Relapse in Progress

Understanding the Loss of Abstinence through a Banana Peel Metaphor

Slip and Slip Prevention:

Say, you are walking down the street and you see a banana peel. When you see the banana peel and realize its slippery potential, you might walk around it in order to avoid a slip. In this see-but-not-slip scenario, you are preventing a slip (Slip Prevention). If you hadn’t been paying attention, you would have stepped on the banana peel and slipped – i.e. lost your balance…

Lapse and Lapse Prevention:

Say, you are walking down the street and you are not paying attention. So, you step on the banana peel and as a result you slip up – i.e. you lost your balance. Reflexively, you flail your hands and gyrate your torso so as to regain your balance.

And voila! – you did not fall even though you slipped. You regained the balance and prevented a fall. In this slip-but-not-fall scenario you prevented a lapse (i.e. a fall) (which constitutes Lapse Prevention).

Relapse and Relapse Prevention

Say, you are walking down the street and you are not paying attention. You step on the banana peel and slip up, i.e. lose your balance. You flail your hands and gyrate your torso – but to no avail. You are not able to regain your balance and you fall (i.e. lapse).

As you try to get back up on your feet, you might fall again (re-fall, re-lapse). The three reasons you might fall again while you are trying to get back up are a) you got too hurt and it is too painful to get back up, b) you lose your balance as you try to get up and fall back again, and c) you are feeling a little shaky and unsteady on your feet and as you have nothing to lean on or support yourself with you fall back down again.

If, however, you look around, mindfully size up what you need in order to safely get back on your feet, if, perhaps, you first calm down, maybe rest, and possibly ask for help to prop you up as you plan to steady yourself once back on your feet, you just might be able to prevent another fall (re-lapse) (which would constitute Re-Lapse Prevention).

Review: Slip vs. Lapse vs. Relapse

The Disease Model of substance use does not make a distinction between a lapse and a relapse.

In fact, a slip – a craving, a potentially transient loss of psycho-physiological balance – is synonymous with a relapse.

Lewis, Dana, and Blevin (1994), in their review of various prevention models, note that the Disease view of addiction "defines the client as either abstinent or relapsed" (p. 171).

This catastrophized, all-or-nothing view is based on the idea that "because it is so difficult to fight against the powerful and uncontrollable forces of the disease, the relapse is seen as a probable event" (Lewis et al, 1994, p. 171).

What a truly disempowering and dehumanizing prognosis this is, I have to say.

Abraham Twerski (the founder of the Gateway Rehabilitation Center) provides a vignette that has the beginning of the Banana Peel metaphor that had the promise of elucidating the distinctions between the slip, lapse, and relapse.

Unfortunately, his own experience of not being able to regain a loss of balance that led to a fall (see below) led to a conceptual denial of an important prevention U-turn opportunity to Twerski’s clients.

Twerski (1997) writes that one day he had a package at the mail to pick up and since his car battery was dead he decided to walk to the post-office on a winter day. Twerski writes: "I tried to watch for slippery spots on the sidewalk, but, in spite of my caution, I slipped and fell hard" (p. 118). Twerski continues: "I knew that whether I fell because of the deceptive appearance of the sidewalk or my negligence, I was not going to get to the post office unless I got up and walked, pain and all."

In the next paragraph, Twerski continues: "In spite of my painful fall, I was two blocks closer to my destination than when I had started," and adds "This is how we can view relapse. Regardless of its pain, relapse is not a regression back to square one" (p. 118)