joshua P. Smith, assistant professor and program coordinator for the outpatient substance abuse clinic at the Medical University of South Carolina. "It's important to minimize the time spent in that slip, and the consequences of it," he says. Reframing relapses as learning experiences can enhance a quitter's confidence and resolve, giving him or her the mental energy to stick with it.

One of the reasons relapses are so common is that temptations seem to emerge out of nowhere. In fact, many invisible pressures, psychological and circumstantial, may build gradually, then suddenly combine to push you over the edge. For Diane Webber-Thrush, the moment came after a rough episode at her job at an educational nonprofit in Washington, D.C. Five months before, she had quit a long-standing habit, which was drinking a couple of glasses of wine every night after work. In the annals of vices, it was pretty mild: She stopped at two, so she didn't get drunk or have a hangover. But she didn't like the fact that she depended on the wine each night to relax. "It wasn't optional, and I saw that as a danger signal," she says.

So she quit. Every night, she walked right past the wine store and relaxed by listening to music instead. But then the pressure ramped up at work just as her boisterous 6-year-old twins went through an especially energetic phase. One day last fall, she got chewed out for missing a minor deadline. Walking out the door, she told herself, "I deserve a glass of wine at the end of this day." She bought a bottle on the way home, intending to have just one glass, and quickly slid back into her old two-drinks-a-night habit. "I reopened the door to the wine store, literally," she sighs. "And I haven't closed it yet."

Two types of factors play into such relapses. To learn from her slipup, Webber-Thrush could analyze them: proximal or short-term situational factors, and distal or underlying causes. Proximal factors often include personal conflicts, bad moods, and unpredictable events. For her, those would be the missed deadline and the reprimand. The biggest distal factor in her case might just be the fact that being a working mother demands a lot of energy and patience. "My life is wonderful, but it's stressful," she says. "I come home to little boys who are bouncing off the walls." Other common distal factors include having poor social support—your friends and family might be unavailable or even undermining. Not knowing how to recognize your feelings can be another underlying problem; if you don't realize what you are feeling, anger or frustration may overwhelm you.

By identifying proximal and distal factors, it's easier to anticipate and respond to an urge. Relapses often follow a similar pattern, psychologist Saul Shiffman has found in his studies of smokers. He uses a technique called "ecological momentary assessment" to scrutinize the exact moment of relapse. Smokers who are trying to quit get electronic diaries that regularly prompt them to record their mood and surroundings. If they do yield to temptation and light up, they are asked to fill out a more detailed record, including location, activity, and consumption of food or drink.

Being around other smokers and drinking alcohol are powerful triggers. No surprise there. But Shiffman found that the number-one predictor of lapses was emotional: the level of "negative affect" during the four to five hours leading up to the lapse. Anger, anxiety, depression, and upset are the most powerful potentiators, especially a bad mood that ramps up over a period of hours. "It's not a matter of how you feel these days, but a matter of hours and minutes," Shiffman told a national smoking cessation conference in the UK. "Life can come at you rather fast sometimes." Studies of alcohol, cocaine, and heroin relapses suggest that the same dynamic may be at work in these addictions.

 
Plans, Tactics, and Grand Pursuits

Identifying the factors behind a relapse is only the start; the crucial step is to make an explicit plan to counteract or avoid them. If an addiction is not debilitating or severe, it is possible to engage in that exercise yourself, says James McKay, a professor of psychology in psychiatry at the University of Pennsylvania. "Some people are better at that than others, and you need some time to think about it," he says. The plan should be concrete: Webber-Thrush could change her route so that she doesn't walk past the wine store, for example.

People who are in the thrall of a life-threatening or mind-altering addiction may need professional help to analyze triggers and come up with a coping plan, says Morgenstern. In his work with alcoholics undergoing treatment, he asks them to think through potential scenarios that might emerge in the coming months, and helps each of them develop a plan to avoid the hazards. Each is unique: One person might be vulnerable to boredom, another to stress. "We ask, 'What are the situations that can potentially get you into trouble?' says Morgenstern. "It's like disaster preparedness—you want to have a disaster kit at home."

Dieter Mike Di Ioia, a New Jersey-based graphic designer, has made a "disaster kit" out of a meticulous plan that itemizes every bite of food he puts in his mouth. Each day, he gets up at 5, has a cup of yogurt and hits the gym. At 10 am he has exactly 28 pieces of cereal, and at 11 am an apple. The rest of the day is mapped out just as precisely, to ensure he will never be blindsided by hunger and cravings. "I've always been goal-oriented," Di Ioia says. He writes down everything he eats, scripts detailed shopping lists, and has healthy low-calorie foods like carrots or fruit on hand at all times. (Quite a change for somebody who used to down two Big Mac meals at one sitting.)

He has thought through potential pitfalls and has plans for each of them. If someone brings pizzas into the office, he goes for a walk. If his train gets delayed on the way to the office, he has an alternate gym workout that takes less time. Di Ioia has shed 137 pounds since last summer, and is still losing weight. By preparing rigorously, he relapsed only once: pasta and stuffing at Thanksgiving, after which he got right back on his program.

Cognitive tricks are another way to prevent relapse. Marlatt teaches what he calls "urge surfing"—learning to mentally detach yourself from the craving by monitoring the way your desire builds and then recedes. In one study, he tantalized smokers by giving them cigarettes to hold and light, but did not allow them to actually inhale. They were asked to visualize their craving as an actual wave that rose and fell, and to imagine riding along with the wave rather than struggling against it. A week later, the participants who had been taught this and other techniques smoked an average of one-and-a-half cigarettes a day less than a control group.

Another trick is cultivating a vivid memory of the past you are trying to leave behind. Morgenstern found that people with a stronger "past-harm appraisal"—an enduring painful memory of the damage done by their addiction—were less likely to relapse. Di Ioia, for example, flashes back to the week and a half he spent in the hospital with a heart arrhythmia brought on in part by his bad habits. "Now, if I start overeating, I think about the way I was a year ago, and what it was like to be in that place"—seriously overweight and worried about his health. That mental image is a "kick in the ass," he says. The testimonials that are a part of every 12-step meeting serve the same effect.

A wide range of coping techniques can be effective, Shiffman found in his studies of smokers: Eating or drinking as a diversion, distracting yourself, escaping the situation, or focusing on the consequences of giving in. But doing something is essential: People who use some kind of coping technique in response to an urge are 25 times more likely to resist the temptation than those who try to just gut it out.

Cognitive techniques are just half of the equation. Morgenstern and other addiction psychologists also encourage recovering addicts to develop meaningful life goals, which may have been forgotten or cast aside in the obsession of addiction. Quitters need to reconnect with parts of life that provide pleasure, enjoyment and meaning—so-called "emotional future goals," as Morgenstern puts it. Renewing ties with friends and family and becoming involved in naturally rewarding activities weaken the pull of the addiction. New goals that are incompatible with the old habit—bicycling 50 miles instead of smoking, or looking good in a tight dress instead of eating donuts—also help. "It's not enough to have the threat of punishment," says Morgenstern. "People need to be embedded in a life that is rewarding."

 
Don't Be Trigger Happy

 How to navigate potential relapse scenarios

 1. Your former drinking buddy is in town and wants to take you out. 

The warmer the relationship, the more likely you'll remember the bonding and not the bad consequences of getting smashed together.

The Plan: Tell him you're not drinking and you'd like to go to a cafe. If the place doesn't serve, he can't nudge you to join him. Arrange for a supportive tee-totaling friend to pick you up later in the evening, in case you feel tempted to move to a bar for old time's sake.

2. You had a fight with your sweetheart, and now you're brooding.

The biggest predictor of relapses among smokers in one study was a negative mood that gets worse over a period of hours. Anxiety, anger, and tension can fester and build.

The Plan: Know that you risk relapsing for the rest of the day, not just in the moments after the blow-out. Suggest the two of you go to a movie, where you can't smoke and you're bound to get distracted into a better frame of mind.

3. Everyone is feting Becky in the conference room at 4 pm.

You'll look like a non-team player if you skip a workplace celebration, but if you go, you're bound to leave with a belly full of powdered sugar.

The Plan: Walk in armed with your own healthy snack and bottle of water. Your hands will be too full to hold a slice of cake but you can still sing "Happy Birthday."

A Long and Worthy Cause

The flip side of accepting relapse is recognizing that the work of kicking an addiction may never be fully complete. The way many researchers describe addiction today is a "chronic disease" that may be in remission but is rarely fully cured. It has been 23 years since Connecticut resident Diane Potvin has had a drink, but she says she is still "petrified" of relapse. She fell hard into alcoholism, and it controlled her life for a long time. "I never drew a sober breath for twenty-some-odd years," she says. All her friends drank; she had no career, no place to live, and no idea how to put her life back on track. At age 42, she went into a treatment plan, and slowly put the pieces into place. Now, in her work as director of recovery community centers for Connecticut Community for Addiction Recovery, she's seen people spiral back into addiction after many years of sobriety. For her, personally, the memories of her old bad life haunt her. "I know if I pick up a drink, I am unemployed, I am homeless. Sooner or later, that's what's going to happen."

Even long after vanquishing an old bad habit, it's not entirely erased from the brain—on a biological level, the connections are still there. Continued "booster shots" of treatment or reevaluation may be necessary months or even years after stopping. "People can't just turn the light switch on and off," says Smith. "If somebody who smoked crack but has been sober for years comes across a crack pipe, they'll react."

So the real milestone to celebrate isn't the day you quit, or even your 20-year anniversary. It's every day you get back on track after a relapse. It's those nights that you decide to go home before you backslide because you know you want to get up early for a run. Eventually, moment by moment, the little successes add up. The result: one big triumph. —Kathleen McGowan

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