Urge Surfing - Relapse Prevention
Urge surfing is a term coined by Alan Marlatt as part of a program of relapse prevention he developed for people recovering from addictions to alcohol and other drugs.
It can actually be used to help with any addictive behaviour such as gambling, overeating, inappropriate sex or any other destructive impulses.
Urges for substance use rarely last for very long. In fact, they almost never last for longer than about 30 minutes, if there is no opportunity to use.
People admitted to a high quality detoxification centre where there is no access to their drug of choice often find it remarkable how little craving they get.
If there is no opportunity to use then there is no internal struggle. It is this internal struggle that feeds the cravings. Trying to fight cravings is like trying to block a waterfall. We end up being inundated.
With the approach of mindfulness, we step aside and watch the water (cravings, impulses & urges) just go right past. This is true for everybody, but few addicts ever give themselves the chance to prove it.
Exercise: Reflecting on Urges
Ask yourself whether there have been times when you could not give in to an urge when it presented.
Did the urge pass?
Most of us will have had past experiences of urges passing.
This is an important strategy to identify, as it can greatly improve self efficacy for riding out urges.
The main message is that urges do not have to be acted upon.
Exercise: Experiencing The Changing Nature & Impermanence of Urges
- Sit with back unsupported in a chair or on a cushion on the floor
- Start Mindfulness Meditation
- Wait for any sense of discomfort e.g. Restlessness, an itch
- Note the desire to move and resist it
- Notice thoughts that arise - e.g. "I wish this itch would go".............."It is driving me crazy".............."This too will pass" - in a calm tone..........."This too will pass" - in an irritable tone.............."It is is not bloody well passing!"............."I would love to scratch right now" etc etc
- These thoughts are just thoughts. So gently bring your attention back to your breath and bodily sensations
- Note the changing position, shape and quality of the discomfort over time. Be interested in feeling it as precisely as you can. Notice how the shape and intensity changes with the cycle of the breath. Is it stronger during the in breath or during the out breath?
- You might find your thoughts spontaneously going to other matters, e.g. Your shopping list, a fight with you partner, a football game, planning a holiday
- These are still just thoughts. Gently bring your attention back to your breath and body sensations. They are probably different again.
You have just observed the changing nature and impermanence of urges. When you notice the physical sensations with interest, you are directly facing the urges rather than feeding them through fighting them.
How fighting urges feeds them.
Often people try to eliminate the urges by distraction or talking themselves out of them. This usually just feeds the urges and creates the illusion that they are interminable until you give in to them.
Suppressing a thought feeling or sensation, including pain ultimately increases it. (Clark Ball & Pape 1991, Gold & Wegner 1995, Wegner, Schneider, Carter & White, 1987, Wegner, Schneider, Knutson & McMahon 1991, Cioffi & Holloway 1993)
For example Wegner et al (1987) conducted a series of experiments to assess the effects of thought suppression called the "white bear" experiments. The bear was chosen because one of the researchers remembered reading that when Russian author Tolstoy challenged his brother not to think of a white bear, the brother remained perplexed for quite a while .
In one of the more sophisticated experiments people were shown a movie about white bears. These people were then given a sorting task which required concentration. They were then divided into two groups. The first group was instructed to suppress the white-bear thoughts.
The second group was given no instruction to suppress these thoughts. Both groups were asked to hit a counter button every time they thought of white bears while doing the other task. The initial suppression group reported a significantly higher rate of "white bear" thoughts during this time.
Prochaska (1992) et al in their study of how people change habitual behaviour, note that most people go through a long contemplative stage before they actually change. This stage is marked by ambivalence. Argumentation usually results in the client completing the other side of the ambivalent equation thus maintaining a state of therapeutic paralysis.
It is reasonable to assume that the same problem exists with the client's internal disputation over the ambivalently regarded behaviour. (e.g. "I have to give up smoking because I could get cancer" receives a reply "Yes but that isn't going to happen to me - at least not for a long time.")
The Technique of Urge Surfing
Mindfulness allows us to bypass these problems associated with avoidance and disputation. Instead of trying to distract from or argue with the unpleasant thoughts, feelings or urges, mindfulness simply makes the thoughts, feelings or urges less important. When we use mindfulness we stay exposed to the thoughts feelings or urges for their natural duration without feeding or repressing them.
In fact, if we just let an urge be - non judgmentally - without feeding it or fighting it (Fighting it is just another way of feeding it anyway) then it will crest subside and pass.
Of course they come back again but over a period of time. However each time you overcome a bout of cravings they become less intense and less frequent if we don't feed the urges and if we don't give in to the addiction. Moreover our mindfulness technique of urge surfing improves. If we have a slip and give into the impulse we will have increased urges for a while. However we can still apply urge surfing all over again.
Urges can be compared with feeding a stray cat. In the beginning, you may want to feed the cat because it cries for food and attention. You may find that it is a nice thing to do and you feel good for being kind. However, your act of feeding the cat encourages it to repeat its cries and attention seeking. You find yourself giving in each time. Over a period of time the cat grows bolder and other cats join it in crying for food and attention.
You may begin to regret your actions, as a large number of strays are now contributing to noise and other problems. But you cannot resist the feeling of ignoring their cries. You may believe that their survival now depends on you, and that your actions are more important than ever. They have you trapped in a cycle of your own pattern of repeated problem behaviours.
If you make a decision to resist feeding the "cat army," there will be loud and pitiful cries for a few days. In fact they will be at their strongest when you have decided not to reinforce their behaviour. Soon, however, they will come to realise that they are no longer being reinforced, and will gradually diminish and disappear. Your decision to stick with the action you know is best for you will "undo" the problem that you unknowingly built up in the first place.
Urges do go away, but they may be very strong for a short while immediately after quitting. Knowing that they will weaken will help you to continue to surf the impulses that you feel, especially in response to your personal triggers.
Urge Surfing Summary
To experience the cravings in a new way and to "ride them out" until they go away
1. Remember that urges pass by themselves.
2. Imagined that urges are like ocean waves. that arrive crest and subside. They are small when they start, will grow in size, and then will break up and dissipate.
3. Practise mindfulness regularly and especially notice any impulses or urges that appear. Then we are well prepared to ride these waves without giving in to the urge by using mindfulness.
Urge surfing itself
* Practise mindfulness
* Watch the breath. Don't alter it. Let the breath breathe itself.
* Notice your thoughts.
* Without judging them, feeding them or fighting them gently bring your attention back to the breath
* Notice the craving experience as it affects the body.
* Focusing on one area where the urge is being felt and noticing what is occurring.
o Notice quality, position, boundaries & intensity of the sensation
o Notice how these change with the in-breath and out-breath
* Repeating the focusing process with each part of the body involved.
* Be curious about what occurs and notice changes over time.
The key is replacing the fearful wish that craving will go away with interest in our experience. When we do this we notice the cravings change, crest and subside like waves in the ocean. In this way it becomes more manageable.
Teaching Urge Surfing To Clients
It is very difficult for clients to understand urge surfing unless they have an experience of it. Even though the idea of watching cravings come and go makes sense, it is a skill that can only be learnt through practice. Just as it is easier to coach someone how to kick a football, when they are actually kicking a football is also easier to coach someone as to how to surf urges when they are actually having urges.
We can do this in two ways. Firstly we can create a situation where urges arise and secondly we can respond opportunistically when a craving arises spontaneously in the presence of the therapist.
Manufacturing Opportunities for Urge Surfing.
This is not as difficult as it sounds, as there are many kinds of urges apart from drug cravings. There are urges to scratch, to move, to eat, to drink, to go to the toilet etc. When we reflect on this as it becomes clear that all adults including those who consider they have hopeless addictions have the capacity to have urges come and go without acting on them. After all, unless we are physically ill we can all control our need to go to the toilet!
When we sit with our back supported in a chair or on a cushion on the floor and start mindfulness meditation, sooner or later some sense of discomfort will arise, such as restlessness or an itch. Along with these sensations there will be a urge to move.
This is an opportunity to practice urge surfing. So we can notice the difficult sensations that go with this and the thoughts that arise. Instead of acting in our normal way of trying to get rid of this unpleasant feeling, we become curious. We become like natural scientists seeing a strange plant or animal for the first time.
We try to describe what we are observing as closely as possible. In this way we replace an aversion with curiosity. So we do this by noticing the physical sensation that goes with the urge as precisely s possible.
If we are guiding a client through this process we then ask them to notice:
* The exact physical sensation in the body,
* It's quality:
o Whether it is tight or loose
o It's temperature whether it is hot or cold.
* The location of the sensation,
* It's exact borders
* Whether these borders are well defined and firm like the edge of a football or soft and fuzzy like cotton wool.
* How these qualities vary with the respiratory cycle
We need to watch it for at least five cycles of breathing to get a sense if it.
Does it get larger or smaller, more or less intense or does the quality of it change?
When we find our mind turning to thoughts, notice the thoughts and come back to the physical sensations of the urge.
Opportunistically Teaching Urge Surfing
Sometimes when talking to a client an urge arrises spontaneously. Sometimes it can be spotted as a subtle smile on the face as the client fondly remembers using the drug. At this point, the therapist can say to the client:
"It looks like you might be having an urge to use right now."
If the client agrees to this, then the therapist can ask them:
"How does this urge feel in your body? Whereabouts is it in your body?"
Then slowly guide the client through the questions that define the sensations or the urge in the body.
At first there will be a resistance and a desire to go into the story about the urges. It is then helpful to explain to the client that we can go into the story later. We can explain:
"It would be good if you could become aware of how this urge feels in your body right now. I'm very interested in knowing exactly how it feels for you. This is an opportunity for you to practice urge surfing. So see if you can just bear with it for a little while."
Then ask the client to define the edges of this sensation, where they are and the quality of the edges, then the quality of the actual sensation itself including the temperature. And finally how it changes with the cycle of breathing. Then you can ask the client if the sensations has changed since we first started talking about it.
Any observation of change is good. It does not matter if the feeling is stronger. What is important is that the client can see the sensation is not one solid unchanging entity.
So having done this, it is worthwhile to then divert the client's attention a little by talking about the matter at hand that elicited the urge in the first place. After doing this for a few minutes, it is very useful to return attention to the body and ask the client how the sensation feels now.
At this point with their increased level of mindful awareness of the physical sensation they are capable of noticing how the urge has changed. It has often changed dramatically. When a client has had the opportunity to be taken though this three or four times, they begin to have enough faith in the process to practice urge surfing successfully by themselves.
Cioffi D. & Holloway J. (1993) Delayed costs of suppressed pain. Journal of Personality and Social Psychology 64, 274-282
Clark D.M., Ball S, & Pape D. (1991) An Experimental Investigation of Thought Suppression Behaviour Research and Therapy, 29, 253-257
Gold D.B. & Wegner D.M. (1995) Origins of ruminative thought: trauma, incompleteness, non-disclosure and suppression. Journal of Applied Social Psychology 25, 1245-1261
Prochaska, J. O., Diclemente, C. C., & Norcross, J. C. (1992) In search of how people change. American Psychologist, 47, 1102-11
Wegner D.M., Schneider D.J., Carter S.R. & White T.L. (1987) Paradoxical Effects of Thought Suppression. Journal of Personality and Social Psychology 53, 5-13
Wegner D.M., Schneider D.J., Knutson B. & McMahon S.R. (1991) Polluting the stream of consciousness: The effect of thought suppression on the mind's environment. Cognitive Therapy and Research 15, 141-151