Refocusing – The role of distraction and substitution in recovery

This is an extremely relevant and useful guest post. I have come across many different formulas for a step-wise approach to recovery, but this is the most coherent and sensible one I’ve seen. The middle step is often our downfall, and Fred helps clarify the problem.

…by Fred…

In a recent post, Marc fleshed out the idea that addicts need to shift their perception of the tradeoff between their addictive behavior and the potential consequences of that behavior.  It is well known that addicts tend to overvalue the current rewards of using, and undervalue the tonguepotential rewards that might come from staying sober.  One definition of addiction is “emotional immaturity and lack of discipline,” and it is this difficulty in seeing the big picture that trumps everything else when an addict tries to revalue the tradeoff between using and not using.

In his book “In the Realm of Hungry Ghosts”, Gabor Maté builds on the work of Jeffrey Schwartz in laying out an approach to resisting relapse called “The 5 Rs”.  When the urge to use occurs, the addict is encouraged to “Relabel” the thought (it’s just a thought, not a command), “Reattribute” the thought (it’s my old addictive pattern again – my brain’s old behavior), “Refocus” (distract and turn one’s mind to healthy activities), “Revalue” (play the tape forward and clarify all the negative consequences that could occur because of relapse), and finally “Recreate”, where the addict focuses attention on his or her dreams for a new sober life.

1. Relabel

2. Reattribute

3. Refocus

4. Revalue

5. Recreate

The 4th and 5th Rs, Revalue and Recreate, are explicitly about addressing the addict’s distorted thinking when weighing short-term payoffs against long-term chaos.  But first, the addict needs to have enough mindfulness to consciously intervene in his or her own addictive cycle (the first 2 Rs).  See the recent post by Matt Robert for more about how this works.  At that point, it’s important to give the mind something else to do — to interrupt the cycle. This is where the third R comes in — Refocus.  This is a process that combines distraction and substitution to stop the addictive thought process and ritual, and, ideally, to address the deeper needs underlying the urge to use.

Addicts use, in part, as a form of mood regulation.  The addictive ritual and behavior releases nature’s mood enhancers — endorphins, dopamine, serotonin, noradrenaline and darkmoodadrenaline.  Stress, boredom, loneliness, grief, resentment and other uncomfortable feelings can all create a desire for refuge and an urge to use.  Sometimes, simply being exposed to a certain place, or image, or a particular person, can start the cycle.  Revaluing and Recreating in that scenario are probably not going to be strong enough, especially in early recovery, to interrupt the cycle and protect the addict from relapse.  That’s because the unpleasant mood state that the addict is in (which is often accompanied by negative physical sensations) is difficult to tolerate, and the future benefits of staying sober are merely conceptual.  They alone won’t shift the mood.  This is where Refocusing (i.e., distraction and substitution) is critical.  By getting away from the immediate stimulus and unsafe environment, and focusing the body and mind on a healthy substitute activity, the addict has a better chance of riding out the urge to use, and sometimes directly address the underlying stressor and associated emotions.

mother&childWhen confronted with stress, a young child seeks comfort in the arms of a caregiver.  The endorphins released by the loving touch and soothing presence of the attachment figure help to calm the child.  Adults also experience endorphin release as a result of intimate touch and connection with others.  But, for the addict, this source of endorphins is typically unavailable — the addiction makes safe intimate relationships impossible.  Similarly, the elevated dopamine levels that accompany craving make it difficult for the addict to focus on anything but the anticipated high, thereby ignoring everyday activities that might otherwise be rewarding and satisfying.  The addict’s artificial mood regulation strategy cuts off the ability to regulate in healthy ways — through close relationships and meaningful activities.

Refocusing not only helps the addict stay sober until the urge to use passes, it can actually start inculcating new mood regulation habits.  Instead of relapsing in response to a trigger, the addict might develop the habit of picking up the phone and calling a friend in recovery, or phoninggoing to a 12-step meeting, or exercising, or reading a novel, or doing a kindness for someone in need.  These types of activities will not only provide a distraction, they will substitute a behavior that reduces stress in a healthy way and helps to alleviate negative moods.

Faced with pain from life, our addictions temporarily soothe us, but they leave us more alone, and even more vulnerable to pain.  It’s suicide on the installment plan.  In recovery, faced with pain from life, we replace the mood-regulation strategy of addiction with caring for ourselves and connecting with others.  Consoled, we begin to believe in, and create, a future free from addiction and filled with the blessings of a life worth living.

27 thoughts on “Refocusing – The role of distraction and substitution in recovery

  1. Mark June 27, 2014 at 9:02 am #

    “But first, the addict needs to have enough mindfulness to consciously intervene in his or her own addictive cycle (the first 2 Rs).”

    We now have a pretty good idea of how to actually grow the neural fibers of mindfulness … http://bigthink.com/21st-century-spirituality/how-contemplation-changes-our-brains-for-the-better

    • Marc June 28, 2014 at 3:33 am #

      This is a cool article. I’ve also written about brain changes related to meditation in this post. In fact both the areas this author mentions are part of the “default mode network” — and that’s the system that shows reduced activation with meditation practice.

      • Valeria June 29, 2014 at 4:36 am #

        Hi Marc,
        you have also written that our increased focus on “now” can alter our habit, redirect our memories, and clarify perception and action…and that, meditation icreases our self control!!!
        I don’t remember in which post you have written about the ‘first step’…about the defaut mode network…that you consider crucial in the development of an addiction behavior…maybe your most important intuition!!!
        Thank again for your post!!!

    • Fred June 28, 2014 at 1:18 pm #

      To me, this article speaks to the potential role of meditation in reducing some of the stress responses that might trigger addictions. In that way, meditation – an intentional contemplative practice – should certainly be considered a useful “refocusing” activity. It not only puts us on a cushion (instead of engaging in our addictive rituals), it may actually calm the distress that triggered the addictive cravings in the first place.

    • Waylon June 30, 2014 at 11:54 am #

      Thanks for sharing! This is a great article!

  2. Cheryl June 27, 2014 at 2:33 pm #

    Mindfulness is a transforming practice. I think the first practice of mindfulness in moving one forward is choosing to redefine how it is you are defining yourself, your worth, your past, your possibilities in the future. Mindfulness is re-writing the story of who you really are rather than replaying the story of who you think society, friends, family, YOU….think you are. Fact is there much about each of us, our past and future that is beyond brilliant that is beyond worthiness.

    • Fred June 28, 2014 at 5:10 pm #

      Hi, Cheryl: I agree that mindfulness can be a gateway to becoming aware of the stories we tell ourselves about the world and our place in it. It’s very hard to change our behavior today if we believe a story that the future can’t get any better. As you point out, with mindfulness we can see the thought for just what it is – a thought – and we then have a chance to “recreate” (step 5) a new story that is consistent with a life free of addictive distraction.

      • Marc July 5, 2014 at 5:16 am #

        Yes, that’s an incredibly important benefit of mindfulness/meditation. Forging that connection between the present self (helpless, addicted fuck-up) and a future self that is fundamentally different…is very difficult. I’ve emphasized this in talks, but it’s hard to get across HOW difficult. The problem is that the future self who isn’t an addict, who is living a different kind of life, feels almost like a stranger — an arbitrary character in a novel — not an extension of WHO I AM right now. Whereas, conversely, the extension of the present self you place in the future — and I mean even next week — is still some version of an addict, still a disappointment, still helpless.

        It’s an imaginary leap to connect these two personae…also a leap of faith. Some kind of self-trust, inner warmth, self-acceptance is so important to bridge the two. And M/M is one of the only ways I know to help make it happen.

  3. Marc June 28, 2014 at 3:18 am #

    Although I see the value of considering these five steps as steps, I guess I think of them more as a cluster or cycle of conscious activities rather than a sequence. For example, the first two steps do indeed include some kind of mindfulness, but that can come after rather than before the Refocusing step. In fact, often refocusing allows us the time and space to consider how we label and attribute these feelings. Sometimes you have to change lanes first and then think about where you’ve been and where you’re going.

    So I see it more as a cycle of mental acts that can lead in a sort of spiral out of addiction, given a bit of time and a bit of luck.

    • Fred June 28, 2014 at 5:21 pm #

      Each of these steps can interweave, though as created by Schwarz and expanded by Maté, they were suggested to be a cook-book kind of process – applied by the OCD sufferer, or addict, in the moment, as described. It’s actually recommended to keep a journal and work through these steps daily and whenever triggers arise, recording thoughts about each of the steps and what “refocusing” actions were taken. I think such a rigorous, rules-based approach can be very helpful in early recovery – don’t think about it, just do these 5 Rs, in order. But, as sobriety becomes the new normal, one can call on any one of these at any point and use that to strengthen recovery, or bring a new richer life to reality.

      • Marc July 5, 2014 at 5:20 am #

        Good, I can see this. It’s really not that different from learning to play an instrument. First you practice your scales, then put them together in a more complex and rich exercise, then practice a piece that you already know, then start working on the next piece, the one you don’t know yet. You can repeat these steps each time you sit down to play. But they do form a sequence. And after some practice, you can move quickly into the later steps, whereas, at first, you didn’t get much beyond the basic exercises.

  4. Matt June 28, 2014 at 8:00 am #

    Fred, thank you SO much for this. What an elegant description of this most inelegant process. I agree with Marc. It’s a cycle and a process we are constantly going through— another reason it’s so confusing. This intermix of rational thought and contradictory desire (wanting to quit+wanting to use). But any of the relabeling, etc can help because it reframes and objectifies this stuff making it more manageable psycho-dynamically. We continually move from controlling impulsivity (acute), developing awareness of triggers and other pitfalls (post acute/early recovery) to examining our own developmental processes that led to the addiction to begin with. Then we become better able to work on them (understanding, “normal” life, “recovery”). They are concentric circles expanding out that meditation and mindfulness help us get a better handle on. It’s sort of like the discovery Dorothy makes in the Wizard of Oz: “if I ever go looking for my heart’s desire again, I won’t look any further than my own backyard; because if it isn’t there, I never really lost it to begin with” Is that all there is?”
    That’s all there is. We just have to make our way back to Kansas…

    • Fred June 28, 2014 at 5:33 pm #

      Thanks, Matt. I agree that one’s relationship to this 5 step process changes over time. In the acute stage, it’s all about stopping the behavior. Interestingly, though, withdrawal can be a time of intense insight. Because the anesthetic effect of the addiction is off, a lot of strong emotion can come up, and unresolved pain, anger and grief can come to the surface, pointing the way toward the deeper work of those outer circles.
      I like your Dorothy quote. In our addiction, we sought out the perfect score, the highest high. Sometimes, in recovery, we can get caught up in whether our sober life, and relationships, are as they “should” be, so we go looking off into a different Oz, trying to find the magic mix of meetings, sponsors, new friends, new jobs, new lovers. And our pursuit again is chasing mirages. Mindfulness allows us to sit with life, just as it is, and keep at it, even when it’s boring and uncomfortable. At some point, we might come to love it, just as it is.

      • Matt June 30, 2014 at 6:12 am #

        Thanks, Fred. Yes I’ve noticed in many meetings mindful ness has become a helpful adjunct. People have to go through what they have to go through to piece together their own recovery plan, but with meditation it becomes more focused, and often accelerated as a result. It helps identify troublesome thoughts and feelings more neutrally, as well as better process what happened in their meeting that was meaningful to them. I think just going home more relaxed bolsters this positive effect as well. It’s never good to leave a meeting more anxious than when you came in..

        • Fred June 30, 2014 at 6:00 pm #

          I’ve been encouraged by the work of Marsha Linehan, creator of Dialectical Behavioral Therapy, which trains clients in mindfulness without stressing meditation. This is a plus for people who can’t or won’t “meditate”. DBT emphasizes 3 “what” skills (observing, describing, participating) and 3 “how” skills (non-judgmentally, one-mindedly, effectively/intentionally). This framework can help even those folks who find “meditation” difficult to do.

  5. Mark June 28, 2014 at 9:40 am #

    There’s a free online MOOC Coursera course happening right now on The Addicted Brain for anyone on the list who might be interested. It’s offered by Michael Kuhar at Emory University: https://class.coursera.org/addictedbrain-001/quiz/feedback?submission_id=10215

  6. jasmine June 29, 2014 at 4:16 am #

    Hi “Fred” and Others:

    What a great post! Gratitude your way ;)

    If I understand correctly, and I believe Marc (you) touch/es on this: moving out of addiction is about supplanting. I was actually just talking (seriously, with my Mom ;) about how smoking marijuana (which I don’t like now – at all – and know its a depressant), helped me quit smoking. Those few puffs of a joint for a lil while did really “work” – at least for me.

    Perhaps more importantly, there is so much talk – and now compelling science – about how addictive substances can alter neural pathways and transmitters (if that is the correct terminology). Knowing this, and having lived some of it, I just find it a stretch for anyone to “come down” without some real struggles of basic functioning, let alone (mindfulness) meditation, or journalling.

    I recently saw a pin (Pinterest) that said: “It’s okay if all you did was breathe today.” So, how about some concrete suggestions – ones that can seem “do-able” at different stages of the “recovery” process? Foods, herbs, short (mental) exercises and activities that grow in depth and breadth over time? I totally realize there is not a “one size fits all” approach to anything, though surely some remedies etc. have more supporting evidence than others…

    So, maybe after one can feel okay with simply breathing, they can think about what to eat etc. and stretch their inner elastic from thereon ;)

    • Fred June 29, 2014 at 9:36 am #

      Thanks, Jasmine. Your story is a great illustration of refocusing/supplanting. I’m hoping other readers will respond with some of their favorite supplanting activities – things that have worked for them and others whom they know.

      There’s a nice piece of AA literature called “Living Sober” which provides 30 short essays on handling challenging situations – everything from what to do when offered a drink at a party to using hard candy as a substitute for the act of drinking. Many of the things it talks about are supplanting (or refocusing) activities.

      I used to work at a high-tech company which provided free soft drinks in every break room. I got into the habit of having one of these several times a day. After some years of this, I had put 4 inches on my waistline, and eventually decided that I’d had enough. My very first step toward losing weight was giving up the sugared drinks. But, importantly, I didn’t give up my habit of grabbing something cold to drink several times a day. I just switched from Pepsi (my drink of choice) to cans of (zero calorie) sparkling water. I began to lose weight and feel better, and that set in motion a process where I lost over 50 pounds over the next several years. And it all began with supplanting Pepsi with sparkling water.

  7. Robin Roger June 29, 2014 at 12:10 pm #

    I am a great admirer of Schwartz for his creative adaptation of mindfulness and often reflect on the profound implications of following these steps. The only aspect of it I would consider adjusting is the use of the word “distract” as it has an association to conditions such as ADHD, and is generally thought of as a non-volitional state. Willful redirection of attention seems to me to be slightly different. I apologize for being hair splitting, but something like “shift attention and refocus” might be more helpful.

    • Fred June 29, 2014 at 6:56 pm #

      Excellent point, Robin. This is indeed a process of intentionally directing attention and behavior away from the addictive thoughts and rituals, so “distraction” isn’t exactly the word. Perhaps that’s why Schwarz chooses “refocus” (and it fits in with the “R”s)!

  8. Jehu Pole July 1, 2014 at 11:15 pm #

    If I understand correctly, and I believe Marc (you) touch/es on this: moving out of addiction is about supplanting. I was actually just talking (seriously, with my Mom ;) about how smoking marijuana (which I don’t like now – at all – and know its a depressant), helped me quit smoking. Those few puffs of a joint for a lil while did really “work” – at least for me.

    • Marc July 5, 2014 at 5:31 am #

      That’s an interesting “alternative” example, Jehu. Although I hesitate to say this on an addiction blog, I don’t see anything fundamentally wrong (morally or practically) with using one drug — temporarily, we hope — to help get you off another one. Drugs do serve to distract, supplant, refocus, etc. Which is partly why we use them to escape our painful emotions. But they can also serve as the kick-in-the-butt people need to help them out of a deep rut.

      The principle fits (loosely, at least) the harm reduction perspective. But it’s quite a bit different than, say, methadone maintenance, because it isn’t just more of the same, more safely packaged.

  9. Jaliya July 6, 2014 at 1:07 pm #

    Reading all this, I think … NAB IT! — Nab that first trigger as it’s emerging from the brain into waylaying thought … Today I noticed that the first trigger of my morning was making a cup of tea. Cigarettes are my killing thing … Somewhere between firing up the kettle (hmm — “firing up!”) and reaching for a tea bag, there it was, that hook … that autopilot urge, that assumption, that surge of dopamine, the rush to get through the tea-making for a smoke. NAB IT!

    Amazing that something so ephemeral, so intangible — one thought — can feel to us like a cement belt that sinks us in a second. I tell myself: DON’T PUT ON THE BELT. Refocus … refocus. MOVE. One of the great teachers of somatic education, Moshe Feldenkrais, kept saying, “Movement is life.” ~ That, and “One step at a time” as a literal phrase … Getting off our backsides into actual movement relays an entirely new directive through the whole person … I find this by getting out and walking … and sometimes (especially if the weather’s lousy) just standing up and walking in place while I watch and listen to a directed meditation or a talk (like yours, Marc :-) ) … sometimes I’ll play music of a certain rhythm, and say NO with every step. I often read pages 294 – 297 of your memoir to give myself a reminder of that NO you first said to yourself … for a ‘hit’ of that “wisp of self-love” you write of … for embodying possibility in every such step taken out of the old trance.

    Jasmine wrote above of a saying: “It’s okay if all you did was breathe today” — I think, “One breath at a time” — a steadying ground for my own refocus. For anyone whose addiction comes in the form of an inhalant, “One breath at a time” is a lifesaver.

    Thanks to all for your thoughts, your courage, your insistence on staying the course … there’s a depth and transparency of dialogue here that I’ve not seen anywhere else.

    • Fred July 19, 2014 at 10:18 pm #

      Jaliya, I appreciate how you have brought the notion of physical movement into the discussion (along with your emphasis on becoming aware of those little thoughts that can become so powerful). Physically getting away from the triggering environment or stimulus can be very helpful. Even better, you add a healthy activity in its place. That’s what refocusing is all about.

    • Marc July 20, 2014 at 9:07 am #

      Hi Jaliya, What a beautiful little poem of a comment. And I’m very much honored that you go to a passage in my book for that kind of inspiration. I have nothing much to add, except to say, check out the last or almost-last comment by Peter in the previous post. He says that quitting rides on diversity, or movement, over a landscape of possibilities…at least that’s one way of putting it. And your emphasis on movement, both mental and physical, corresponds perfectly. His exact words:

      There are…

      ““wonderful little packages of golden learning opportunities within everything, including the recovery choices people make”

      Great way to end the “season” and I hope you come back in September.

      Good luck with your NABBING!
      Cheers,
      Marc

  10. George August 13, 2014 at 2:37 am #

    I am writing this today, as so much of the news is about Robin Williams.
    There is much to ponder.

  11. shane watson October 13, 2014 at 12:37 am #

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