When people first detox, it is common for them to believe that they will be able to manage their sobriety and recovery by themselves. It’s also common for them to resume substance use in a matter of days or weeks without some type of aftercare, support, or recovery plan. This is not about someone’s level of resolve or good intentions; this is about behavior and how the brain functions.

The expression used in the recovery mainstream is that people “Don’t know what they don’t know.” In nursing, this is called knowledge deficit.

There are a couple of things going on when someone stops using the substance they were dependent on. The first one has to do with learned behavior. The skill of driving serves to illustrate.

The first time I got in the car for the purpose of driving was overwhelming. I sat in the driver’s seat, confronted with the steering wheel, the controls, the transmission stick, and the pedals. In those days, we learned on standard transmissions, so there were a clutch and gears to contend with. Then, there were all the rules of the road, recently learned in a driver’s education classroom. After the requisite clumsy practice with the clutch in first and second gear in an empty parking lot, I went out on a quiet back road near our house. I needed every ounce of my full attention to think about all the elements and details of driving. I was anxiously aware that I did not know how to drive. You could say that I was consciously unskilled.

Fast-forward to the present day. I get in the car and head to a routine destination. I think about what I’m going to be doing later when I arrive... or just about anything else. Last weekend, next weekend, a grocery list... I’m thinking about anything and everything except driving. That’s because I’m driving automatically. I have practiced and rehearsed driving so much that I can do it without consciously thinking about it. I’m still obeying the rules of the road, signaling, stopping, merging; I’m just doing it automatically. Now you could say that I am unconsciously skilled. 

As with the skill of driving, where I practiced until I did it automatically, substance use becomes an unconscious skill.

I practiced going to the liquor store, drinking on the way home, secreting the open bottle under the seat, and the other various skills of chaotic substance use—all unconsciously. I mastered them and did them automatically. Then, there were other associated skills that reflected my mental process and behavior. Maintaining adequate supply was always an important consideration. However, the most compelling behavior was the amount and level of deception practiced toward everyone in my life. I was completely dishonest about the quantity and type of drinking I was doing regardless of the situation. Most heavy drinkers are. This was completely automatic, as though it was firewalled from any critical analysis on my part.

Most people who have used substances to the point of physical dependency have learned all the unconsciously skilled behaviors related to that.

The same principles also apply to recovery from substance use, where we find ourselves consciously unskilled. The problem is we don’t realize it; we don’t know what we don’t know.

After I’ve completed a detox and I am free of the symptoms of withdrawal, it feels reasonable to assume, “I got this.” Many people think this way. In fact, in most cases they would pass a lie detector test—no, they don’t intend to drink or use.

So, what happens? Basically, it comes down to unconsciously skilled against consciously unskilled—automatic behavior versus having to consciously think through every step. A series of small, seemingly harmless choices and decisions take someone into a position where drinking or using seems like one more small choice or decision. The following example is almost verbatim what someone once shared with me. You need gas. You decide to stop at the combination gas station/convenience mart. This happens to be where you often bought beer or cigarettes or kratom, or you bought a little packet of powder from a guy you know who works there. You’re just planning on getting gas. However, you make the small decision to go inside. Once inside to pay for the gas you could have paid for at the pump, you see that the guy you know is working. You don’t want to be rude, so, of course, you say hello. Or you pass the beer refrigerators or the energy drink section. The cigarette display is in your face. Small decisions have put you in the position of going against your automatic behavior, which was to buy beer, cigarettes, kratom, or whatever the guy you know is holding. You now have to consciously decide to not do what you would normally do unconsciously.

Even if you make it out of the gas station/convenience mart with your recovery intact, you probably considered one more decision to resume using your substance of choice. You thought about it. More likely than not, this risky situation will leave persistent thoughts in your mind. You will now have to contend with a little devil on one shoulder and a little angel on the other, both trying to tell you what to do. By putting yourself in this situation to begin with, you put that devil on your shoulder and it’s not going to shut up for a while.

But wait, there’s more.

As if the conscious and unconscious behaviors and automatic thoughts weren’t enough, there’s an issue with your brain when you first stop using substances. The neurotransmitter, or brain chemical, that governs your motivation and sense of pleasure and reward is temporarily out of order.

Dopamine is the brain chemical that not only registers how much we like using substances but also lights a fire under our asses to chase those substances. Dopamine serves an important purpose, and it helped us to survive as a species and evolve. We maintain a baseline level. When we do something pleasurable, we get a boost, which in turn makes us want to repeat the process. We need to eat to survive; we get a dopamine boost from a nice meal. Most people associate greater pleasure with sweet-tasting food. In primitive hunter/gatherer times before supermarkets, if we found some sweet berries or fruit, we would chow down on them. We might store the extra calories as a little body fat and survive another day during lean times. That’s dopamine at work.

On a quiet Friday night at home, dopamine is what makes me pause the DVR, find my shoes, wallet, and car keys, and drive to the store. I peruse the ice cream section, make a selection, pay and return home. Back in front of the TV with a bowl of chocolate-chip cookie-dough ice cream, I have fulfilled the biological imperative of dopamine, which motivated me to get up and go for the sake of pleasure and reward.

Substance use boosts dopamine. The first drink provides a noticeable bump; we feel like a million bucks. Unfortunately, the second drink falls short of making us feel like two million bucks, so the tendency is to keep trying. This is why some people just keep drinking once they start. Other substances raise the dopamine level by as much as 500 percent, 800 percent, even 1000 percent. This is not sustainable, and the pleasure reward system adapts. The body and central nervous system always want to stay level, so the dopamine response dials back. The result, when substance use ceases, is a dopamine deficit. The baseline level of dopamine goes down.

The dopamine deficit is temporary and lasts about 30 days in most cases. The possible results are mood disruption in the forms of depression and irritability, as well as lack of motivation and dysregulation of sleep and appetite. There is decreased sense of pleasure and decreased tolerance to discomfort.[i] The irritability might present as low tolerance for people and life’s routine annoyances. This puts the individual experiencing dopamine deficit at high risk for resuming substance use.[ii]

These two distinct conditions of early recovery, the knowledge deficit and the dopamine deficit, conspire to make the first weeks and months of recovery precarious. The stakes are high and the circumstances are adverse. It’s like wandering through a minefield without even knowing exactly what your destination is. The desired outcome is that you know what to do, how to do it, and you do it automatically; you get exactly the opposite in the first days of recovery. These behavioral and physiological conditions are rudiments of neuroscience, and I teach them to every patient, client, or interested individual I encounter.

So, how do you navigate from knowledge deficit past dopamine deficit? How does someone transition from being consciously unskilled to unconsciously skilled? How do people learn and practice the skills of recovery automatically?

The first step is awareness and understanding. Numerous people have come back to share with me, “I’m so glad you told me about that.” The tendency to feel isolated, that there is something wrong with you, is common to many in early recovery. Knowing what to expect changes the game. Incorporating a relatable example like learning to drive helps people to make the leap from learning new information to practical understanding. Later, when they catch themselves feeling moody or short-tempered, it clicks.  

Sometimes this happens in a forensic context, when we are looking back at what went wrong. A young patient had started his recovery with our office-based treatment from day one. About a month later, he came in testing positive for cocaine in his urine drug screen. He was open and forthright about this.

“It was just like you said. It was like I was fed up with everything, but it was really nothing. I knew getting high would make me feel better. Temporarily, I mean.” In these situations, it’s not about someone’s willpower, resolve, or intention. This is just how brains heal.

Information sticks better when people understand the why part. Better recovery starts with better information and understanding of leading-edge concepts. Many therapists and clinicians know and share this, but it’s not in the mainstream yet. The future of recovery is a shift toward people understanding these basic principles of neuroscience and the empowerment of that understanding.

The skills of recovery are learned through practice. When we first learn information, it is stored as a distinct episodic memory. Each experience observing and being exposed to information is consciously associated with the occasion when it happened. It can be consciously retrieved. For example, when you are brand-new in recovery and faced with choices, such as getting gas where you bought beer, you might remember the time you heard someone say that has risks. This takes deliberate effort in the early going, however.

With repeated practice, episodic memory becomes procedural memory. The memory gradually becomes more automatic, requiring less conscious control to recall the learning experience. The associated brain activity shifts from areas of conscious control to regions handling automatic programs. This happens through an effect called neuroplasticity, the ability of the brain to change and adapt its networking pathways. In a literal sense, the brain rewires itself. This occurs best with consistent practice—many, many repetitions. As the memory of the specific learning occasion fades, the procedural knowledge remains. I don’t remember learning to write my name, but I know how to write my name.

People in successful long-term recovery have often developed a modified version of the basic human skill of pattern recognition. Pattern recognition is the ability to identify relationships in information, in the present or from past experiences. Inherent in that is identifying that certain actions lead to certain outcomes (or consequences), or that events tend to occur in particular sequences. As a recovery skill, this can come in handy when deciding where to purchase gasoline, as an example. The ability to associate certain situations with their potential for undesirable outcomes is a considerable asset.

Mindfulness is widely thought to be a trainable skill. Paying full attention to one’s thoughts, feelings, and bodily sensations in a nonjudgmental manner promotes the self-awareness of better recovery. Introspection figures prominently in the process of changing one’s relationship with a substance. Self-examination is significant in the stages of change and motivation previously referenced. People think about their feelings and well-being. People think about their lives. The capacity to engage in this process and corresponding self-awareness is directly proportionate to the ability to change and recover. The level of investment in the process is based in self-awareness. How intense is someone’s conviction? Is the desire to move forward absolute? Is someone all in, mentally, physically and emotionally?

Better recovery is based in higher levels of motivation. On the first day of my recovery, while I couldn’t lay claim to being in a state remotely as graceful as mindfulness, I was intensely self-aware. My decision to recover carried a level of conviction and intensity that was greater than the power my addiction held over me. I knew that recovery was the right thing for me to do. This form of motivation, sometimes referred to as ethical motivation—it’s the right thing to do—is a higher form than my previous level of motivation, avoiding consequences. I had been like an amoeba, moving instinctively to avoid a threat in the environment. Experience shows that the lower forms of motivation like avoiding consequences and reward motivation do not translate to strong and sustainable recoveries. The only data I have to support that is 35 years of observation, but I will stand by that.

My early recovery, based in absolute conviction that it was the right thing for me to do, was the launching point. Soon, my recovery moved further up the motivational scale. Beyond ethical motivation, there is purpose motivation. I’m on a mission. I wake up every day with a burning desire to grow and improve, and even more importantly, to help people who live as I once did. Better recovery is a self-aware, self-actualized way of being that is based in a sense of purpose.