It's about 7.30pm on the locked unit. People have had their evening meal. Some have settled down to watch television in the group room. Others are sleeping already in their beds.We used to take people out for a cigarette break but that doesn't happen anymore. Smoking is dangerous to the health, and nicotine is an addictive substance. It makes no sense to advocate a recovery motif, including the non-support for addictive substances but then to support smoking.Although it is annoying to have to fend off the complaining and whining about not being able to smoke, no staff members want to escort the patients onto the landing and stand in the midst of their smoke, nor for that matter to deal with them when they start begging for a second cigarette.Inside, nobody looks at the methadone being handed out. We don't want to think too deeply about supporting one habit while complaining about another. In fact, some people come in for treatment precisely because they've become addicted to medication that has been prescribed in an entirely legal fashion. Some are addicted to pain medication. Others are addicted to anti-anxiety medications.“Has the doctor called yet?!”A young man whines as he sidles up to the window at the nurse's station.“Not yet,” he is told.His face screams agony. It is the face of addiction. He looks like he's going to cry. Then he asks the staff for the fifth time to make sure that the doctor sees him immediately after getting onto the locked unit, and the staff members all assure him that they will.The terms “addiction” and “self-medicating behaviours” overlap. For some people and contexts of discussion they could refer to the same thing. A very strict understanding of addiction requires physiological dependence on one or more illegal drugs, tolerance, and withdrawal. A wider understanding would identify addiction with anything in which people are given over or overwhelmingly consumed with some kind of behaviour that becomes centrifugal in nature, that is, forcing other parts of life to the periphery of living.Self-medicating behaviours are those that include features of addiction but that provide soothing or relief and thus are psychologically reinforcing. They can include eating, sex, drugs, spending or shopping, and rage. When self-medicating overlaps addiction, behaviours can include substance abuse, eating disorders, and compulsive gambling.An addiction is apparent when there is a loss of control over the use of a substance or the repetition of behaviour and that use or behaviour continues in spite of negative consequences. Early on, Terence Gorski, a leading expert on addiction and recovery claimed that addiction is a matter of the drinking or drugging problem (the effects of the substance itself) and the thinking problem (the effects of thinking that supports or maintains the addictive use or behaviour). The thinking problem includes irrational thoughts, unmanageable feelings, and self-defeating behaviours.According to Carl DiClemente, in his book ‘Addiction and Change: How Addictions Develop and Addicted People Recover', the critical dimensions for an addiction are (1) the development of a solidly established, problematic pattern of an appetitive that is, pleasurable and reinforcing-behaviour; (2) the presence of physiological and psychological components of the behaviour pattern that create dependence; (3) the interaction of these components in the life of the individual that make the behaviour resistant to change.Addictive behaviour patterns are repeated and become predictable in their regularity and excess. Dependence is the second necessary and critical dimension to define addiction. The term dependence indicates that the pattern of behaviour involves poor self-regulatory control, continues despite negative feedback, and often appears to be out of control. Moreover, reinforcers for engaging in this behaviour become very strong. Reinforcers are both physiological and psychological and combine to create a very powerful reward system that clouds awareness of problematic consequences related to the behaviour and makes change difficult and, at times, seemingly impossible. In fact, failure to change, despite the outward appearance that change would be both possible and in the best interest of the individual, is considered a cardinal characteristic in defining addictions.Addiction and the self-medicating character of certain behaviours become so recurrent, and so habitual that they become ways of life. According to Michael Clemmens in his book ‘Getting Beyond Sobriety' they are the first things an addict turns to under virtually any kind of stimulation. Addictive behaviours are complex disorders that develop through multiple processes that are biological, cognitive, psychological, and sociocultural in nature. In order to reverse the trends of addiction in an individual that person needs to change his or her lifestyle, and that is what leads to what is commonly called “working a programme”. It is a programme of recovery that structures change and turns addictive processes around.A person in Bermuda can go away to a residential treatment centre and learn the language and concepts of a given programme. He or she will still need follow up upon returning to the Island. When residential treatment is too expensive in terms of time and money, an addicted person serious about change can use the Turning Point programme at Mid-Atlantic Wellness Institute, or they can consult with an outpatient psychotherapist familiar with the treatment of addictions and compulsive, self-medicating behaviours.When I, for instance, meet with someone who comes for an addiction or to overcome some recurring self-medicating behaviour, the client and I create a recovery programme together, building it up piece by piece, but I have a general template in mind. I understand relapse prevention, and I know that relapse is a normal part of the journey. So, part of the programme we create together is the creative use of relapse to inform and further shape the process of recovery.That recovery, to be successful, takes time. It requires that a person stick it out through difficulty. Going into residential care may be the first choice in terms of best practices for addiction, but when that is not an option then seeking out an experienced outpatient therapist can work to avoid the defeating experience of just trying harder “this time”, or simply doing the same old thing and hoping something different will happen.