Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part V



The Recovery Book- Al J. Mooney, et al.
Chapter 29- A Guide to Preventing & Surviving Relapse. pp. 541-555

Most accidents are programmed to happen. A distracted parent a toddler to play near an open stairway. A harried cook neglects to wipe up a spill on the kitchen floor. A sports fan polishes off a six-pack at a game and then heads home behind the wheel of his car. The tragedies that follow are almost inevitable. it's the same with relapse. It usually begins long before the recovering addict yields to the prodding of a companion or of a treacherous inner voice with "oh, what the hell! Why not?" So it's important to become familiar with attitudes and behaviors that can undermine recovery, to be alert to situations that can trigger relapse, and to recognize warning signs that your recovery is about to take a turn for the worse.
    It's no secret that the risk of relapse is greatest in the first few months of being clean or sober. That risk diminishes with time, but it never completely fades away. Many life events--for example, ill health--can send the risks soaring once more. Those with the incurable disease known as alcoholism/addiction are always walking the edge of a cliff. just one false move, one misstep, and they can tumble deep into the abyss of drinking and drugging. After the fall it's not impossible to haul oneself up again. But you can spare yourself a lot of bruises if you build a good strong fence between you and the cliff. Whether you just picked up a thirty-day chip or took a bow at a meeting for thirty years, continued vigilance is the price of sobriety.

What is Relapse?

Relapse is a medical term describing the return of signs and symptoms of a disease after an apparent recovery. You can have a relapse with the flu--and you can have one with the disease of alcoholism/addiction. In neither case is the prognosis grave. It's likely you will recover from both, but while the flu will probably be self-limiting and go by on its own, you'll have to take very positive steps to recover from relapse into alcoholism/addiction.
    A person in recovery is considered to be in relapse when he or she starts drinking or using again. The behavior can be out of control or there may be an attempt to control it. A slip, on the other hand, as we use the term here, is taking that first drink (or drug) or two and getting help before going further. Anywhere from 10 to 60 percent of those in recovery will have at least one relapse. (The percentage depends on hose statistics you use. No two programs have the same success rates.) Most relapses occur early in recovery, and the prognosis for those who relapse early is better than for those who relapse later. Of those who relapse afterr a solid foundation in treatment, most will eventually have a successful recovery. These people come to understand relapse not as a failure but as a lesson in how to succeed, not as a sign at they should resign themselves to a life of substance abuse, but as a sign at they need to work harder at escaping that life.

Myths Related to Relapse

Because relapse is shrouded in shame and embarrassment, many myths have grown up around it--myths that may endanger recovery if they aren't recognized as such. You may have heard these recited as gospel:
"Relapse is inevitable.'' Sometimes people in recovery hear so much about relapse that they begin to believe it's part of getting better. "I might as well have my slip now and get it over with" is not an uncommon attitude. But in fact, most successfully sober individuals have never relapsed, and the chances of staying sober in the long run are better if you don't relapse.
"Relapse inevitably means failure." For some people, relapse is an important part of recovery. They aren't truly committed to sobriety the first time around; they haven't experienced enough pain to persuade them that they can't safely drink or use drugs. But they learn something each go-around, and by the time they're truly motivated to remain clean and sober permanently, they've acquired the tools to get the job done. Of course, those who don't learn from their relapses are doomed to more of the same.
"Relapse can't be prevented." Not only is it possible to prevent a relapse, it is possible for the great majority of people in recovery to do so successfully. Avoiding relapse is much less a matter of willpower than of being knowledgeable about what causes a relapse, how to minimize the risk in unsafe situations, what the signs of impending relapse are, and what to do if a slip is about to occur.
"Relapse after a period of sobriety and it will take months or years to hit bottom again." Alcoholism/ addiction is a progressive disease. It continues to get worse in a kind of shadow progression during recovery. Those who relapse usually find that when they wake up "the morning after," they are in worse trouble than when they swore off. In fact it generally takes only a few hours to a few days to reach bottom in a relapse.

Lapses That Can Trigger a Relapse

If you've been in recovery for a while and have really been paying attention, you can probably come up with a long personal list of behaviors and attitudes that could put you at risk for relapse. Your list may include the following:
Dishonesty. Shakespeare said it first, but it's a reminder that can't be repeated too often: "To thine own self be true." Self-deception denies your disease, dodges your responsibilities, neglects the fundamentals of your recovery program, rationalizes unwise actions, and fails to evaluate you (or your good and bad traits) honestly.
    You live outside your own value system--cheating on your spouse, defrauding your employer, breaking the hearts of your parents. A sociopath, whose mental illness makes him hostile toward society and its moral code, might not have a problem with this, but most of us are uncomfortable living a lie. And this discomfort can jeopardize recovery. Even if you aren't ready to admit that what you are doing wrong, if you know someone is being hurt by it, you are still endangering your recovery by creating uneasy feelings of guilt. Such feelings are hard to live with, and it's natural to want to smother them with drugs or drown them in gin. It's just as necessary to be truthful with others--at home, at work, at play. Failing to confide the truth, nothing but the truth, to those trying to help you--physicians, counselors, sponsors, others in AA--is another way dishonesty can sabotage recovery. Sometimes we lie as a way of protecting ourselves, hoping to avoid the consequences of the truth. But in the long run, the consequences of lying are always worse. We lose the respect of others. Perhaps worse, we lose self respect. Those with successful recoveries will testify that absolute honesty is the single most important factor in preventing relapse.
HALT. Hunger, Anger, Loneliness, or Tiredness can make you vulnerable to relapse, so be sure to guard against each of these. Eat three square meals a day with regular snacks in between to keep up your blood sugar level and ward off hunger. Talk about your anger and examine it honestly. Take charge of it before it begins to take charge of you (it is believed to act as a mood changing drug, making people do things they wouldn't do otherwise). Remain active in a recovery community such as AA, and attend meetings often enough to keep loneliness at bay. Regular social activities with recovering friends are also helpful. When loneliness troubles you, immediately call a sponsor or AA buddy. Avoid overdoing at both work and play to avoid fatigue; don't take on more than you can handle. Exercise regularly, since moderate amounts of exercise increase energy levels.
Unrequited Thirst. Finding yourself thirsty (especially hot and thirsty) with nothing to drink but a frosty beer can be extremely risky. So avoid such situations by being sure that, whether you are sailing a boat, cheering your favorite team at a ball game, or playing a sweaty set of singles on a tennis court, you're well-supplied with frosty sodas, juice, or ice water. If necessary, bring your own thermos.
Negative Feelings. Resentment, ingratitude, self-pity (telling yourself you're the victim of bad luck rather than someone who's made poor choices), pessimism (your thermos is always half-empty rather than half-full), impatience (you crave instant gratification--one day at a time isn't good enough), frustration ("Why can't everything go just the way I want it to?"), are all attitudes that can undermine recovery. If you don't acknowledge these feelings and deal with them quickly and constructively (see Chapter 15), they will inevitably lead you over the edge of Relapse Cliff.
Unrealistic Expectations. Expecting too much too soon (a trait typical of alcoholics/addicts) can lead to disappointment and resentment, which in turn can lead to the nearest bar or dealer. In early recovery, it should be enough that at the end of each day you can say, "I've stayed clean and sober today." See page 315 for dealing with expectations realistically.
Unattended-to Phase One Issues. If haven't worked Steps One, Two, Three, if you never got a sponsor (or don't really confide in the one you have), if you haven't dealt with other basic issues of early recovery (Chapters 6 through 15), then your recovery has a weak foundation. This will make it difficult for you to be strong when faced (as you will be daily) with temptation.
Unresolved Phase Two Issues. If problems in your relationships, your work, or other aspects of your life still have not been adequately faced and solved, they will make negative feelings simmer and eventually come to a boil. If this is the case, return and finish your Phase Two work now, before its unresolved issues finish you. Most winners in recovery agree that they can't afford the luxury of "emotional litter" in their lives. Dealing with emotions rather than ignoring them keeps that litter from piling up. See Chapters 17 through 21.
Renewing old friendships. Once recovery seems well established, it may seem silly or over-cautious not to see an old friend you used to drink or use with. "She called and sounded so friendly--why shouldn't I see her? Am I supposed to live the rest of my life like an orchid in a hothouse?" But unless and until that person is in recovery to, you're in permanent danger of picking up where your relationship left off.
Getting Back on the Old Merry-Go-Round. As your recovery progresses, feelings of invulnerability are likely to recur: "I'm doing great. Seeing some of my old playmates, visiting some of my old playgrounds, won't bother me a bit." But that's like skydiving without a parachute: the odds are definitely not your favor. If you find yourself invited to a party or other event that is important to attend but that you suspect could be risky, take an AA ally along if at all possible. Study the partying tips on page 180 and use them to plan your every move ahead of time: What will I do if offered a drink? A joint? A snort? When you're on the spot, stick to your plan like the tortoise to his shell.
Remembering the Old Days. Otherwise known as "romancing the drink (or the drug]." Putting a shine on the bad old days ("Hey, remember that time when we all got loaded and ... ? ") can make them suddenly seem like good old days. Don't dwell on the past or you'll dwell in it. If someone else tries to romanticize your drinking or drugging days, put on the brakes with your own memories: "Yeah, and you vomited all over yourself and your date." If you're the one who starts romanticizing, bring yourself up short.
Indulging in doubtful habits. Nicotine (in tobacco) and sugar (in most processed foods and almost all desserts) have been associated with relapse in some recoverees. Although studies haven't shown this scientifically, a number of observers nevertheless believe it's a fact. Other compulsive behaviors--gambling, sex, eating--may also weaken defenses against relapse. So follow the life-extending, sobriety-sustaining health bits recommended in Phase Three.
Shifting the Blame. If you can always find someone or something else to blame for your problems, past or present, you aren't putting the responsibility for your life where it belongs: your own lap. By relinquishing your responsibility to deal with your life, you return to the irresponsible behavior of addiction. The next step is to turn to addiction itself.

Situations That Invite Relapse

Sometimes those in recovery don't do anything specific to set themselves up for a relapse, but life itself sets them up. Certain situations, while not inevitably leading to relapse, do weaken one's defenses. The only protection: eternal vigilance. If find yourself in one of the following situations, stay constantly aware of the risk of relapse. As necessary, take steps on page 547 to be sure that moment passes you safely by.
Bad Times. Not surprisingly, many people relapse when something goes awry in their lives. Almost any major problem can trigger a slip, including the death of a spouse, child, or other loved one; the loss of a job; natural catastrophe (a home destroyed by fire flood, for example); or an illness--anything from a cold to cancer.
Good Times. While you might be alert to a possible slip when things go wrong, you're much less likely to be wary when everything's coming up daffodils--you inherit a substantial amount of money, you patch up your marriage, you get a great new job or a promotion. In fact, most people tend to let their guard down completely when everything is going right. They toast themselves mentally: "I'm doing great. Staying sober is easy. I don't have the problems others have. I'm in control." Gradually, counseling sessions are canceled, "better" ways are found to spend evenings than going to AA meetings, and before you know it, you've slipped on a banana daiquiri.
Milestones. Being sober for thirty days, six months, one year, or five years is certainly something to celebrate. But it should also be a reminder: Keep working your program. A clean and sober anniversary can be a time of confidence and elation ("Everything's going so well!"), of anxiety and depression ("Things are going too well; it can't last." or "They aren't going well enough"), or of complacency ("This sobriety is a breeze; now what?"). Unless it's also a time of caution and reflection, a recovery milestone can put recovery at risk. Don't be the runner who, having crossed the finish line and achieved his goal of running a marathon, bronzes his running shoes and takes to his rocking chair.
    Few people pick up their chip and then celebrate with a binge, but many think, "Okay, I've proved I can do it. Now I can relax a little." They take to that rocking chair, skip the next meeting or neglect to check in with a sponsor, and their sobriety becomes vulnerable. The riskiest clean and sober anniversaries, experience shows, seem to be three months, six months, and one year.
Vacations. Getting away from it all can be a tonic for anyone, recovering or not. But because that often takes vacationers far away from their usual support systems, it can also be a great opportunity for a gin-and-tonic relapse. So pick and choose vacation destinations thoughtfully. Choose recovery-related retreats and conventions in early recovery, and later on stick to resorts and destinations that stress sobriety. When possible, share vacations with support group friends. Tips on sober getaways, see page 10.
Change. Starting a new relationship or breaking up an old one, switching jobs, and moving all seem to increase risk of relapse. It's not surprising--all rank high on any psychologist's list of super-stressors. They all, involve adventures into the unknown, and the attendant high anxiety creates an uneasy thirst. So if you can avoid or postpone them, make no major changes until you are solidly in Phase Two, and even then be alert to the potential risk.
Boredom. Once the early work of recovery is completed and work and relationships are on an even keel, the addict may long wistfully for excitement-often for the wrong kind. If you crave the rush that excitement brings, get it the safe way.
Illness or Physical Ailments. Aches and pains--headaches, backaches, surgery, dental problems, injuries, or other physical complaints--all have been linked to the start of drinking and drugging. Not surprisingly, they've been linked to relapse too. Sometimes that's because of the anxiety and depression the illness triggers. Sometimes it's because of the medications prescribed to chase the pain.
    Some people in recovery feel safe taking a prescribed medication (sometimes, even a sleeping preparation), as though the doctor's imprimatur somehow magically prevents a drug from acting like a drug. Not so. The patient believes he can control such usage, but more often than not finds out too late that he was wrong. Result: relapse. And the fact that the drug was prescribed and used with the best of intentions, and that relapse was accidental, doesn't help its victim one bit.  So if you experience frequent headaches, intestinal disturbances, muscular spasms, or any other symptoms, be alert for signposts warning that you're speeding toward what might be called a medically prescribed relapse. If you become seriously ill and require medication for either treatment or surgery, or if you're about to have a baby and think you might need pain relief in labor, be sure that you and your physician follow the guidelines discussed on page 247.
Unexpected Exposure. You're a nurse, and you find yourself with the key to the narcotics cabinet. You're doing the spring cleaning, and you turn up a cache of vodka you'd forgotten about. On the commuter train en route home every evening, you start running into a guy you used to get high with. If you don't have a workable plan for such eventualities, relapse is only a misstep away. So be sure you plan ahead.
Triggers: Something you see (powdered sugar spilled on the table, a photogenic frosty mug of beer in a TV commercial, the outfit you used to wear to wild parties); something you hear (rock music you associate with shooting up, soul music that takes you back to your drinking days, the music you were listening to the first time you smoked a joint); something you smell (bourbon or stale beer, the perfume worn by the girl you used to do cocaine with, vanilla extract when you're baking a cake, an acrid whiff of marijuana from the joint of a passer-by); something you taste (nonalcoholic beer or wine, ice cream artificially flavored with rum, a bowl of pretzels or salted peanuts like the ones canny bartenders use to double your thirst); something you touch (grains of sugar, a leather jacket, a flat mirrored surface or highly polished oak countertop). Any these flashback stimuli could trigger a craving for alcohol or drugs. Again, vigilance--being prepared for psychological ambushes--lessens the danger.

Red Flags

Relapse doesn't just happen. There's an early warning system built into recovery. If you're always on the alert for its red flags--behaviors that quietly (or noisily) signal that a relapse may be imminent--you can head off a slip before it happens. If any of the following are suddenly part of your life (or if they've been part of your life in recovery all along), then take preventive action immediately. There's no time to lose.
Elaborate excuse-making. When you find yourself going to great creative lengths to rationalize or explain away your behavior--why you missed a couple of meetings, why you've been late to dinner every night for a week, or why a report at work is long overdue--you are probably tottering on the brink.
Panic in the streets. Or anywhere else. Anxiety or panic attacks, thoughts of suicide, compulsive behaviors (gambling, promiscuous sex), and eating peculiarities, are sure signs that your life is getting out of hand. They require immediate attention. If seeing to your Phase One priorities doesn't get you better fast, seek help from a professional.
Irresponsibility. You start avoiding your commitments, failing to do what must be done. You do things that you know are not in your own best interests, or that are in the worst interests of those you care about.
Breaking the rules. The rules laid out for aftercare no longer seem to apply you. You've "forgotten" to refill the prescription for Antabuse. You make a beeline for your old haunts and hangouts instead of detouring around them. You don't see the need to promptly make amends when you make a mistake. You stop taking inventory.
Lying low. You used to check in with your sponsor a couple of times a week. Suddenly you realize it's been more than two weeks.
Sick thinking. How can you tell your thinking is running a fever? You start missing the action at the bar and wonder if it really was the alcohol that caused your problems. While sipping a soda, you ponder the possibility of an innocent little "scientific experiment" social drinking. You feel sorry for yourself . You start to dial your sponsor when temptation invades your mind; you abruptly hang up. You act on impulse rather than with forethought.
Strapping on spare parachutes. You discover that you've kept the numbers of pushers or liquor stores in your phone file, but you reason that they're important reminders of the error of your old ways. You decide to leave them there as historic markers. You turn down a ride to a meeting with an AA friend because you know you can't stop for a drink with him "just in case" you need one. When an old drugging buddy calls to ask "What's happening?", you reply vaguely rather than with a clear, firm "I'm finished with drinking and drugging. I've joined AA."
Treading water. You've hit a plateau. You follow your program faithfully, but things are not getting better day to day, month to month. If this lack of progress continues for six months to a year, it's time to think about seeking professional help, even if you had treatment (in- or outpatient) earlier. Some people are so sick initially, their ability to think so dampened by drugs, that treatment is less effective than it could have been. For these people recovery often stagnates, and some form of booster treatment without waiting for relapse is often the way to go.
Going to hell with yourself. You find yourself forgetting to take a bath, roll on the deodorant, brush your teeth before you slip into bed, get your hair cut, wash your clothes, see the doctor when you are ill. The next thing you're likely to forget is your sobriety. Keep an eye open for deteriorating personal hygiene. A deteriorating recovery program often lies behind it.
Switching poisons. Alcohol is your nemesis, so what could be wrong with smoking a joint or two? You're a cocaine addict who never had trouble with alcohol, so why not just switch to harmless social drinking? Or tranquilizers were your downfall, so why should a short snort be a problem? The answers will swiftly become evident page.
Denial. If any of the above describes your behavior, yet you insist you aren't at risk for relapse, you've just followed Alice down a rabbit hole into Wonderand. Your denial could be taking the form of refusing to believe that, now that you're sober, you have an alcoholism/addiction problem at all. Or you may be denying other problems--health problems, financial problems, relationship problems, work problems. Continued denial of reality could lead to giving up on recovery and trying to escape your problems in an old familiar way: through the brief Nirvana of substance use. The only way to "escape" problems is to face them head-on and just plain wrestle them into submission.

Heading Off a Relapse

If you notice any of the mentioned red flags (or any like them) waving in front of your face, try any or all of the following suggestions to avoid falling off the wagon and under its wheels. Remember, the compulsion to drink or drug will pass, if you do something else.
--Call your sponsor (or counselor or addiction specialist) immediately. Here's where that list of emergency numbers in your purse or wallet comes in. If you fail to contact the first person you call, work your way down the list until you do reach someone.
-- Go to a meeting. If your usual meeting isn't on, go to one that is across town or, if necessary, in another town. Make no excuses. Spare no expense. Do whatever it takes to get you there.
-- Increase the number of meetings you've been going to. You may have to do a meeting a day--or more--for several days or weeks to get back on track.
-- Put mileage between yourself and temptation. If you're a health professional, ask a trusted colleague to take charge of your key to the narcotics cabinet. Walk out of a party or other event the moment you begin to sense "that old feeling" coming on. Say sayonara to the "friend" urging you to have "just one."
-- Try relaxation techniques, meditation, prayer, reading (the Big Book or other inspirational materials), pick-me-ups (munchies, exercise), or other methods of smothering a compulsion to use or drink.
-- Sign up immediately for a recovery weekend or retreat. Total immersion in a convivial, sharing, understanding atmosphere for forty-eight hours can be a very sobering experience.
-- Remember what pre-sobriety life was really like. Now is the time to pull out that cache of rub-your-nose-in-it materials you prepared in early recovery (the history, letters, photos, videos, etc.) so that you don't forget to remember all the gory details. Ask yourself what it is you want to get out of the drink or drug that's tempting you, and whether there might be a better way to reach that goal. Also, think about the term effects of that drink or drug you and on those you love most. Our surveys of successful recoveries indicate that perhaps the most powerful force restraining people who feel a compulsion is pure old-fashioned fear--of sliding back into hell, of pain degradation, of dying.
-- Always be prepared. Know what would do in a whole list of perilous "if" situations: if you suddenly discover a bottle of liquor you buried long under a pile of sweaters in the cedar closet. If you're offered a joint a new friend who doesn't know your history. If an emergency room doctor prescribes a mood-altering drug for the blinding pain of an ankle sprained on the ski slopes. If you run into an old drinking or drugging buddy.
    Know not just roughly what you would do, but precisely, including the very words you would use. Anticipate the kind of response you might get in turn, and decide how you would handle it. Role-play with AA friends to prepare for the real thing. Rehearsing sticky situations beforehand opens up a prepared escape route. And knowing what to expect from yourself helps you live up to your expectations.
-- If you feel a slip is close and fear you'll fail the challenge, consider giving yourself a "booster" at a weekend retreat, a refresher program, or an in- or outpatient treatment facility. Some treatment centers do not accept sober people, and most insurance carriers will not cover treatment for someone who hasn't relapsed. You may be able to arrange an admission for mental health reasons or for an impending relapse, and be covered that way.
    Signing-in before you actually have a slip, you skip the detox portion of the treatment and move directly to dealing with your mental state--which is where the problem is, anyway.
-- If you spot a pattern of regular slips, or a cycle of periodic sobriety followed by slips, try to head them off. If, for example, you seem to relapse every six months or so, check in for a booster after four or five months. This tinkering with your body's clock could block that relapse.
-- Strengthen your recovery. Thoughtfully and honestly evaluate your recovery program to expose the weaknesses that keep you tottering on the brink of relapse. Then return to Phase One (Chapters 6 through 15) to find the best ways to overcome them. Also study Chapter 5 of the Big Book (How It [AA] Works), and suggest discussion topics at meetings that you think will be helpful. Dropping back to square one (in this case, Phase One) now, before a slip, will be a lot easier, and more productive in the long run. It's like a talented rookie shortstop in a batting slump being sent down to the minors for a few weeks to work on hitting the curve ball. If he looks upon it as a learning opportunity, not a disgrace, he'll be back. And so will you.

If You Do Slip

First of all, remember that one slip (taking that first drink or fix) does not an irreversible relapse make. A close call or an actual slip doesn't mean you're a failure, just that your recovery program needs immediate first aid. For some people, one or more slips, or even a full-blown relapse, may become a meaningful part of their recovery process. The following steps can turn a slip into a learning experience--one that, instead of damaging your recovery, will strengthen it.
-- Recognize that you made a mistake, but that you don't have to compound it. One drink doesn't deserve another. Don't surrender to the "Now that I've had one, what difference will a few more make?" despair. The difference could be considerable--between being sober this time next year and being dead.
-- Leave the scene of the crime without a moment's hesitation. If you're at home, dump the drug or alcohol down the toilet before you go, or it will be waiting for you on your return. Your destination should be an AA meeting, your sponsor's home, the home of another friend, your counselor's or doctor's office, or some other safe haven.
-- Get immediate help--from your counselor, your doctor, your treatment program, your sponsor, or whoever you feel would be most useful in directing you back to the road to recovery. Pick up the nearest telephone and start calling your list; keep trying until you reach someone. Don't be embarrassed to ask for help. You are not the first person in recovery to slip, and you won't be the last.
-- No relapse "just happens." Once the immediate crisis is over, do an inventory to try to determine why you slipped. Look over the risky attitudes, behaviors, and situations described in the preceding pages, and see which may have been responsible for your fall. Were there physical cues--sights, smells, sounds, tastes--that triggered your actions? Figure out how to evade or alter them in the future, and take measures to be certain that you do.
-- Reinforce your recovery program as though you were starting from scratch in Phase One: go to more meetings, rework the Twelve Steps, read the Big Book and other literature, do more meditations, and so on.
-- Consider a treatment booster shot in- or outpatient.
-- Assure yourself that you can succeed. You can.

If You Relapse

At any time in. recovery you return to your drinking or drug using behavior, even only sporadically, you are in relapse. Taking the appropriate action is critical to your survival:
Get short-term help. Don't think about it--do it. As soon as you can pull yourself together to make a phone call, call your counselor, sponsor, doctor, treatment program, or another strong, reliable AA person. If you wait until you hit bottom again (even if it's just a few days), it's no melodramatic exaggeration to say that you may not live to make another stab at recovery. Leave a message if you can't reach someone, then call the next name on your list. Don't stop calling until you've reached a sympathetic and sober person who is able to come immediately. Alternately, call a cab to take you to an AA meeting. When you get in the taxi, ask driver to take you directly to your destination "even if I change my mind the on way."
Detoxify. If you experienced withdrawal the first time you quit, you are likely to again, even after just a small dose of alcohol or another drug. Since withdrawal symptoms are generally more severe the second time (or subsequent times) around, you may require medical detox. A few days of hospitalization by your family doctor may be all you need. If you--and someone you trust, who has considerable experience in these matters--decide that you don't need hospitalization, fully and carefully follow the procedures on page 80 for safe home detox, even if you didn't the first time. Attempt this only if you have an AA member or another steadfast, knowledgeable, and thoroughly reliable friend keeping the vigil with you. If your AA clubhouse has cots, you may be able to withdraw there.
Get long-term help. If you didn't go the formal treatment route the first time around, now is a good time to try it. If you did but lacked motivation the first time, professional treatment may be particularly valuable now. If you really open up your mind, all the words you listened to but didn't make a part of your life then should now finally make sense.
    If you have a history of periodic sobriety and relapse, professional treatment may be not only valuable but absolutely necessary for your survival. Impaired judgment from drinking could set you up for self-destructive behavior, even suicide. Typically, relapse is a time when many people alternately seethe with anger and wallow in self-pity: "I'm never going to climb out of this hell. Nobody gives a damn about me. My family would be better off without me. I might as well end it all."
    There are a variety of professional treatment options (see Chapter 3). Which you choose will depend on your health, your addiction, your wallet (or your employer's), and personal factors. Down the line, you may be able to further protect your recovery by agreeing to drug testing at work or school, by having your sponsor or counselor agree to report you to your boss or dean at the first sign of a slip
Spotlight your shortcomings. You didn't relapse accidentally, unless a friend with a distorted sense of humor sneaked some booze or hash into your beef goulash. (What were you doing socializing with anyone who could think that was funny, anyway?) The newly sober recognize that they have a lot to learn about recovery. But relapsers sometimes feel that they are experts on recovery, that the relapse was "just a fluke." If told "What you need is ninety meetings in ninety days," their smart-aleck response is likely to be "I know what I need, and that ain't it!" But someone who lacks the humility necessary to crawl back on the recovery wagon is likely to see it roll without him.
    If you want to get sober again-this time for good--the first thing you're going to have to admit is that what you know about recovery couldn't fill a shot glass. Then start your program over from scratch, soul-searching for the chinks in your recovery armor that made it possible for drugs or alcohol to seep through. You can go to your old group, or if you find it more comfortable, make a fresh start at a new group, one where you aren't recognized as an old-timer.
Re-focus on recovery. Eventually, what you learn from your relapse will allow you to carry a powerful message to others. Right now you have to forget about being a sponsor or helping other people, and instead look after number one. Even if you've been sober for years, a relapse means you have to stop everything and concentrate on the work of recovery--on Phase One work. You'll probably complete it in less time than you did the first time around, but you need to "get it" better than you did then.
Making meetings mandatory. Don't ever let going to Twelve-Step meetings become a random activity; structure your life so that meetings are a routine part of it. Going to the same meeting at the same time and in the same place each day (or later in recovery, once or twice each week) will strengthen the habit--though the Twelve-Step meeting on Monday night, for example, may not be with the same group as the one on Friday afternoon.
    Link your meeting attendance to your regular routine. Go to a meeting on your way home from work, while you're out for your exercise, or en route to an evening class. That way you know where you're going in advance and don't have to make a fresh decision each time. You can say to friends, "See you next week," or arrange to meet someone for a meal before the next meeting or to drive there together. If you find yourself trying to choose between going to a Rotary meeting (or a movie, or a basketball game) and going to your regular AA meeting, there could be trouble ahead. If you reach the point where you find yourself choosing the movie or a game over the meetings, or chronically missing meetings for other reasons, take action. There's very likely a relapse in near future.
Unmask the villains. Carefully examine your current involvement in AA (do you have and regularly confer with a sponsor? Have you gotten careless and cavalier about attending meetings? Do you read the Big Book and other AA literature often?) and your life (are your relationships healthy, is your job interesting and on track, is there too much stress, too little fun in your life, too few friends?).
Don't be embarrassed. Your friends at AA know that nobody's perfect and you're probably thinking "There but for the grace of God go I." You may feel uncomfortable having to start all over again, and may even have to take some ribbing at AA; but mostly you will get a lot of loving support.
Think Positive. Anyone can become successfully clan and sober--anyone who is motivated and willing to put in the necessary hard work. This time, that anyone can be you.


An Elementary Textbook of Psychoanalysis- Charles Brenner
Chapter VII- Dreams, pp. 149-170

The study of dreams occupies a particular place in psychoanalysis. The Interpretation of Dreams (Freud, 1900) was as revolutionary and as monumental a contribution to psychology as the Origin of Species was to biology a half century earlier. As late as 1931 Freud himself wrote, in a foreword to the third edition of Brill's translation of The Interpretation of Dreams, "It contains, even according to my present-day judgment, the most valuable of all the discoveries it has been my good fortune to make. Insight such as this falls to one's lot but once in a lifetime." Moreover, his success in understanding dreams was of immense help to him during the early years of this century, at a time when his professional work was of necessity carried on in complete isolation from his medical colleagues. In that difficult time he was struggling to understand and to learn how to treat successfully the neuroses from which his patients suffered. As we know from his letters (Freud, 1954) he was often discouraged and sometimes even in despair. Yet however discouraged he might be, he was able to take courage from the discoveries which he had made about dreams. There he knew that he was on firm ground and this knowledge gave him the confidence that he needed in order to go forward (Freud, 1933).
    Freud was certainly right in valuing his work on dreams so highly. In no other phenomenon of normal psychic life are so many of the unconscious processes of the mind revealed so clearly and made so accessible to study. Dreams are indeed a royal road to the unconscious reaches of the mind. Yet even this does not exhaust the reasons for their importance and value to the psychoanalyst. The fact is that the study of dreams does not simply lead to an understanding of unconscious mental processes and contents in general. It leads particularly to those mental contents which have been repressed, or otherwise excluded from consciousness and discharge by the defensive activities of the ego. Since it is precisely the part of the id which has been barred from consciousness that is involved in the pathogenic processes which give rise to neuroses and perhaps to psychoses as well, one can readily understand that this characteristic of dreams is still another, very important reason for the special place that the study of dreams occupies in psychoanalysis.
    The psychoanalytic theory of dreams may be formulated as follows. The subjective experience which appears in consciousness during sleep and which, after waking, is referred to by the sleeper as a dream is only the end result of unconscious mental activity during sleep which, by its nature or its intensity, threatens to interfere with sleep itself. Instead of waking, the sleeper dreams. We call the conscious experience during sleep, which the sleeper may or may not recall after waking, the manifest dream. Its various elements are referred to as the manifest dream content. The unconscious thoughts and wishes which threaten to waken the sleeper we call the latent dream content. The unconscious mental operations by which the latent dream content is transformed into the manifest dream we call the dream work.
    It is of the utmost importance to keep these distinctions clearly in mind. A failure to do so constitutes the greatest source of the frequent confusion and misunderstandings that arise concerning the psychoanalytic theory of dreams. Strictly speaking, the word "dream'' (in psychoanalytic terminology) should only be used to designate the total phenomenon of which the latent dream content, the dream work, and the manifest dream are the several, component parts. In practice, in the psychoanalytic literature, "dream" is very often used to designate "manifest dream." Usually when this is done it leads to no confusion if the reader is well acquainted with the psychoanalytic theory of dreams already. For example, the statement, "the patient had the following dream," when followed by the verbal text of the manifest dream, leaves no in the mind of the informed reader that the word is intended to mean "manifest dream." However, it is essential for the reader who is not yet fully at home in field of dream theory to ask himself what the author meant by the unqualified word "dream" whenever he encounters it in the psychoanalytic literature. There is another term which in practice appears in the literature and in discussion and which it is convenient to define here. This is the "the meaning of a dream," or, "a dream means." Properly speaking, the meaning of a dream can signify only the dream content. In our present discussion we shall try keep our terminology precise in order to avoid the possibility of misunderstanding.
    Having defined the three component parts of a dream, let us proceed to a discussion of that part which we believe initiates the process of dreaming, namely of the latent dream content. This content is divisible into three major categories. The first category is an obvious one. It comprises nocturnal sensory impressions. Such impressions are continually impinging on the sleeper's sense organs and at times some of them take part in initiating a dream, in which case they form part of the latent content of that dream. Examples of such sensations are familiar to all of us. The sound of an alarm clock, thirst, hunger, urinary or fecal urgency, pain from an injury or disease process, or from the cramped position of part of the body, uncomfortable heat or cold, all can be a part of the latent dream content. In this connection it is important to bear two facts in mind. The first is that most sensory stimuli do not disturb sleep, even to the extent of participating in the formation of a dream. On the contrary, the vast majority of the impulses from our sensory apparatus are without discernible effect upon our minds during sleep. This is true even of sensations which in our waking state we should evaluate as rather intense. There are persons who can sleep through a violent thunderstorm without either waking or dreaming, despite the fact that their hearing is quite normally acute. The second fact is that a disturbing sensory impression during sleep can have the effect of waking the sleeper directly, without any dream, at least as far as we can tell. This is particularly obvious in those situations in which we are sleeping "with one ear cocked," or "with one eye, open," as happens for example with parents when a child in the family is sick. In such a case the parent will often waken immediately at the first disturbing sound from the child, however slight its intensity.
    The second category of the latent dream content comprises thoughts and ideas which are connected with the activities and the preoccupations of the dreamer's current, waking life and which remain unconsciously active in his mind during sleep. Because of their continued activity they tend toward waking the sleeper, in the same way as impinging sensory stimuli during sleep tend to do. If the sleeper dreams instead of waking, these thoughts and ideas act as part of the latent dream content. Examples are innumerable. They include the whole variety of interests and memories which are ordinarily accessible to the ego, with whatever feelings of hope or fear, pride or humiliation, interest or repugnance which may accompany them. They may be thoughts about an entertainment of the night before, concern about an unfinished task, the anticipation of a happy event in the future, or whatever else one might care to imagine that is of current interest in the sleeper's life.
    The third category comprises one or several id impulses which, at least in their original, infantile form, are barred by the ego's defenses from consciousness or direct gratification in waking life. This is the part of the id which Freud called "the repressed" in his monograph on the structural hypothesis of the psychic apparatus (Freud, 1923), although he later favored the view, now generally accepted by psychoanalysts, that repression is not the only defense which the ego employs against id impulses which are inadmissible to consciousness. Nevertheless, the original term, "the repressed," continues in usage to designate this part of the id. With this understanding, therefore, we may say that the third category of the latent dream content in any particular dream is an impulse, or impulses, from the repressed part of the id. Since the most important and far-reaching of the ego's defenses against the id are those which are instituted during the pre-oedipal and oedipal phases of the child's life, it follows that id impulses from those early years are the chief content of the repressed. Accordingly, that part of the latent dream content which derives from the repressed is generally childish or infantile, that is to say, it consists of a wish appropriate to and stemming from early childhood.
    As we can see, this is in contrast to the first two categories of the latent dream content which comprise, respectively, current sensations and current concerns. Naturally in childhood the current and the childish may coincide. However, far as dreams of later childhood and adult life are concerned, the latent content has two sources, the one in the present and the other in the past.  We naturally wish to know what is the relative importance of the three parts of the latent content and whether all three are to be found in the latent content of every dream. As to the first question, Freud (1933) declared unequivocally that the essential part of the latent content is that which comes from the repressed. He believed that it is this part which contributes the major share of the psychic energy necessary for dreaming and that without its participation there can be no dream. A nocturnal sensory stimulus, however intense it be, must, as Freud expressed it, enlist the aid of one or more wishes from the repressed before it can give rise to a dream and the same thing is true of the concerns of waking however compelling may be their claim on the sleeper's attention and interest.
    As to the second question, it follows from our answer to the first one that one or more wishes or impulses from the repressed are an essential part of the latent content of every dream. It also appears to be the case that at least some concerns from current, waking life are a part of every latent dream content. Nocturnal sensations, on the other hand, are not demonstrable in the latent content of every dream, although they play a conspicuous role in some dreams.
    We wish now to consider the relationship between the latent dream content and the manifest dream, or, to be more specific, the elements or content of the manifest dream. Depending on the dream, this relationship may be very simple or very complex, but there is one element that is constant. The latent content is unconscious, while the manifest content is conscious. The simplest possible relationship between the two, therefore, would be that the latent content become conscious.
    It is possible that this does happen occasionally in the case of sensory stimuli during sleep. For example, a person may be told in the morning, after waking, that fire engines passed the house during the night while he was asleep and he may then recall that he heard a fire siren in his sleep. However, we should probably be inclined to look on such an experience as a borderline or transitional experience between ordinary, waking perception and a typical dream rather than to classify it as a true dream. We might even suspect that the sleeper awoke momentarily when he heard the sirens, although we must admit that this cannot be more than an assumption on our part.
    In any case, for our present purposes we shall do better to confine ourselves to a consideration of phenomena which are unquestionably dreams. Of these, it is the dreams of early childhood which most often offer us examples of the simplest relationship between latent and manifest content. For one thing, in such dreams we need not distinguish between infantile and current concerns. They are one and the same. For another thing, there is not as yet any clear distinction to be made between the repressed and the rest of the id, since the very little child's ego has not yet developed to the point of having erected permanent defenses against any of the impulses of the id.
    Let us take as an example the dream of a two-year-old whose mother had just returned from the hospital with a new baby. On the morning after his mother's return he reported a dream with the following manifest content: "See baby go away." What was the latent content of this dream? Ordinarily this is something that we can determine only from the dreamer's associations, that is by the use of the psychoanalytic method. Naturally, a two-year-old child cannot understand or consciously cooperate in such an undertaking. However, in this case we can justifiably take the child's known behavior and attitude toward the new baby, which were hostile and rejecting, as the equivalents of associations to the manifest content of the dream. If we do so, we can conclude that the latent content of the dream was a hostile impulse toward the new baby and a wish to destroy or get rid of it.
    Now what is the relationship between the latent and the manifest content of the dream in our example? The answer seems to be that the manifest content differs from the latent one in the following respects. First, as we have already said, the former is conscious and the latter, unconscious. Second, the manifest content is a visual image, while the latent content is something like a wish or impulse. Finally, the manifest content is a fantasy which represents the latent wish or impulse as gratified, that is, it is a fantasy which consists essentially of the gratification of the latent wish or impulse. We may say then that in the case we have chosen as an example, the relation between the latent and the manifest dream content is that the manifest dream is a conscious fantasy that the latent wish has been or is being gratified, expressed in the form of a visual image or experience. Consequently, the dream work in this example consisted of the formation or selection of a wish-fulfilling fantasy and its representation in visual form.
    This is the relationship that obtains between the latent and the manifest dream content in all of the dreams of early childhood, as far as we know. Moreover, it is the basic pattern for this relationship which is followed in the dreams of later childhood and of adult life as well, even though in these more complex dreams the pattern is elaborated and complicated by factors which we shall discuss shortly.   First, however, we note that the process of dreaming is in essence a process of gratifying an id impulse in fantasy. We can better understand now how it happens that a dream makes it possible for a sleeper to keep on sleeping instead of being wakened by a disturbing, unconscious mental activity. It is because the disturbing wish or impulse from the id, which regularly forms a part of the latent content of the dream, is gratified in fantasy and in that way loses at least some of its urgency and hence some of its power to waken the sleeper.
    Conversely, we understand that the fact that the manifest dream is regularly a wish fulfillment is due to the nature of the latent content, which after all is the initiator of the dream as well as its principal source of psychic energy. The id element which plays this role in the latent content can only press constantly for gratification, since this is the very nature of the instinctual drives of which it is a derivative. What happens in a dream is that a partial gratification is achieved by means of fantasy, since full gratification through appropriate action is rendered impossible by the state of sleep. Since motility is blocked, fantasy is used as a substitute. If we express the same idea in terms of psychic energy, we shall say that the cathexis which is attached to the id element in the latent content activates the psychic apparatus to carry out the dream work and achieves partial discharge via the wish-fulfilling fantasy image which constitutes the manifest dream.
    At this point we must take account of the obvious fact that the manifest content of most of the dreams of later childhood and of adult life is not at all recognizable as a wish fulfillment on first, or even on second glance. Some dreams, indeed, have as their manifest content images which are sad or even frightening, and this fact has been cited repeatedly in the past fifty years as an argument to disprove Freud's assertion that every manifest dream is a fantasied wish fulfillment. How can we understand this apparent discrepancy between our theory and the obvious facts?
    The answer to our question is a very simple one. As we have said, in the case of the dreams of early childhood the latent dream content gives rise, via the dream work, to a manifest dream which is a fantasy of the satisfaction of the impulse or wish which constitutes the latent content. This fantasy is experienced by the dreamer in the form of sensory impressions. The same obvious relationship between the latent and the manifest dream content is sometimes found in a dream of later life. These dreams closely resemble the simple ones of early childhood. However, it is more often the case that the manifest content of a dream of later life is the disguised and distorted version of a wish-fulfilling fantasy, experienced predominantly as a visual image, or a series of visual images. The disguise and distortion are often so extensive that the wish-fulfilling aspect of the manifest dream is quite unrecognizable. Indeed, as we all know, the manifest dream is sometimes a mere hodgepodge of apparently unrelated fragments and seems to make no sense whatever, much less to represent the fulfillment of a wish. At other times the disguise and distortion are present in such high degree that the manifest dream is actually experienced as frightening and unwelcome, rather than retaining the pleasurable character that we should expect a wish-fulfilling fantasy to have.  It is the dream work which creates the disguise and distortion which are such prominent features of the manifest dreams of later childhood and of adult life. We are interested to know what processes are involved in the dream work and how each of them contributes to disguising the latent content so that it is no longer recognizable in the manifest dream.
    Freud was able to show that there are two principal factors to be considered in connection with the dream work and one subsidiary one. The first principal factor, which is, indeed, the very essence of the dream work, is that it is a translation into the language of the primary process of those parts of the latent content which are not already expressed in that language, followed by a condensation of all of the elements of the latent content into a wish-fulfilling fantasy. The second principal factor consists of the defensive operations of the ego, which exercise a profound influence on the process of translation and fantasy formation, an influence which Freud likened to that of a news censor with wide powers to suppress objectionable items. The third, subsidiary factor is what Freud called secondary revision.
    Let us consider each of these factors in turn. In the first place, as we have said, the dream work consists of the translation into primary process thinking of that part of the latent dream content which is originally expressed according to the secondary process. This would only include what we have called the concerns and interests of current life. Moreover, as Freud pointed out, this translation occurs in a certain way. As he put it, there is a regard for the possibility of expressing the result of the translation in the form of a plastic, visual image. This regard for plastic representability, of course, corresponds to the fact that the manifest dream content consists principally of such images. A similar regard for plastic representability is exercised consciously in some activities of norm4 waking life, as for example in charades and in composing cartoons and rebuses.
    Another consideration that doubtless affects this process of translation in the dream work is the nature of the latent dream elements which are already in primary process language, that is, essentially, the memories, images, and fantasies associated with the wish or impulse from the repressed. In other words, the dream work will tend to translate the current concerns of waking life into terms or images that stand in as close a relationship as possible to the material which is connected or associated with the repressed. At the same time, of the several or even, perhaps, of the many fantasies of gratification which are associated with the repressed impulse, the dream work chooses that one which can most easily be brought into connection with the translated current concerns of waking life. All of this is a necessarily clumsy way of saying that the dream work effects as close an approximation as possible among the various latent dream elements in the course of translating into primary process language those parts of the latent content that need translating, while at the same time creating or selecting a fantasy which represents the gratification of the impulse from the repressed that is also a part of the latent content. As we said in the previous paragraph, all of this is done with regard to visual representability. In addition, the process of approximation which we have just described makes it possible for a single image to represent several latent dream elements simultaneously. This results in a high degree of what Freud called "condensation," which is to say that, at least in the vast majority of cases, the manifest dream is a highly condensed version of the thoughts, sensations and wishes which make up the latent dream content.
    Before we proceed to a discussion of the part played in the dream work by the ego's defenses, we may pause to ask whether that part of the dream work which we have already discussed is responsible for any part of the disguise and distortion which we have said characterizes most manifest dreams and, if so, how great a role it plays in this direction.  It is understandable that expressing concerns of waking life in the language of the primary process should result in a considerable degree of distortion of their meaning and content. However, the reader may well ask why this psychic operation should have the effect of rendering its end result unintelligible to the dreamer. After all, the person who composes a cartoon, a charade, or a rebus can understand the meaning of its images, despite the fact that the meaning has been expressed in the language of the primary process. In fact, the meaning of these creations is grasped by many persons other than the composer himself. Moreover, ideas which are expressed in the language of the primary process are intelligible to us in other situations, as for example in the case of witticisms, as we saw in Chapter VI. Why then should a manifest dream be unintelligible, simply because it contains ideas which are expressed via the primary process?
    One part of the answer to this question would appear to be the following. Wit, cartoons, rebuses, and even charades, are composed with a special requirement, namely that they be intelligible. They must communicate a meaning to an actual or potential audience if they are to be "good." A manifest dream, on the other hand, is subject to no such restriction. It is merely the end result of a process which aims at the fantasied gratification of a wish, or, alternatively expressed, at the discharge of enough of the psychic energy associated with the latent dream content to prevent this content from awakening the sleeper. It is not surprising, therefore, that the manifest dream is not generally immediately comprehensible even to the sleeper himself.
    However, the second of the principal factors which we have mentioned as participating in the dream work plays much the more important role in disguising the latent dream content and making the manifest dream unintelligible. This second factor, as the reader will remember, is the operation of the defenses of the ego. We may note in passing that Freud's first description of this factor long preceded his formulation of the structural hypothesis concerning the psychic apparatus, of which the terms "ego" and "defenses" are a part. For that reason he had to devise a name for the factor in question and the one that he chose, as we said above, was "the dream censor, a most apt and evocative term.
    In order to understand clearly the operation of the ego's defenses in the process of the formation of the manifest dream, we must first recognize that it affects the different parts of the latent dream content to different degrees. The part of the latent content consisting of nocturnal sensations is ordinarily subject to no defensive operations of the ego, unless, perhaps, we should consider that the ego attempts to deny all such sensations in consequence of its wish to sleep. However, we are really not certain whether this attitude of the sleeper toward nocturnal sensations is an ego defense in the usual meaning of the term and we may safely leave it out of consideration for the purposes of our present discussion.
    In marked contrast to nocturnal sensations, the part of the latent dream content which consists of wishes or impulses from the repressed is directly opposed by the defenses of the ego. We know indeed that this opposition is a long-standing and essentially permanent one and that its presence is the reason for our speaking of "the repressed." We have no difficulty, therefore, in understanding that the ego's defenses tend to oppose the appearance of this part of the latent dream content in the conscious, manifest dream, since they are permanently opposed to its appearance in consciousness in waking life as well. It is the opposition of the defenses of the ego to this part of the latent content of the dream which is principally responsible for the fact that the manifest dream is so often incomprehensible as such and quite unrecognizable as a wish-fulfilling, fantasy image.
    The remaining part of the latent dream content, that is, the current concerns of waking life, occupies a position with respect to the ego's defenses which is intermediary between those of the two parts which we have just discussed. Many of the concerns of waking life are unobjectionable to the ego except, perhaps, as potential disturbers of sleep. Some are even considered by the ego to be pleasurable and desirable. However, there are other current concerns which are directly unpleasurable to the ego as sources of either anxiety or guilt. During sleep, therefore, the ego's defense mechanisms attempt to bar from consciousness these sources of unpleasure. The reader will remember from our discussion in Chapter IV that it is unpleasure, or the prospect of unpleasure, that calls into action the ego's defenses in general. In the case of such latent dream elements as we are presently discussing, we believe that the strength of the ego's unconscious opposition to them is proportional to the intensity of the anxiety or guilt, that is, of unpleasure, which is associated with them.
    We see then that the ego's defenses strongly oppose the entry into consciousness of the part of the latent dream content which derives from the repressed and oppose more or less strongly, as the case may be, various of the concerns of waking life which are also a part of the latent content. However, by definition, the unconscious thoughts, strivings and sensations which we call the latent content of the dream do in fact succeed in forcing their way into consciousness, where they appear as a manifest dream. The ego cannot prevent this, but can and does influence the dream work so that the manifest dream is unrecognizably distorted and consequently unintelligible. Thus the incomprehensibility of most manifest dreams is not due simply to the fact that they are expressed in the language of the primary process with no regard for intelligibility. The major reason for their incomprehensibility is that the ego's defenses make them that way.
    Freud (1933) called the manifest dream a "compromise formation," by which he meant that its various elements could thought of as compromises between the opposing forces of the latent dream content, on the one hand, and those of the defenses of the ego, on the other. As we shall see in Chap. VIII, a neurotic symptom is likewise a compromise formation between an element of the repressed and the defenses the ego.
    Perhaps a simple example might be helpful at this point. Let us assume that the dreamer is a woman and that the part the latent dream content deriving from the repressed is a wish, originating in the dreamer's Oedipal phase, for a sexual relationship with her father. This might be represented in the manifest dream, in accordance with an appropriate fantasy from that period of life, by an image of the dreamer and her father fighting together with an accompanying feeling of sexual excitement. However, if the ego's defenses oppose such an undisguised expression of this oedipal wish, the sexual excitement may be barred from consciousness, with the result that the manifest dream element becomes merely an image of fighting with father, with no attendant sexual excitement. If this is still too close to the original fantasy to be tolerated by the ego without anxiety or guilt, the image of the father may fail to appear, and instead an image may appear in which the dreamer is fighting with someone else, for example, with her own son. If the image of fighting is still too close to the fantasy, it may be replaced by some other physical activity, as, for example, dancing, so that the manifest dream is that of the dreamer dancing with her son. Even this may be objectionable to the ego, however, and instead of the manifest dream element just described there may appear in the dream an image of a strange woman with a boy who is her son, in a room with a polished floor.
    We should really end this series of examples with the words 'and so on,' since the possibilities for disguising the true nature of any element of the latent dream content are, for practical purposes, infinite in number. In fact it is the balance between the strength of the defenses and that of the latent dream element which will determine how closely or how distantly related is the manifest to the latent dream, that is, how much disguise has been imposed on the latent dream element during the dream work. Incidentally, in the example given in the previous paragraph, the reader should understand that each of the manifest dream images which were described is a separate possibility which might appear in a particular dream under the proper circumstances. The example is not intended to imply that, in a particular dream, manifest content "A" is tried first, then, if the ego will not tolerate "A," "B" is substituted, if not "B," then "C," and so forth. On the contrary, depending on the balance of forces between the defenses and the latent dream element, either "A" or "B" or "C," etc., will appear in the manifest dream.
    As might be expected, our example did not exhaust, or even suggest, the variety of "compromise formations" that are possible between defense and latent content. Anything approaching a complete list of such possibilities would be quite beyond the scope of the present chapter, but there are a few important or typical ones that we should mention. For one thing, things that belong together in the latent content may appear in widely separated parts of the manifest content. Thus, the dreamer of the example which we gave above might have seen herself fighting with someone in one part of the manifest dream, while her father was present in quite a different part. Such disruptions of connections are common results of the dream work.
    Another common "compromise" phenomenon is that a part, or even all, of the manifest dream is very vague. As Freud pointed out, this invariably indicates that the opposition of the defenses to the corresponding element or elements of the latent dream is very great. True, the defenses were not quite strong enough to prevent the part of the manifest dream in question from appearing in consciousness altogether, but they were strong enough to keep it from being more than half or vaguely conscious.
    The affects or emotions which belong to the latent dream content are also subjected to a variety of vicissitudes by the dream work. We have already illustrated the possibility that such an emotion, which in the case of our example was sexual excitement, might not appear in the manifest content at all. Another possibility is that the emotion may appear with greatly diminished intensity or somewhat altered in form. Thus, for instance, what was rage in the latent content may appear as annoyance, or as a mild dislike in the manifest content, or may even be represented by an awareness of not being annoyed. Closely related to the last of these alternatives the possibility that an affect belonging to the latent dream may be represented in the manifest dream by its opposite.  A latent longing may therefore appear as a manifest repugnance, or vice versa, hate may appear as love, sadness as joy, and so on. Such changes represent a "compromise," in Freud's sense of the word, between the ego and latent content and introduce an enormous element of disguise into the manifest dream.
    No discussion of affects in dreams would be complete without including the particular affect of anxiety. As we mentioned earlier in the course of this chapter, some of Freud's critics have attempted to disprove his statement that every manifest dream is a wish fulfillment on the basis that there exists a whole class of dreams in which anxiety is a prominent feature of the manifest content. In the psychoanalytic literature these dreams are usually called anxiety dreams. In nonanalytic literature the most severe of them are referred to as nightmares. The most extensive psychoanalytic study of the latter is that by Jones (1931). In general we may say of anxiety dreams that they signal a failure in the defensive operations of the ego. What has happened is that an element of the latent dream content has succeeded, despite the efforts of the ego's defenses, in forcing its way into consciousness, that is, into the manifest dream content, in a form which is too direct or too recognizable for the ego to tolerate. The consequence is that the ego reacts with anxiety. On this basis we can understand, as Jones pointed out, that oedipal fantasies appear in the manifest content of the classical nightmare with relatively little disguise and that, indeed, sexual gratification and terror are not infrequently present together in the conscious or manifest portion of such dreams.
    There is another class of dreams which is closely related to anxiety dreams and which are often referred to as punishment dreams. In these dreams, as in so many others, the ego anticipates guilt, that is, superego condemnation, if the part of the latent content which derives from the repressed should find too direct an expression in the manifest dream. Consequently the ego's defenses oppose the emergence of this part of the latent content, which is again no different from what goes on in most other dreams. However, the result in the so-called punishment dreams is that the manifest dream, instead of expressing a more or less disguised fantasy of the fulfillment of a repressed wish, expresses a more or less disguised fantasy of punishment for the wish in question, certainly a most extraordinary "compromise" among ego, id, and superego.
    At this point we must pose a question which may already have occurred to the reader. We have said that in dreams an unconscious wish or impulse from the repressed appears in consciousness, though more or less disguised, as the wish fulfilling fantasy image which constitutes a manifest dream. Now, by definition, this is precisely what an impulse belonging to the repressed cannot do. That is to say, we have defined "the repressed" as comprising those id impulses, with their directly associated fantasies, memories, and so forth, which the ego's defenses permanently bar from direct access to consciousness. How then can the repressed appear in conscious. ness in a dream?
    The answer to this question lies in the psychology of sleep (Freud, 1916b). During sleep, perhaps because the path to motility is effectively barred, the strength of the ego's defenses is considerably diminished. It is as though the ego said, "I don't have to worry about these objectionable impulses. They can't do anything as long as I'm asleep and stay in bed." On the other hand, Freud assumed that the drive cathexes at the disposal of the repressed, that is, the strength with which they push toward becoming conscious, is not significantly reduced during sleep. Thus sleep tends to produce a relative weakening of the defenses vis-a-vis the repressed, with the result that the latter has a better chance of becoming conscious during sleep than during waking life.
    We should realize that this difference between sleep and waking life is one of degree rather than one of kind. It is true that during sleep an element of the repressed has a better chance of becoming conscious than it has during waking life, but, as we have seen, in many dreams the ego's defenses introduce or compel such a high degree of distortion and disguise during the dream work that the access of the repressed to consciousness is hardly a very direct one in those cases. Conversely, under certain circumstances, elements of the repressed may gain fairly direct access to consciousness during waking life. For example, in Chapter VI, the case of the patient who "accidentally" knocked down an old man with his car at a busy intersection illustrates how an oedipal impulse from the repressed may momentarily control behavior and thus achieve rather direct expression even during waking life. Since other phenomena which illustrate the same point are by no means rare, it is clear that we cannot directly contrast sleep and waking life in this respect. However, the fact remains that by and large the repressed will appear in a manifest dream more directly than it is apt to do in the conscious thought or behavior of waking life.
    As we have said there is still another process, much less important than the two which we have discussed so far, which contributes to the final form of the manifest dream and which may add to its lack of intelligibility. This process might well be considered to be the final phase of the dream work, although Freud (1933) preferred to separate the two. He called this final process secondary revision. By it he meant the attempts on the part of the ego to mold the manifest dream content into a semblance of logic and coherence. The ego attempts, as it were, to make the manifest dream "sensible" in just the same way as it tries to make sense of whatever impressions come within its domain.
    We wish now to say a few words about a characteristic of the manifest dream to which we have already referred several times and which, on a purely descriptive level, is its most typical feature. This is the fact that a manifest dream nearly always consists chiefly of visual impressions. Indeed, it not infrequently consists exclusively of such impressions. However, other sensations may be perceived as part of the manifest dream as well. Next in frequency to visual sensory experiences in the manifest dream come auditory ones and occasionally any of the other modalities of sensation may appear in the manifest dream. It is also by no means rare for thoughts, or fragments of thoughts to appear as parts of the manifest dream in later life as, for example, when a dreamer reports, "I saw a man with a beard and I knew he was going to visit a friend of mine." Nevertheless, when such thoughts do appear in a manifest dream they nearly always occupy a position in it which is distinctly subordinate to that of the sensory impressions.
    As we all know from our own experience, the sensory impressions of a manifest dream command full credence while we are asleep. They are just as real to us as our waking sensory perceptions. In this respect these elements of the manifest dream are comparable to the hallucinations which are often present as symptoms in causes of severe mental illness. Indeed, Freud (1916b) referred to dreams as transient psychoses, though there is no doubt that dreams are not in themselves pathological phenomena. The problem therefore arises of accounting for the fact that the end result of the dream work, that is, the manifest dream, is essentially a hallucination, albeit a normal, sleeping one.
    In terms of the present-day psychoanalytic theory of the psychic apparatus, the so-called structural hypothesis, we should formulate our explanation of the fact that the manifest dream is essentially a hallucination about as follows. During sleep many of the ego's functions are more or less suspended. As examples, we have already mentioned the diminution in the ego's defenses during sleep and the nearly complete cessation of voluntary motor activity. What is important for our present argument is that during sleep there is also a marked impairment in the ego's function of reality testing, that is, in its ability to differentiate between stimuli of internal and of external origin. In addition to this, there also occurs in sleep a profound regression in ego functioning to a level characteristic of very early life. For example, thinking is in the mode of the primary rather than of the secondary process and is even largely preverbal, that is, it consists largely of sensory images which are primarily visual ones. Perhaps the loss of reality testing is also merely a consequence of the far-reaching ego regression that occurs during sleep. In any case, during sleep there is both a tendency for thinking to be in preverbal, largely visual images and inability on the part of the ego to recognize that these images arise from inner rather than from outer stimuli. It is as a result of these factors, we believe, that the manifest dream is essentially a visual hallucination.
    One easily observable fact that speaks in favor of the explanation which is based on the structural hypothesis as opposed to the simpler explanation based on the topographic hypothesis is the following. During many dreams, the capacity to test reality is not entirely lost. The dreamer is aware to some extent even while he is dreaming that what he is experiencing is not real, or is "only a dream." Such a partial preservation of the function of reality testing is difficult to reconcile with the explanation based on the topographic hypothesis. It is, however, perfectly compatible with the one based on the structural hypothesis.
    This concludes what we have to say about the psychoanalytic theory of the nature of dreams. We have discussed the three parts of a dream, that is, the latent content, the dream work, and the manifest content, and have tried to indicate how the dream work operates and what factors influence it. In practice, of course, when one attempts to study an individual dream, one is confronted by a manifest content and has then the task of ascertaining in some way what the latent content might be. When the task is completed successfully and we are able to discover the latent content of a dream, we say that we have interpreted the dream or discovered its meaning.  The task of interpreting dreams is pretty well limited to psychoanalytic therapy, since it generally requires the application of the psychoanalytic technique. We shall not discuss dream interpretation here because it is. in fact, a technical procedure and is properly part of psychoanalytic practice rather than of psychoanalytic theory.