Expectation and Deprivation In The Urge to Relapse, by Charles Perkel
Recovery involves the strengthening of conscious intention to free oneself from the ‘vicious’ cycle, to translate intention into an action that opposes the urge to use and tolerates the feelings of loss.
Many addicts describe their addiction as a habit—one that continues despite unpleasant consequences. Many clinicians struggle with their role in assisting the addict. In this article, Charles Perkel discusses some ideas based on current research and understanding that may be useful for clinicians working with addicts, specifically as regards how to work with expectation and the feelings of deprivation associated with relapse.
Intention hijacked
Conscious intention is a uniquely human quality that describes having a purpose in mind. Addiction involves the ‘hijacking’ of conscious purpose as the addict becomes habitually devoted to a behavior with problematic outcomes. It results from chronically repeated, highly euphoric experiences (often the use of a psychoactive chemical) that cause progressive changes in the brain. As these changes occur, the behavior becomes compulsive and automatic, is characterized by conscious craving to repeat it, a loss of control over the behavior and escalating consequences because of it. (6) A woman addicted to analgesics describes this experience as “so impulsive... I don’t even process it... it’s just my nature now.”
Crisis
Ultimately a point of crisis is reached, driven by conflicting desires: The desire to stop the pain of escalating consequences versus the desire for the immediate relief and reward from the habit. Furthermore, attempts to discontinue are associated with unpleasant feelings of deprivation, withdrawal and stress sensitivity that amplify the need to repeat the habit. This dysphoria can go on for weeks or months and has been referred to as the ‘dark side’ of addiction that reinforces the need to continue getting high. The process of negative reinforcement intensifies even as the positive reinforcement diminishes.(7) The addiction shifts from the desire for the euphoric effects of the behavior to the desire for relief from the dysphoric effects of stopping the behavior. (10)
Paradoxical choices
Thus a ‘vicious cycle’ develops in which many addicts find themselves mired. After all, the behavior reliably offers instant relief from growing unpleasant feelings even as tolerance and consequences erode the quality of the reward. This drives the addict to paradoxically escalate the behavior to keep the same kind of feeling even when it makes total sense to stop. This correlates in a shift from reward-driven to habit-driven behaviors. It feels like an unstoppable force. An alcoholic man describes this as “the constant battle between me thinking I can control it and the reality of it... I wish something that is impossible.”
The addictive behavior thus becomes the ‘best’ choice when the frame of reference is restricted to the current moment but the worst choice when the frame of reference expands to include future costs and other people’s needs. This is spoken of as ‘delay discounting’ and refers to the mounting difficulty experienced in delaying gratification and staying the impulse to engage the behavior.(10)
Ambivalence
Existing chronically in this state of ambivalence erodes self-confidence and self-efficacy. Compounding this are feelings of guilt and shame due to negative judgment from self and others. This evokes defensiveness. The addict defends the side of ambivalence that justifies non-change. Ambivalence is an essential part of habit change but extremely problematic when it is stuck. To quote Miller and Rollnick “Ambivalence is a reasonable place to visit, but you wouldn't want to live there”. (3, p.14)
Those who give well-meaning and logical advice (including clinicians) can further intensify the addict’s tendency to defend the non-change side of ambivalence. They hear such advice over and over and find ways to explain to themselves and others the continuation of an irrational behavior. They resort to minimizing the problem, denial, rationalizations and other ways of explaining it, both to themselves and those offering the sage advice to abstain. They may feel internally split and may talk about the addict within as if it is a separate being living in the same body.
Craving and cues
The addiction is driven by a desire for the reward, which is termed ‘craving’ and is an ubiquitous part of the process. DSM-5 has recognized this and added craving or a strong desire or urge as part of their criteria for the diagnosis of a substance use disorder. (15) There is some debate as to how conscious, urgent and uncontrollable this ought to be in order for it to qualify as craving. (8) Part of the confusion arises from the observation that many relapses are impulsive and automatic, with little forethought.
Studies suggest that physiological and brain responses to drug cues are often not in synch with reported craving and reflect more accurately the immediate availability and proximity of the desired reward.(9) The perceived opportunity to use drugs increases relapse potential and may be viewed as a conditioned cue.(11) The brain is finely tuned to assess the value of a reward but its value is changeable. We all know that food value shifts depending on hunger or satiation. In addiction this is aberrant because satiation become increasingly difficult to reach and the value of the behavior becomes stuck at high volume. Nonetheless, the immediate salience of the reward is still changeable depending on its availability. Flight attendants who smoke, for example, report higher smoking urges immediately before landing, independent of the length of the flight.(12)
Relapse urge and expectation
Thus expectation to use drives the desire, and expectation is influenced by many factors, including the immediacy of the reward. A more proximal reward is more valuable. Our brains are programmed to shift us towards a higher value immediate reward. This is termed cue-induced reactivity and may occur outside of the realm of conscious craving while still influencing the urge to act.(9) As the value of the reward increases, so does the process of delay discounting, especially as the more abstract and remote value of not using doesn’t shift. The good feelings are immediate, the bad feelings are delayed.
An urge can be defined as a force or impulse toward an activity or goal. The interesting quality of an urge is that it can be both a conscious desire and/ or an unconscious force. The mere idea of an action prepares us to act without the necessary involvement of conscious thought. A significant part of the process in which our brain weighs up complex information to make decisions to act occurs at a non-conscious level. In fact, what we experience as a conscious decision to act may be the inference of an already primed cognitive state influenced by external and internal cues that may be conscious or non-conscious. (13) In a healthy state, conscious motivation and unconscious urges are synchronous (for example preparing for dinner), but become conflictual in addiction.
Compromised cortical
Moreover addiction itself has been associated with disruption in cortical control centers that modulate our responses to reward and stress.(5) It takes healthy executive frontal lobe skills to delay gratification; rational decision making skills are compromised in active addiction and early sobriety and may be easily overwhelmed and eclipsed by the powerful emotional limbic impulses to get high. Other strong feelings, such as fear, sadness or stress, may also impair executive functions in the moment disinhibit otherwise suppressed urges to use.
Relapse potential is more accurately reflected in the urge, rather than the conscious craving to use, and may occur without self-awareness. When the awareness to use does occur it may be late in the process and tough to stop.
Irrational relapse
We can thus conceptualize the urge to relapse as a being driven by a continuum of intensity of both conscious craving and unconscious drive for the feeling of the reward. The mildest urge may evoke a passing wistful or uncomfortable memory of the feeling of using in someone solid in their recovery, where potential relapse is remote; a more severe urge is one that arises when relapse is being considered and may evoke more risky behaviors and stronger cravings; most severe is the unstoppable compulsive urge that arises when relapse is decided and availability immediate.
Someone committed to sobriety in a moment of circumstances that escalates the value of the reward may find themselves impulsively relapsing. The clinician hears the person making an earnest and honest commitment to never using again only to witness that person shortly thereafter again in active addiction. This can be both bewildering and devastating for everyone involved, including the addicted individual. Strong reactions can be evoked in clinicians who can feel deceived, manipulated, deskilled and cynical.
Motivating change
If certain interventions can push someone away from change, is it possible to push that person towards change? It is recognized in the technique of Motivational Interviewing that the clinician’s approach is important and that ‘the way in which one communicates can make it either more or less likely that a person will change’.(3, p.8)
Motivational Interviewing is a therapeutic approach that accepts ambivalence as an inevitable part of change, that ‘people resolve ambivalence by talking themselves into changing’.(4, p. 198) The role of the clinician is to facilitate change talk, ‘to first intensify and then resolve ambivalence by developing discrepancy between the actual present and the desired future’.(3, p. 23)
Recovery
Recovery involves the strengthening of conscious intention to free oneself from the ‘vicious’ cycle, to translate intention into an action that opposes the urge to use and tolerates the feelings of loss. Stopping the cycle briefly is often possible and sometimes is an integral part of the pattern of the addiction (e.g. in binge alcoholics or cocaine users); the difficult emotional work of recovery is in staying ‘stopped’. Detoxification is the first step towards recovery. Maintaining recovery includes managing the brain’s expectation for the euphoric relief that is craved as well as the feeling of deprivation and loss that is experienced when the expected reward is not given.
Recovery is a process and has been compared to the management of a chronic disease like diabetes.(16) The brain needs time to recover and may go through different stages of change over time. Initial approaches require ‘here and now’ strategies that are practical, supportive and crisis-based, but which may later (months or longer after quitting) may be more explorative and insight based.
Cognitive strategies
Utilizing simple cognitive strategies when exposed to triggers to shift attention away from relapse thoughts to neutral thoughts may be helpful. It has been demonstrated that such purposeful strategies of conscious cognitive control can decrease brain activity in deep limbic areas central to motivational drive associated with conditioned cues for reward (the nucleus accumbens) as well as in higher cortical centers associated with the emotional valuation of reward (medial orbitofrontal cortex).(14)
Such learned techniques may decrease the brain’s response to conditioned cues and help strengthen and rebuild weakened cortical control centers. Alcoholics Anonymous and Narcotics Anonymous utilizes this idea with more experienced members sponsoring newer members, whereby the ‘sponsee’ is encouraged to contact his or her sponsor in moments of struggle with potential relapse or relapse triggers. This idea is also used in mindfulness training.
Devaluing the undesirable
Understanding how our brains value and prepare us to attain a desired reward is useful in working with people in recovery. For example, this may involve exploring with the addict triggers, which are cue-conditioned stimuli and how to recognize, manage and, if possible, avoid them. AA and NA talk about ‘people, places and things’. We can devalue a desired reward by making it less immediately available and attainable. If obtaining that reward involves more work or if we work to make it consciously no longer an option then the value of that reward will decrease in the moment and both craving and the urges to use will be more manageable. Creating value in constructive activities is also critical, for example the affirmation of belonging to a recovery group and the positive feeling after doing exercise.
We can appreciate why a small dose of the desired reward rather than satisfying the need only inflames it massively and makes it so much more difficult to resist the urge to take more—why having one or two drinks only is very difficult for someone with an alcohol use disorder. There is often the wish to be able to continue the behavior but in a controlled fashion. This is rarely, if ever, possible for someone who has progressed to point where using is habit driven.
Reflecting back
The therapist can play an important role in assisting the person in recovery to become conscious of his or her own thoughts and behaviors that may signal a move towards relapse, for example, taking note of the addict devaluing elements of recovery work. The person may deny any relapse intention or risk but the clinician notes signals.
Clinicians frequently are involved in acute crisis management, with the addict facing terrible consequences. In this state, with the value of using low and the value of abstinence high, the person commits to sobriety. However many clinicians will become aware as the crisis passes and becomes more remote that this commitment decays and the value of using increases. The clinician can assist the addict to become conscious of this trend before relapse occurs and the crisis replays.
Conditioned withdrawal
Urges to use activate a state of expectation for the reward which, if not obtained, triggers an uncomfortable feeling and a negative emotional state. (1) This feeling can mimic some elements of withdrawal and has been termed conditioned withdrawal. It can be associated with feelings of deprivation that intensify craving and the value of the desired reward. Recognizing feelings of deprivation is important in modulating craving and potential relapse. Feelings of resentment and unfairness may reflect danger signs.
The language of recovery itself can trigger feelings of deprivation. Words such as quit, stop, halt and abstain reflect loss. It is useful to conceptualize recovery as a process of healing that frees the addict from this cycle and allows him or her utilize affirming concepts, such as freedom or liberation from active addiction. The term recovery itself communicates a positive idea of making whole again.
Conclusion
Powerful forces that are often not conscious drive the urge to get high among addicts. The clinician can play an invaluable role in working with these forces to assist the addict to attain and maintain recovery, particularly in cultivating an understanding of the role of expectation as integral to using and the feelings of deprivation that occur when using is denied.
References:
1. George O, Koob GF. Control of craving by the prefrontal cortex. Proc Natl Acad Sci U S A. 2013 Mar 12;110(11):4165-6.
2. Hayashi T, Ko JH, Strafella AP, Dagher A. Proc Natl Acad Sci U S A. Dorsolateral prefrontal and orbitofrontal cortex interactions during self-control of cigarette craving. 2013 Mar 12;110(11):4422-7.
3. Miller, W. R., and Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2nd ed.). New York. Guilford Press.
4. Rosengren, D. B. (2009). Building Motivational Interviewing Skills: a practitioner workbook. New York. Guilford Press.
5. Seo D, Lacadie CM, Tuit K, Hong KI, Constable RT, Sinha R. Disrupted Ventromedial Prefrontal Function, Alcohol Craving, and Subsequent Relapse Risk. JAMA Psychiatry. 2013 May 1:1-13
6. American Society of Addiction Medicine, (2011). The Definition of Addiction.
7. Koob GF, Buck CL, Cohen A, Edwards S, Park PE, Schlosburg JE, Schmeichel B, Vendruscolo LF, Wade CL, Whitfield TW Jr, George O Addiction as a Stress Surfeit Disorder. Neuropharmacology. 2013 Jun 5. pii: S0028-3908(13)
8. Tiffany ST, Wray JM.Ann N Y Acad Sci. The clinical significance of drug craving. 2012 Feb;1248:1-17.
9. Hayashi T, Ko JH, Strafella AP, Dagher A. Dorsolateral prefrontal and orbitofrontal cortex interactions during self-control of cigarette craving. Proc Natl Acad Sci U S A. 2013 Mar 12;110(11):4422-7.
10. MacKillop J, Amlung MT, Few LR, Ray LA, Sweet LH, Munafò MR. Delayed reward discounting and addictive behavior: a meta-analysis. Psychopharmacology (Berl). 2011 Aug;216(3):305-21.
11. Wertz JM, Sayette MA. A review of the effects of perceived drug use opportunity of self-reported urge. Exp Clin Psychopharmacol. 2001 Feb;9(1):3-13. Review
12. Dar R, Rosen-Korakin N, Shapira O, Gottlieb Y, Frenk H. The craving to smoke in flight attendants: relations with smoking deprivation, anticipation of smoking, and actual smoking. Journal of Abnormal Psychology. 2010 Feb;119(1):248-53.
13. Marien H, Custers R, Hassin RR, Aarts HJ Pers Soc Psychol. Unconscious goal activation and the hijacking of the executive function. 2012 Sep;103(3):399-415.
14. Volkow ND, Fowler JS, Wang GJ, Telang F, Logan J, Jayne M, Ma Y, Pradhan K, Wong C, Swanson JM. Cognitive control of drug craving inhibits brain reward regions in cocaine abusers. Neuroimage. 2010 Feb 1;49(3):2536-43.
15. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) by American Psychiatric Association (2013)
16. McLellan AT, Lewis DC, O’Brien CP, and Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695, 2000.
Charles Perkel is the Division Chief of Addiction Psychiatry at the Beth Israel Medical Centre in New York.
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