Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage was what he called Set-Up Behaviors—“ways of thinking, managing feelings, and behaving that increase the risk of relapse.” The second stage was Trigger Events—“events that activate the physiological brain responses associated with craving.” The third stage was the Craving Cycle—“a series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.” For ease of remembrance, we will refer to the first stage as “Ready,” the second stage as “Set,” and the third stage as “Go.”
Within the Ready stage, Gorski described physical, psychological and social set-ups that can lower the individual’s resistance to craving. At the Set stage, he said there were four primary kinds of triggers that could immediately activate a craving: Thoughts, Feelings, Behaviors and Situations. The Go stage, what Gorski called the Craving Cycle, was obsession, compulsion, physical craving and drug-seeking behavior.
There is often a progression from Ready, to Set, to Go—but not always. For example, euphoric recall is one of the psychological set-ups within the Ready stage, but these memories can be powerful enough to immediately activate a craving cycle (the Go stage). Here the memory is a “thought trigger” in the Set stage, one that immediately triggers a craving. Conversely, sometimes there can be set-ups—say socializing with drug-using friends—that don’t trigger thoughts, feelings, behaviors or situations that lead to a craving cycle. But such “misses” can give a person a false sense of security about future opportunities within this kind of set-up. The next time, you may not be so lucky.
The Ready Stage
Gorski said there are five common physical set-ups for cravings. The first is Brain Dysfunction from Drug Use. “Mind altering drugs [including alcohol] damage the brain” when they are misused or abused. I would add that all drugs with mind-altering properties should be included here. The obvious drug classes are the benzodiazepines and opioids. However, I’d also include the antidepressants and the antipsychotics.
Current antidepressant medications typically modify levels of serotonin (or sometimes norepinephrine) in the brain. Antipsychotics generally work by blocking a dopamine receptor referred to as the D2 receptor. This receptor has been suggested in research to be related to compulsive eating and cocaine abuse. Carleton Erickson, in The Science of Addiction, indicated there were fifteen separate receptor subtypes of serotonin involved in chemical dependence, and five separate dopamine receptor subtypes. Neurontin (gabapentin) effects levels of the neurotransmitter GABA, which is influenced by benzodiazepines. GABA dysregulation also plays a part in alcohol dependence. My point is not that all addicts should taper off of their psychotropic medication. But in learning to manage and cope with cravings, they should consider the potential influence of their medications.
The second physical set-up is poor diet. Simply put, “Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.” Gorski adds that many individuals have coexisting eating disorders.
A third physical set-up for cravings is the excessive use of caffeine and nicotine. Gorski noted how both caffeine and nicotine, which are low-grade stimulants, could increase the likelihood of having a craving.
The fourth physical set-up is a lack of exercise. “Regular aerobic exercise is a protective factor against craving.” It can reduce the intensity of cravings.
A fifth physical set-up is poor stress management. Stress management activities such as meditation, relaxation exercises, regular periods of rest, relaxation and sleep are all helpful ways to manage stress. When people do not manage stress appropriately in recovery, they set themselves up for cravings during the times of stress that often occur in early recovery.
Euphoric recall occurs when an addict “romances” past times of drug use. They remember and magnify the pleasurable experiences of past use, while blocking out the painful and unpleasant memories. Spontaneous recollection of past “fun” times is common. To avoid euphoric recall leading to a craving cycle, “play the whole tape.” Don’t stop at the fun times, intentionally add where the pain and unpleasantness of past use fits into the story.
Awfulizing abstinence is another set-up. Here the addict attends to all the negatives and perceived losses about getting sober, while blocking out thoughts of the benefits. This leads to a mistaken belief that “being sober is not nearly as good as using the drug.”
In magical thinking, the addict sees drug use as the solution to their problems. Gorski said this was a combination of euphoric recall (Remember how good using was) and “awfulizing” sobriety (how awful it is that I can’t use). I’d suggest that an individual is also in magical thinking when their using history has demonstrated a clear inability to control drug or alcohol use, but they continue to harbor thoughts that when XYZ happens, they could try social or controlled using again.
This will lead to empowering the compulsion. The person exaggerates the power of the compulsion by telling themselves there is no way they can resist the craving; they can’t stand not having the drug. I’ve seen a subtype of this psychological set-up where the person will convince themselves they wouldn’t be able to resist the compulsion to use again if “X” disaster or crisis happened to them.
Gorski sees the psychological set-ups listed above as leading to the fifth and final one of denial and evasion. Here the addict rejects or denies that their actions could be setting themselves up to have a craving. They may deny that they need the help of a recovery program or treatment. “This denial does not go away simply because they are not using the drug.” Because denial is largely an unconscious process, many addicts believe they are doing the best they can; that they are making the right decision for their life and recovery when, in fact, they aren’t.
The stress of the instability and unmanageable circumstances that often occur in early recovery could lead to this as well. Awfulizing the obligations of early recovery or their lives, such as time away from work and family for treatment or meetings, possibly changing jobs or colleges, fear of financial consequences from not working, etc., can lead to this set-up.
Socializing with drug using friends can be a stumbling block for addicts. Trying to negotiate abstinence without losing the ability to go around certain people who they used to drink and drug with is a major problem for some people. A potential loss of the relationship seems unthinkable at the time. Even when the active user voices support of the individual’s desire to establish and maintain abstinence, the contact may not be a good idea. For one thing, knowing the person is high, or has drugs close by can be a trigger for craving.
One of the reasons that an addict, particularly in early recovery, is drawn to socialize with their using friends is the desire to be with other people who understand them—how they think and what they struggle with. This is why social isolation is so dangerous for someone in recovery. This also points to a couple of the benefits to active participation in AA or NA—these are places where the person can share their fears, doubts and struggles without fear of rejection. And they can form new friendships with people who can relate to how they think and feel.
When open and honest self-disclosure is replaced by superficial communication, the person in recovery gets into trouble. They neutralize another benefit of active participation in self-help groups—the ability to get feedback and reality checks from others who understand how they think and feel about an issue. The lack of honest, heart-felt communication with other people who understand addiction is another social set-up.
If the above lack of honest sharing with others continues, it can lead to isolation from other people in recovery. This can happen through decreased meeting attendance and/or avoiding sober social situations with other recovering addicts. Another contributing factor here is if conflict of some sort occurs and becomes a justification for why the person avoids a particular meeting, or why honest sharing of what they are struggling with is not talked about. Unresolved conflict is another social set-up.
I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is the first of a three part series on coping with cravings. The other two articles are “Getting Set to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.