This article featured in the September 2017 issue of Substance Dependence Treatment Review
The three circles is a diagram, and tool, that is encouraged by addiction therapists to help recovering addicts identify and define various gateway behavior that can lead to a relapse. First described in a 1991 publication by Sex Addicts Anonymous, the three circles have been adapted and used by treatment programmes and 12 step groups who work with people with substance addiction, as well as process addictions.1
The Three Circles Diagram
The three circles look like a concentric, two dimensional diagram with three concentric circles, with an inner, a middle and an outer circle. Although aesthetically it looks like a target, it is more like a funnel, in that the closer the individual gets to the center, the more likely he or she is to relapse back into the addiction.
The closer he or she gets to the outer circle, and the more ground they will have to stay balanced; thereby, maintaining a sober recovery. As a visual tool, the three circles can be very useful for addicts and allow them to realize when they are facing stresses and situations that are dangerous to their maintaining recovery.
The diagnostic part is identifying that, while they have not yet relapsed, that they are in a risky situation, and that they should take action to move back to the outer circle.
Usually, the diagram is presented and discussed with those seeking recovery from an addiction. The individual uses this tool to help identify their own gateway behavior, with guidance from a rehab programme, therapists, support group members, or other individuals.
Starting from the inner circle, and working outward, the individual will want to mentally review the arc of their behavior toward active addiction. Individual instances of use or addictive behavior are reviewed and precursor behavior, situations, and/or events are identified. Along with standard
from the very beginning all the way to the current moment. Thinking about this may stir up painful thoughts or memories of events and experiences that were destructive or harmful. Sometimes it will help to write these thoughts down in order to reflect upon notable moments in which the addictive behavior was especially prominent. At this point, creating the three circles diagram can help.
Note that while there may be gradations of behavior and situations within a given circle, there is a clear delinneation between the circles. The diagram above is meant to convey that distinction.
The Inner Circle - Core Addiction Behavior
The innermost circle is where the individual will list behavior which they recognize as being a core part of the addiction. In the case of alcoholism, it is the use of alcohol. For those in Narcotics Anonymous or Alcoholics Anonymous, any mood-altering substance counts as a part of the addiction.
In general, an addict considers the day they became sober to be the last day he or she engaged in the inner circle behavior. Determining what should be listed in the inner circle could be difficult which is why it can help to have a therapist or counselor.2 Typically, inner circle behavior includes substance use, or in the case of process addictions, the core addictive behavior such as gambling.
The Middle Circle
Creating the middle circle list will require the individual to shift his or her focus from behavior that were harmful to behavior that can lead to harm. These will likely not be injurious in and of themselves, but have the potential to pull the individual downwards. They are the addiction boundaries and can be referred to as gateway behavior. If not kept in check, this behavior can quickly lead a person back to the inner circle. behavior which is questionable can also be listed here and reassessed at a later time. Middle circle behavior may or may not be considered appropriate, but in any case are deemed to be risky. Examples include:
- Procrastination, lack of structure
- Lack of sleep, being overworked
- Self-hate or being too critical
- Staying in unhealthy relationships
- Being around certain people or places
- Feeling lonely or alone, and staying isolated
- Feeling strong anger toward others
Middle circle behavior often come with denial, particularly because the addict may feel that some of the behavior is okay or justified. Engaging in any precipitious behavior may lead down a slippery slope to a relapse and addiction. An example of this might be when an individual believes he or she can visit the shopping mall, even though it is home to the restaurant they drank at every weekend. Or an individual who likes to stay on the computer late at night when they know they need to sleep, to be well-rested for work, and to avoid relapse into depression.
Often it is difficult for the individual to recognize or accept middle circle behavior as containing potential triggers that can quickly move them into the inner circle. On the other hand, the addict may believe they need to be actively engaged in certain behavior because they help to make them feel good and are not the actual substance. Ultimately, it is imperative for a person to acknowledge any risky behavior as being unhealthy and a challenge to their sobriety.
The Outer Circle
The Outer Circle encourages the addict to list their healthy behavior, also known as top line behavior. These are ones which exemplify their best and healthiest self, and have the ability to lead the individual away from middle and inner circle behavior. Twelve step programmes and support groups like Alcoholics Anonymous place a great emphasis on the outer circle as a method of positive reinforcement.3
Outer circle behavior help to prevent the person from approaching a situation or activity that could trigger a slip or relapse. They are things which can enhance the life of the addict as well as his or her recovery. In order to fully understand them, outer circle behavior needs to be approachable, practical, and clear, without any fantasy ideas. Ideally behavior that may already be put into practice or suggested by a therapist, support group, or partner. Examples of outer circle behavior include:
- Attending recovery meetings
- Calling a sponsor or sober support friend
- Reading or journaling
- Practicing yoga or meditation
- Being active, excercise
- Exploring new hobbies
- Spending time with the right people
- Helping other people, in particular, other addicts
The three circles diagram is not meant to be complete after an individual has listed their behavior in the respective areas. Rather, they should be regularly consulted as he or she learns more about their own behavior and the recovery process.
Customizing the Three Circles Diagram
As a visualization tool, the three circles will indicate various behavior associated with using and addiction, and that should be avoided. The diagram can be customized in different ways in order to gain a better understanding of how behavior, thought patterns, and physiological states are linked to addiction and recovery. As in the standard three circle model, the individual will list the most destructive in the inner circle, followed by those that may tempt and tease in the middle circle. The outer circle should list things that are positive and assist in maintaining recovery.
- Outer Circle - Recovery
- Middle Circle - Slippery Zone
- Inner Circle - Active Addiction (Relapse)
Physical, Mental, and Emotional States
One customization of the three circles is to identify and analyze different physiological states that could essentially trigger an addiction.
Each state can be broken down into the three circles and further assessed so that the individual knows which ones are conducive to his or her sobriety and which ones are not. The physiological states, and a few examples, are as follows:
- Physical - Health issues, eating disorders, inability to sleep, daily exercise, mindful eating, etc.
- Mental - Ideas, thoughts, reasoning, and judgment
- Emotional- Happiness, depressed, relaxed, manic, stressed, fearful, etc.
People, Places, and Activities
Thought patterns and behavior are not the only factors to consider when trying to manage recovery. Its alo important to have a clear delineation of how such behavior evolve, and often this has to do with people, places, and activities. Using the same three circles diagram, each category can be broken down into the aforementioned recovery, slippery zone, and active addiction circles.
- Home life - Relationships, family, living environment, abuse, etc.
- Work life - Overworked, underworked, unemployed, employer abuse, underpaid, like/dislike the job, etc.
- Social life - Supportive friends, enabling friends, activities or hobbies that support and/or discourage recovery, etc.
The above customizations of the three circles are also highly encouraged to explore in treatment methods such as community reinforcement and the Minnesota Model.
The notion that certain drugs, particularly alcohol, cannabis, and tobacco, are a precursor to other drug use was introduced in the mid 70s. It was derived after observing young people who had used legal drugs and then graduated onto illegal drugs including cannabis, cocaine, and heroin.
During the 1980s, the term gateway drug was coined and emphasized through tv adverts and printed media over the course of the next decade. With this came an abundant amount of research primarily labeled under the Gateway Hypothesis, and was meant to understand the progression of adolescent drug use by examining various factors including epidemiology, statistics, molecular biology, prevention, sociology, psychology, and animal behavior.4
Although the research is not conclusive, the theory that the use of certain drugs could increase the potential of other drug use is plausible. Medical researchers have suggested that when a young person uses cannabis, alcohol, or tobacco, biological alterations in the brain occur and make them more susceptible to further drug use.
The concept of the gateway drug has been established through observing, and surveying, first time users of different substances. Over longitudinal studies, trends have emerged; examples include:
- A sample group study of 6,624 people who had never used illegal drugs prior to using cannabis were 44.7% more likely to try further illegal substances. Social conditions were also a factor and influenced the height of total probability.5
- In another sample study of 27,461 people who exhibited no signs of alcoholism before using cannabis were reexamined three years later and revealed a 500% increase in alcohol dependence compared to a control group who had not consumed cannabis at all.6
Although research does show a trend with gateway drugs, it only indicates a possibility rather than a fixed outcome. This had led to plausible theories which are dominated by two concepts:
- That biological alterations in the brain occur during early drug use, and
- that there are similar socio-behavioral attitudes across the different types of drugs.7
Gateway Behavior in Substance Misuse
The validity of the gateway hypothesis or gateway drug theory is still uncertain. However, the premise that negative behavior will lead to worse behavior generally holds true. For example, when abusive behavior is exhibited in a relationship, and is not stopped, there is a high likelihood that the abuse will escalate. Likewise, a child who swears in a classroom may encourage the other students to swear, unless a teacher or figurehead takes action to root out the swearing behavior. This behavior may not necessarily dangerous, but they can be unwanted, and lead to a level of distress.
For substance misuse, gateway behavior can be a different kind of substance, such as drinking alcohol, when the substance of choice is cocaine. Those struggling with a cocaine addiction may find in their personal history that drinking alcohol generally came before cocaine-seeking behavior.
Early steps in the progression from recovery to relapse can be identified, such as going into a pub before consuming alcohol. Or perhaps calling in sick to work before eventually going into a pub.
Even mental states can be triggers which result in substance misuse, such as feeling angry or lonely. If those emotions were a precursor to substance misuse, then identifying them, and finding a coping strategy that leads out of the middle circle and back to
Gateway Behavior in Process Addictions
A substance addiction involves a dependency to at least one substance. It is diagnosed when an individual displays changes in their physical, emotional, and mental behavior, and they are unable to function without using.
Up until very recently, non-substance addictions were viewed as being a behavioral problem rather than an actual form of addiction.8 The American Psychiatric Association only recently included process addictions in the DSM5 diagnostic manual.
Behavioral researchers tend to believe that anything capable of stimulating a person can become addictive, and when a habit evolves into an obligation, it is to be considered an addiction. Ongoing research shows that there are certain similarities and differences between drug addiction and process addiction symptoms, yet both exhibit gateway behavior which the three circles diagram attempts to identify and address.
The term process addiction is a new way of describing an addiction to a process or activity that does not include any substances such as alcohol, cigarettes, hard drugs, or in some cases medication. Rather process addiction refers to addictions like over-eating, sex, gambling, shopping, the internet, computer games, and so forth.
The difference between process addictions and substance addictions is that the former causes the individual to become addicted to the behavior or feeling which results from acting out on the process or activity. Unlike a substance addiction, there are little to no physical signs; however, there are often precursors such as depression, social anxiety, a lack of social support or self esteem, and in some cases dependency. Researcher Kimberly Young suggested in her study that people with process addictions exhibit certain symptoms that will lead to the same consequences as those who have a substance addiction.9
From a neurological standpoint, process addictions indirectly affect neurotransmitters in the brain, and have the potential to serve as reinforcers. Whereas substances have a direct affect on these areas (i.e. dopaminergic system). Furthermore, behavior associated with process addictions have been found to induce reward -like effects, similar to substances, through biochemical processes going on in the brain; it is these that can lead to the addiction.
Patients diagnosed with a process addiction, who have been observed by clinicians and researchers, are found to have criteria that is comparable to substance addictions. For instance cravings, withdrawal, excessive behavior, tolerance, loss of control, and suicidal tendencies. With these findings, it has been deemed to be appropriate to categorize such excessive behavior as a valid process addiction that requires similar treatment to that of a substance addiction.
The three circles diagram is a useful tool for anyone who may be coping with an addiction and wants to be in recovery. Gambling, sex addiction, eating disorders, to name some of the main process addictions, all have precursor thoughts and actions that can be diagnosed and actively avoided as a part of recovery.
This article featured in the September 2017 issue of Substance Dependence Treatment Review