Building Motivation from Relapse: Motivational Interviewing Meets the Twelve Steps at the Moment of Relapse

Counselor Magazine 2013/Nov-Dec

 

This article shares the results of a more than thirty-year quest to understand “that first drink or drug” of physical relapse, to help the addict understand and not repeat his or her own decisions to resume use. Two kinds of thinking voice the decision to pick up the first drink or drug after a period of abstinence. It was, in fact, the relentless recurrence of these two kinds of thinking which captured this clinician’s interest over three decades ago.

 

For ten years beginning in 1978, the author used experiential psychotherapy (Meisler, 1991), especially clients “reliving” actual decisions and the situations in which they arose. Together, we mapped the reactions (DuWors, 2000), thoughts and feelings associated with the fateful choice.  In the 1990’s, explicit connections emerged between this work and Twelve Step recovery. The author-clinician was humbled to realize that Alcoholics Anonymous has always focused on “the mental states that precede a relapse into drinking, for obviously that is the crux of the matter” (Anonymous, 2001).

For more than a decade, this practitioner wrestled with the “Trans-theoretical Model of Change,” (TMC) (Prochaska, 1994)  and “Motivational Interviewing,” (MI) (Miller & Rollnick, 1991).  While becoming increasingly fluent and comfortable with these tools, he also became increasingly puzzled and frustrated by the exclusive focus of MI technique and research on “Change.” What about “Maintenance?” Are there specific ways to motivate chronic, relapsing alcoholics and addicts to work at maintaining abstinence and keep working? Are there specific “motivational discrepancies” that motivate beyond the “change” stage of recovery? What keeps some people attending Twelve Step meetings, long after achieving apparently stable abstinence? Why don’t they just leave? These questions, applied to the actual decision to take the first drink or drug of physical relapse and the thoughts that voice that decision, led to discovery of eight “motivational discrepancies,” consistent with MI, but specific to the “maintenance” stage of the Trans-theoretical Model. These discrepancies may be developed from those “failed plans,” which the second edition (2002) of Motivational Interviewing describes as an “opportunity to learn rather than a failure.” They build upon the psychology of the two kinds of relapse thinking, at the moment the old plan finally collapses and use resumes.

 

What is a “Motivational Discrepancy?” 

Both editions of Motivational Interviewing cite the smoker who sees himself neglecting his children. Too late, he realizes, “that I would actually leave my children out in the rain to run after cigarettes.” At least, in this defining example, a “motivational discrepancy” seems to consist of making a decision that betrays an important value, only to perceive one’s betrayal after taking action. One actually experiences the discrepancy in that moment of dismay, whether it occurs before (What am I thinking!), during (What am I doing!) or after (What have I done!). As one early story in Alcoholics Anonymous (2001) put it, “I begin to see I am not the person I had thought myself.”

Work with relapse decisions parallels this process, helping the client to look back at the decision itself, to see any gaps between who they think they are and what that moment of choice may say about them. The two kinds of thinking found at such moments are described below, followed by the eight “motivational discrepancies” they reveal.

 

Two Kinds of Relapse Decision: “Wishful” and “Expletive” Thinking 

An alcoholic or addict decides to quit for good. He or she does quit, sometimes for years, possibly for weeks or months. Then the person decides to start again, almost always vocalizing one of two kinds of thinking, if not both. One may be described as “wishful”—“One won’t hurt,”  “I can handle it now,” “This time will be different,” and a handful of variations we have all heard so many times. Beck (1993) identifies these thoughts as “permission-giving beliefs.”  Alcoholics Anonymous distinguishes the relapse commencing with these ideas as “casual,” all three examples in Chapter three expressing wishful thoughts. The other type of thinking may be called “expletive,” usually beginning with the letter “F.” For reasons of taste, we will use “dammit.” Beck devotes a chapter to anger and relapse without mentioning the angry language at the fatal moment. The AA “Big Book” describes what appears to be the same type of decision/action as “deliberate” relapse. Levin (1995) observes that most slips are “rage responses,” also ignoring semantics. The only other author-clinician not to shrink from this empirical fact, the expletive language at the moment of so many relapses, but not all, is Harvard psychoanalyst Lance Dodes (2002), who constructs a psychoanalytic theory of addiction and relapse out of it. These two types of thinking, almost universally present at moments of deciding to resume use, provide the personal experience from which the eight motivational discrepancies may be developed for any given client.

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The Eight Motivational Discrepancies  

 

What does it mean that an addict, previously committed to abstinence, changes his or her mind? Thinking, “I’ll just have one” (or any wishful variation) and acting on the thought?  First of all, if there is any such thing as “addiction,” one will hurt, it won’t be “handled,” and “this time” won’t be “different.” Again and again, we see a person believing a falsehood. This offers a vein from which the clinician may develop four “motivational discrepancies” strictly related to wishful thinking. Together, they form the acronym, “MOWS”

 

“M” is for Memory 

• “That I would actually forget the pain of my own suffering; dooming me to repeat it again and again.”

 

 

Failure to learn from experience is a trait neither sought nor admired. The suggestion that learning erodes and may need “remedial” repetition seems insulting. Seeing this in one’s self usually triggers a similar reaction to our paternal smoker—“the feeling was one of humiliation.”  One italicized sentence from Alcoholics Anonymous, as poignant as it is pedantic, summarizes the problem: “We are unable, at certain times, to bring into consciousness with sufficient force, the suffering and humiliation of even a week or a month ago.”

 

This “memory problem” (DuWors, 2006) directly implies a maintenance task—to remember, by whatever means possible, the reasons for getting and staying sober. Not just for two months or two years, but for the rest of the person’s life.

 

“O” is for Ownership  

 

• “That I am actually the one to pick up the first drink/drug, when there is no drug/alcohol in my brain.”

 

 

“I once was blind but now I see,” sings joyously of newfound awareness in “Amazing Grace.”  The lyrics do not celebrate the wrenching pain of disillusionment. The process hurts, as if the scales on our eyes were pasted on with superglue. But singing joyously in community suggests “maintenance” beyond the original epiphany.

 

Alcoholics Anonymous concludes discussion of taking that first drink, “these observations would be academic and pointless if our friend never took the first drink . . . therefore, the main problem of the alcoholic centers in his mind.” Clearly, the “ownership” discrepancy reveals who must change. The respectable “Dr. Jekyll” does not move from the TMC stages of pre-contemplation or contemplation to preparation and action until he stops blaming the already intoxicated “Mr. Hyde.” Even then, it may take a relapse or two for him to take ownership of the lifelong maintenance work that could be necessary.

“W” is for Willpower 

• “That I would actually decide to control use and fail, then decide to abstain, only to fail at that.”

 

 

This discrepancy reveals the alcoholic or addict as “powerless” in two ways; first, the inability to consistently control use once begun, and second, the inability to make a decision to abstain and make it stick without further on-going action. Alcoholics Anonymous summarizes, “. . . you find you cannot quit entirely, or . . . you have little control over the amount you take.” In a different but related context, Miller and Rollnick observed, “Success is not simply a matter of ‘willpower’ once the goal is set.” No responsible therapist would support an epileptic who plans to control the illness by “willpower.” Medication is precisely what the epileptic does control. It is his or her realistic “self-efficacy.”

 

No one wants to think he or she is not in control of self. One of several ways Alcoholics Anonymous expresses this fearful realization is, “Our human resources, as marshaled by the will, were not sufficient; they failed utterly.” The “willpower” discrepancy may well trigger fear and helplessness. If the person does not get “power” from somewhere, he or she stands to lose everything. This “power” may well be the energy saved and/or released when any human stops fighting reality. It may also be the energy derived from the feeling of community—“we” are all in the same boat.” Others might attribute it to the effect of discipline and/or spiritual practice, releasing the energy the practitioner does not have without it. Regardless, humbly facing the truth, letting facts (not desire) guide us, may define “surrender.” It may also take a “slip” or two to convince someone who faces the “willpower” discrepancy that the “higher power” tends to fail without maintenance.

 

“S” is for Sanity

 

• “That I could actually be so deluded making decisions to resume use, not even recognizing I was doing just that.”

 

 

Few among us embrace “illogical,” “wrong,” or “irrational,” much less “delusional” or “insane” as qualities of our ideal self. Yet Alcoholics Anonymous describes a particularly creative example of wishful thinking and concludes, “We call this plain insanity.” The “Big Book” then emphasizes, “This type of thinking has been characteristic of every single one of us.” Like the failure of “willpower,” perception of this discrepancy can be both humiliating and terrifying.

 

After a group exercise which draws out the delusional basis of the “wishful” decision, a common response is, “I feel sick.” The task is as clear as it is daunting. Thich Nhat Hanh (Hanh, 1975) defines “mindfulness” as “keeping alive in consciousness the reality of the present moment.”   Addiction challenges the person to keep alive the reality of the disease itself, including what will happen if he or she does not, even for a moment. AA nourishes this life-and-death mindfulness (2012) at several levels and through multiple practices (2011)

 

Four Generic Discrepancies of “Expletive” Thinking

The first two things we notice about “expletive” relapse decisions are negative emotion and meaninglessness. The person is upset and about to do something as negative as it is meaningful.  Yet the actual words are irrelevant. Exploration of the real meaning generates four more discrepancies based on expletive thinking that form the acronym “QUIC.”

 

“Q” is for Quitting

 

• “That I am actually throwing in the towel, giving up the effort to cope and/or remain clean and sober, when I say ‘dammit’ and pick up that first drink/drug.”

 

 

“Welcome to Quitters Anonymous! My name is G. and I am a quitter!” The group responds, “Hi, G.!” Who would attend such a meeting, enthusiastically proclaiming such an identity? Yet group after group of alcoholics and addicts will translate “Dammit” as “I quit,” “I give up,” “I’ve had it,” or “It isn’t worth it.” Only later do they admit what the words actually meant, and even then the ownership of “quitting” may be intellectual and temporary. The clinician carries the burden of fleshing out the realization and turning it into motivation.

 

Finding a way to maintain abstinence under duress is the very heart of the task implied by the discrepancy of quitting. Most addictive clients have never considered that it is possible to give up a struggle without drinking/drugging. If two core slogans or tools of AA, “Keep coming back!” and “One day at a time!” do anything, they counter the sometimes overwhelming urge to throw in the towel of abstinence.

 

“U” is for Uncaring

 

• “That I actually told myself I did not care when I did, and actually acted as if I did not care, when I did.”

 

The group motivational exercise “Expletive Deleted,” (DuWors, 2010) elicits “translations” of “Dammit.” Most groups offer “I don’t care” first and it is almost never omitted. The aggressive declaration of indifference turns out to be the voice of a double avoidance.

 

Alcoholics Anonymous confesses, “In some circumstances we have gone out deliberately to get drunk, feeling ourselves justified by nervousness, anger, depression, jealousy, or the like.” Whether in individual session or in group, the clinician may ask, “If you did not care, what were you upset about, so upset that you seemed to think it justified drinking/drugging?” This may need to be followed, or preceded, by an empathic explanation of the intimate relationship between caring and vulnerability to pain. The “uncaring” discrepancy reveals a negative form of wishful thinking—“I want to believe I do not care, because the truth is too painful, I do care.”

 

Facing this discrepancy motivates people to reduce unwise caring and unnecessary pain. It may also open people to learning how to “accept” the vulnerability and inevitable pain of caring about all sorts of things over which one has no control. These changes are of little benefit unless they are maintained.

 

In addition to being upset about what has already happened, the “uncaring” discrepancy represents denial of being effected by what will happen: “Damn the torpedoes!” “Devil take the hindmost!” “Let the chips fall where they may!” But now that the chips have fallen, is the person suffering from or about consequences of the devil-may-care decision? What do they make of that? What would their now suffering self say to the uncaring, “dammit”-self who picked up that first drink or drug?

 

What are the tasks here? To develop ways to step back and look at what is really happening, what the predictable consequences of use may be, and to remember everything that is important when one thing goes wrong. The task is also to maintain “perspective” and to maintain the ability and motivation to use them for the rest of the person’s life.

 

“I” is for Immaturity  

 

• “That I actually displayed the outrage of a child, crying out my expletive and grabbing my bottle or other ‘pacifier’.”

 

“If life doesn’t give me what I want, or it gives too much of what I don’t want, I’m out of here!” “I want what I want when I want it!” “My way or the highway!”

Ask a group of alcoholics or addicts who said “dammit” as their abstinence broke down, is this the emotional mindset they were in? Nodding heads and sheepish grins. Dr. Beck calls it “Low Frustration Tolerance” (LFT), a worldview that evaluates situations by “Am I getting what I want?” or “Are people getting in my way?” Other clinicians might say “grandiosity,” “entitlement,” “narcissism.” Alcoholics Anonymous observes dryly that “. . . the alcoholic is an extreme example of self-will run riot, though he usually doesn’t think so.”

 

The clinician can ask several generic questions to develop the “immaturity” discrepancy. What was your BAL/UA at the exact moment you said “Dammit” and reached for the first drink or drug?  Never mind the calendar, how old did you feel at that moment? In other words, what will have to change for your abstinent self not to erupt into an expletive and drink or drug the next time life does not give you what you want? Or gives you too much of what you don’t want? Just how big of a change is it from “My way or the highway” to humble realism? How does one “transform?” Whatever the drastic change that may be necessary, how will you maintain it?

 

“C” is for Coping 

 

• “That I would actually be so ‘inadequate,’ so incapable of ‘dealing with’ reality.”

 

Schizophrenics have psychotic breaks. Neurotics have nervous breakdowns. Alcoholics and addicts suffer a breakdown of the willingness and/or ability to cope. The process of relapse may be gradual, but the breaking point is often marked by an expletive of frustration and/or despair, followed by the first drink or drug. Just what is coping? The “Serenity Prayer” offers practical principles to even the most secular mind: to face frustration, to sort out what is and isn’t in his or her control, and to take action where it might make a difference.

 

The “coping” discrepancy and the need for skills seem indistinguishable. Necessity to maintain willingness to practice and new learning are not as immediately obvious. But did you use the tools you practiced earlier in your recovery? What happened to the willingness to use them? For those who once had the tools and yet failed to use them, a “willingness-to-pick-up-the-tools” scaling question may be used retrospectively, to track the relapse process. That willingness generally drops over time. In many cases, this decrease will correlate with falling maintenance activities.

 

Summary

 

This article reports eight motivational discrepancies found at the moment an alcoholic or addict, previously committed to abstinence, acts upon the fateful decision to resume use. “Wishful” and/or “Expletive” thinking voice these decisions and provide the discrepancies, represented by the acronyms, “MOWS” and “QUIC.” Each of the eight discrepancies uses the language of the father/smoker offered by Miller and Rollnick as illustrating their “principle . . . that is quite central to motivational interviewing.” Each also potentially motivates, not just for change, but for maintenance. Throughout the discussion, quotes appear from Alcoholics Anonymous, either spelling out the discrepancy or its resolution. For the chronic, relapsing alcoholic or addict, the person who seems unlikely to “exit” the cycle of change, Twelve Step recovery remains the only “support group” to explicitly identify all eight discrepancies and to offer free lifelong maintenance for each. Alcoholics Anonymous summarizes, “What we really have is a daily reprieve contingent on the maintenance of our spiritual condition.”

“Wishful thinking” reveals a chemical-free mind controlled by illusion, apparently resulting from failure of memory and unacknowledged craving. “Expletive thinking” reveals a child-like refusal and/or inability to accept reality. Empathic exploration of “wishful thinking” generates the tasks of maintaining memory and motivation. “Expletive thinking” reveals the tasks of emotionally growing up and staying that way. Group sharing and exercises, probing questions, bibliotherapy, and timely reflection may develop the above discrepancies. The three supportive principles of Motivational Interviewing, “expressing empathy,” “rolling with resistance,” and “supporting self-efficacy” help the person digest painful truth and take discrepancy as motivation rather than attack.

 

 

 

References

 

Anonymous. (2001). Alcoholics Anonymous, the story of how many thousands of men and women have recovered from alcoholism. New York, NY: Alcoholics Anonymous World Services, Inc.

 

Beck, A., Wright, F., Newman, C., & Liese, B. (1993). Cognitive therapy of substance abuse. New York, NY: The Guilford Press.

 

Dodes, L. M. (2002, April). The heart of addiction: A new approach to understanding and managing alcoholism and other addictive behaviors. New York, NY: Harper Collins.

 

DuWors, G. (2000). White knuckles and wishful thinking, learning from the moment of relapse in alcoholism and other addictions. Seattle, WA: Hogrefe and Huber.

 

DuWors, G. (2006). Memory, motivation, and maintenance: The challenge of wishful thinking in addiction and relapse. Addiction Professional Magazine, 4(2): 40-43.

 

DuWors, G. (2011, December). The mindful practices of Alcoholics Anonymous. Wise Brain Bulletin.

 

DuWors, G. (2012). Maintenance talk in a maintenance community. Counselor, 13(1): 56-57.

 

DuWors, G. M. (2010). Expletive deleted: A group motivational exercise. Counselor, 11(6): 42-43.

 

Hanh, T. (1975). The miracle of mindfulness, an introduction to the practice of meditation. Boston, MA: Beacon Press.

 

Levin, J. (1995). Introduction to alcoholism  counseling, a bio-psycho-social approach. Washington, DC: Taylor and Francis.

 

Meisler, J. (1991). Effective psychotherapy for patient and therapist. New York, NY: Praeger Publishers.

 

Miller, W., & Rollnick, S. (1991). Motivational interviewing, preparing people to change addictive behavior. New York, NY: The Guilford Press.

 

Miller, W., & Rollnick, S. (2002). Motivational interviewing, preparing people for change. New York, NY: The Guilford Press.

 

Prochaska, J. O. (1994). Changing for good. New York, NY: HarperCollins.