Rationale

Craving is most often experienced early in treatment, but episodes of craving may persist for weeks, months, and sometimes even years after some alcoholics stop drinking.

Craving may be uncomfortable but is a very common experience and does not mean something is wrong. You should expect craving to occur from time to time and be prepared to cope with it if and when it occurs.

Urges to drink, or cravings, can be triggered by things you see in the environment that remind you of using alcohol.

Physical signs may include tightness in your stomach or feeling nervous through your body; psychological signs may include increased thoughts of how good you would like to feel from using alcohol or drugs, remembering times you used alcohol in the past, planning how you would go about getting a drink, or feeling you need alcohol.

Craving and urges are time-limited, that is, they usually last only a few minutes and at most a few hours. Rather than increasing steadily until they become unbearable, they usually peak after a few minutes and then die down, like a wave. Urges will become less frequent and less intense as you learn how to cope with them.

Skill Guidelines

Learn how to recognize urge “triggers” so you can reduce your exposure to them.

Common triggers include—

Exposure to alcohol itself.

Seeing other people drinking.

Contact with people, places, times of day, and situations commonly associated with drinking (such as drinking buddies, parties and bars, getting home from work, weekends).

Particular types of emotions (such as frustration, fatigue, feeling stressed out). Even positive emotions (elation, excitement, feelings of accomplishment) can be triggers.

Physical feelings (feeling sick, shaky, tense).

Some triggers are hard to recognize, and self-monitoring, which will be assigned as the practice exercise this week, can help you recognize them.

The easiest way to deal with cravings and urges is to try to avoid them in the first place. This can be done by reducing your exposure to craving triggers (getting rid of alcohol in the house, not going to parties or bars, reducing contact with friends who drink, and so on).

Sometimes craving cannot be avoided, and it is necessary to find a way to cope with it. There are many different strategies for coping with craving:

Get involved in some distracting activity. Reading, a hobby, going to a movie, exercising (jogging, biking) are good examples of distracting activities. Once you get interested in something else, you’ll find the urges go away. Another effective response to craving is eating, as most people do not feel like drinking after eating a big meal or something very sweet.

Talk it through. Talk to friends or family members about craving when it occurs. Talking about cravings and urges can be very helpful in pinpointing the source of the craving. Also, talking about craving often helps to discharge and relieve the feeling and will help restore honesty in your relationship. Craving is nothing to feel bad about.

Urge surf. Many people try to cope with their urges by gritting their teeth and toughing it out. Some urges, especially when you first return to your old drinking environment, are just too strong to ignore.

When this happens, it can be useful to stay with your urge to drink until it passes. This technique is called urge surfing.

Urges are a lot like ocean waves. They are small when they start, grow in size, and then break up and dissipate. You can imagine yourself as a surfer who will ride the wave, staying on top of it until it crests, breaks, and turns into less powerful, foamy surf.

The idea behind urge surfing is similar to the idea behind many martial arts. In judo, one overpowers an opponent by first going with the force of the attack. By joining with the opponent’s force, one can take control of it and redirect it to one’s advantage.

This technique of gaining control by first going with the opponent also allows one to take control while expending minimal energy. Urge surfing is similar. You can initially join with an urge (as opposed to meeting it with a strong opposing force) as a way of taking control of it.

After you have practiced urge surfing several times and become familiar with it, you may find it a useful technique when you have a strong urge to drink.

There are three basic steps in urge surfing:

Take an inventory of how you experience the craving. Do this by sitting in a comfortable chair with your feet flat on the floor and your hands in a comfortable position.

Take a few deep breaths and focus your attention inward. Allow your attention to wander through your body. Notice where in your body you experience the craving and what the sensations are like.

Notice each area where you experience the urge, and tell yourself what you are experiencing. For example, “Let me see . . . My craving is in my mouth and nose and in my stomach.”

Focus on one area where you are experiencing the urge. Notice the exact sensations in that area. For example, do you feel hot, cold, tingly, or numb? Are your muscles tense or relaxed? How large an area is involved?

Notice the sensations and describe them to yourself. Notice the changes that occur in the sensation. “Well, my mouth feels dry and parched. There is tension in my lips and tongue. I keep swallowing. As I exhale, I can imagine the smell and tingle of booze.”

Repeat the focusing with each part of your body that experiences the craving. Pay attention to and describe to yourself the changes that occur in the sensations.

Notice how the urge comes and goes. Many people, when they urge surf, notice that after a few minutes the craving has vanished. The purpose of this exercise, however, is not to make the craving go away but to experience the craving in a new way. If you practice urge surfing, you will become familiar with your cravings and learn how to ride them out until they go away naturally.

Challenge and change your thoughts. When experiencing a craving, many people have a tendency to remember only the positive effects of alcohol and often forget the negative consequences of drinking.

Therefore, when experiencing craving, many people find it helpful to remind themselves of the benefits of not drinking and the negative consequences of drinking.

This way, you can remind yourself that you really won’t “feel better if you just have one drink,” and that you stand to lose a lot by drinking. Sometimes it is helpful to have these benefits and consequences listed on a small card that you can keep with you.

People constantly appraise and think about things that happen to them and the things that they do. The way that you feel and act can be highly influenced by these subjective facts or appraisals as well as objective facts.
 
What you tell yourself about your urges to drink will affect how you experience and handle them. Your self-talk can be put to use to strengthen or weaken your urges.

The process of making self-statements becomes so automatic by the time you are an adult, you may not notice that you do this; it simply does not require any attention now.

A self-statement that has become automatic for you is, “The big hand is on the 7, so it is 35 minutes after. The little hand is between the 2 and 3, so it is 2 o’clock. That means that the time is 2:35.” Instead, you automatically read the clock to tell time.

Hidden or automatic self-statements about urges can make them harder to handle (“Now I want a drink. I won’t be able to stand this. The urge is going to keep getting stronger and stronger until I blow up or drink.”).

Other types of self-statements can make the urge easier to handle (“Even though my mind is made up to stay sober, my body will take a while to learn this too. This urge is uncomfortable, but in 15 minutes or so, I’ll be feeling like myself again.”).

There are two basic steps in using self-talk constructively:

Pinpoint what you tell yourself about an urge that makes it harder to cope with the urge. One way to tell if you are on the right track is when you hit upon a self-statement that increases your discomfort. That discomfort-raising self-statement is a leading suspect for challenge, since it pushes your buttons.

Use self-talk constructively to challenge that statement. An effective challenge will make you feel better (less tense, anxious, panicky) even though it may not make the feelings disappear entirely. The most effective challenges are ones that are tailored to your specific upsetting self-statements.

Listed below are some stock challenges that people find useful:

What is the evidence?  What is the evidence that if you don’t have a drink in the next 10 minutes, you will die? Has anyone (who has been detoxed) ever died from not drinking? What’s the evidence that people who are recovering from an alcohol problem don’t experience the feelings that you have? What is the evidence that there is something the matter with you, that you will never improve?

What is so awful about that?  What’s so awful about feeling bad? Of course you can survive it. Who said that sobriety would be easy? What’s so terrible about experiencing an urge? If you hang in there, you will feel fine. These urges are not like being hungry or thirsty or needing to relieve yourself—they are more like a craving for food or an urge to talk to a particular person—they pass, in time.

You are a regular human being and have a right to make mistakes. Maybe you worry about being irritable, preoccupied, or hard to get along with. What’s so bad about that? We all make mistakes, and in a situation that is complicated, there is no right or perfect way to get along. Our most memorable lessons, invariably, are learned in the school of hard knocks. It’s a school that every single one of us attends throughout life.

Some of the substitute thoughts or self-statements will only be necessary or helpful initially, as ways of distracting yourself from persistent urges; you’ll have an easier time if you replace the uncomfortable thoughts with other activities. After a while, sobriety will feel less unnatural; many of the urges will diminish and drop out, and you won’t need constant replacements.

In-Session Exercises

Make a list of craving triggers. Circle the triggers that you can avoid or to which you can reduce your exposure (like not having alcohol in your home).

Make up a craving plan. Pick two or three of the general strategies that were discussed and make up a plan about how you would put them into practice if you experience an urge.

Remember—cravings can come when you least expect them! For example, if you think getting involved in a distracting activity would be helpful, which activities would you pick?

Are these available to you now? Which may take some preparation? If you were feeling craving, who would be best for you to call? If you have not tried urge surfing before, it might be very helpful to practice with your therapist before trying it when facing an urge.
 
Coping with Cravings and Urges

Reminder Sheet

Urges are common in the recovery process. They are not a sign of failure. Instead, try to learn from them about what your craving triggers are.

Urges are like ocean waves. They get stronger only to a point, then they start to go away.

You win every time you defeat an urge by not using. Urges only get stronger if you give in and feed them. An urge will eventually weaken and die if you do not feed it.

Practice Exercises

For next week, make a daily record of urges to use drugs or drink, the intensity of those urges, and the coping behaviors you used.

Fill out the DAILY RECORD OF URGES TO DRINK

Date

Situation: Include anything about the situation or your thoughts or feelings that seemed to trigger the urge to drink.
Intensity of thirst: Rate your thirst, where 1 = none at all, 100 = worst ever.

Coping behavior. Use this column to note how you attempted to cope with the urge to drink. If it seems like it would help, note the effectiveness of your coping.

[See source page for form.]
http://pubs.niaaa.nih.gov/publications/MATCHSeries3/core.htm