I Strong-Arm My Attention to Help Myself Not Use

In the moment when a longing to use a problematic substance arises, or the opportunity to use it appears, if I can become aware of my longing, strong-arm my attention away from my longing and toward my preferences, I can increase my chances of not using.

If I have substance use disorder, why a longing arises has complex origins. In the moment, I don’t have time to figure any of that out. I can endanger myself and others with a return to use. I need something to work for me right now.

Scent of rosemary can draw attentionThe ability to use one’s attention with gentle but intentional force may be a fundamental skill for preventing a return to use. I draw that conclusion from my relentless review of the research on addiction, my professional training, my observation of the experience of others, and my personal experience.

To set myself up to be able to use my attention with intentional force:

  1. I need to gain awareness, in the moment, of my longing to use.
  2. Prior to the moment of the longing to use, I need to have already collected the data described below, practiced the skills, and trained with that data.
  3. In the moment, I need to skillfully use the process described below to give my best attempt to help myself not use.
  4. Repeat.

“Indeed, lack of awareness of substance craving has been shown to be predictive of future relapse.”
Garland, et al., 2013

Awareness

I practice on-going awareness of what’s going on with me so I can instantly become aware – in the midst of the wonder and complexity of being me in this astonishing world – of a longing to use. To do this, I focus on my feelings, thoughts, physical sensations, and actions.

I ask myself:

  • “What am I feeling?”
  • “What am I thinking?”
  • “What am I sensing?”
  • “What am I doing?”

Further help with practicing awareness:

Data

List 1: Real-Time Sensory Experiences

I need to be able to shift my attention from substances and using to something else. Any old thing will not do. Our preferences make us gloriously ourselves and have the power to draw our attention. The brain is particularly called by sensory experiences. I need to discover and know my preferences, starting with sensory preferences.

What do I prefer to see, hear, taste, touch, and smell? What motion do I prefer to observe?

Worksheet: Discovering My Sensory Preferences. Printable .pdf opens in a new tab. More handouts are here.

One easy way to get started with answering these questions is to take “sensory tours.” I’ve taken sensory tours of my kitchen, living space, yard, a department store, and my town. I become aware of several things I prefer within each sensory category. Then I rank order my options. What would I most prefer for that sense? What would be my second choice? I try to keep at least one of these top-ranked, preferred sensory items with me.

List 2: Imaginary Sensory Experiences

In the moment of longing, I may not have my preferred sensory items at hand. I may not be able to get them. So, the additional data I need to collect is an imagined set of sensory preferences.

If time, space, and money were of no concern, what image would I love to see? What sound would I love to hear? What would I love to taste? What texture would I love to feel? What scent would I love to smell? What would I love to see in motion? I keep a mental list of these sensory experiences.

List 3: What’s at Hand

I may feel flooded with longing, feel alarmed by its intensity, and be unable to remember my sensory items. I look around at my surroundings. I ask myself, “What is my preferred sensory item here?” I engage my attention with it.

List 4: The Breath in My Nostrils

If I’ve got nothing at hand, or I’m in a particularly threatening situation, I may need to shift my attention to the ever-present sensory experience that I own: the sensation of air in my nostrils as I breathe. Taking deep breaths can trigger panic and offer a “tell” about my distress to those I don’t trust. I can engage my attention with the sensation of the air in my nostrils with even the tiniest breaths.

Skills

Here’s the sequence for how to gain muscular control of attention:

  1. Become aware of my attention on that.
  2. Disengage my attention from that.
  3. Shift my attention to my preference.
  4. Engage my attention with this preference.

Become aware > Disengage > Shift > Engage

To have this happen automatically, I need to practice the sequence and train my attention.

I collect some of my preferred sensory items. I put them on a table or on the floor in front of me. I become aware of my attention on one item. I imagine having my hand lightly on the top of the item. I give it my full attention for a moment. Then I disengage my attention from the item by imagining opening my hand. I shift my attention by imagining my hand and arm moving in mid-air from that item to another item. I engage my attention with this item by imagining placing my hand on top of it. I give it my full attention for a moment. Then I disengage, shift, and engage, continuing to practice the sequence, moving from object to object.

Process

Here’s the inner dialogue for the process I use to bring together awareness, data, and skills, and practice when a longing arises or an opportunity to use appears.

  1. I have become aware of a longing to use.
  2. I acknowledge this reality with courage, self-kindness, and without judgment.
  3. I will now strong-arm my attention.
  4. I disengage my attention from longing, substances, and using
  5. I become aware of my preferences, either present or imaginary.
  6. I shift my attention to them, and I engage my attention with my preferences.
  7. When my attention is drawn back to longing, substances and using, I strong-arm my attention back to my preferences.
  8. I continue to strong-arm my attention until the longing passes, until I can get help from someone, or I can leave the situation.

In the moment, this straightforward, mechanical process, distilled from neuroscience findings on addiction and attention, might protect me from a return to use. Sometimes, strong arming my attention doesn’t work. That’s when research suggests I need to interrupt my neurobiology by splashing cold water on my face. If that’s not available, I can press something cool to my face, even if it’s my own cold fingers or the side of a pen. Then I can attempt to engage my attention sequence again.

To manage my longing for substances by managing my attention, the only self-analysis required is awareness of what’s going on within me in the moment. It requires no assessment of my past, my motivations, or my morals. The only inventory it requires is discovering what delights my senses, then making lists of my preferences. Practice and training can happen anywhere, anytime. The only equipment needed is imagination.

While some addiction treatment protocols recommend using distraction to interfere with craving, distraction is a symptom of substance use disorder.  Longing to return distracts me from my plans for my life. Distraction has too much power in my life already and tries to make me do what it wants. With the power of attention, I may be able to counterbalance this symptom and choose to do what I want. I can certainly rest my mind by watching TV, listening to music, or playing a video game, but I want my action to be a conscious choice resulting from me having given it my full attention.

When a longing arises and it’s showtime – on-demand, never scheduled – part of my performance will be limited by the changes my brain has undergone through addiction. I get that. I also get that my brain’s ability to exert will has been compromised by addiction. That’s going to hurt my efforts. Still.

If I can use gentle but intentional force on my attention, practice, train often and intensely enough to gain enough endurance to shift my attention over and over again, I might just be able to help myself not use.

. . . . .

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. However, when treatment is scarce or denied, people with addiction must take treatment matters into their own hands. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Addiction Recovery: Define Terms and End Conflation

People with addiction are at risk of premature death. Defining terms and making sure we know what we’re talking about is an imperative.

Illogic and misinformation can kill people with addiction.

Do no harm. 

Discussion of addiction is plagued with conflation, i.e. thinking things are the same when they are different. Discussion is also compromised by confusing correlation with causation, i.e. assuming that if things happen at the same time, one caused the other.

Definition of conflationFollowing is a list of terms and basic definitions used in this guide. Terms are in narrative order, not in alphabetical order. Terms explicitly not used are listed at the foot of this post.

Addiction is the generally-used, non-clinical term for substance use disorder.

A substance use disorder is a medical condition involving the organ of the brain. The primary symptom of the disorder is persistence in behavior despite negative consequences. (For brevity and the general audience intended for this guide, “addiction” is the term used most often, but interchangeably with “substance use disorder.”)

Dependence is conflated with addiction. The difference between addiction and dependence can mean life or death. Dependence exists when a substance is needed to function and physical withdrawal symptoms will result without the substance. Humans are dependent upon the substances of water and air to function and experience physical symptoms without them. People who cease taking antidepressants can experience withdrawal symptoms. People who cease taking blood pressure medication can experience withdrawal symptoms. People who do not persist in negative consequences, but experience withdrawal symptoms when ceasing substances, are not addicted to those substances.

Similarly, babies born to mothers dependent on substances – whether opioids, antidepressants, nicotine or others – may experience withdrawal symptoms, but are not born addicted to those substances. Babies are developmentally incapable of persisting in behavior despite harmful consequences.

Making it through withdrawal from substance dependence is not a treatment nor a cure for addiction.

The neuroscience of addiction suggest that through compromising the brain’s basal ganglia, extended amygdala, and prefrontal cortex, addiction under-sensitizes people to pleasure, over-sensitizes them to pain, automates use of the substance to feel, not necessarily good, but normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

Co-occurring disorders are medical – including physical illnesses and substance use disorders – and mental illnesses, that may occur simultaneously in an individual. The medical condition of substance use disorder may co-occur with mental illnesses such as anxiety, mood, and or personality disorders, and/or physical illnesses.

Determining which symptoms go with which disorder, how to manage symptoms, and treat the conditions, is an on-going conundrum. Which are due to brain malfunctions, cognitive distortions, perhaps unregulated emotions?

Further, the definition of addiction is conflated with the symptoms of the illness. Although some people with substance use disorder may engage in behaviors that are perceived by society to be immoral, criminal, or illogical, behavior related to addiction results from brain functioning, not from moral functioning, and persists despite negative consequences. Ergo, moral or religious instruction would not be a treatment for a brain disorder. Counseling might help a person with substance use disorder manage symptoms of the illness, but would not directly treat the brain for a brain condition.

Evidence-based treatment is what research reports works for most people, most of the time, better than other treatments, and better than no treatment. Specifically, that means the treatment is supported by numerous, peer-reviewed scientific experiments with rigorous methods that include control groups, randomization of subjects to experimental conditions, and bias-free samples, with statistically significant results. Some treatments that are evidence-based to work for groups may not be helpful to a particular individual, however. It is imperative that individuals engage their treatment teams to continually monitor their condition and progress.

Anecdotal data is an individual’s personal experience. Research data – the evidence resulting from research experiments – is conflated with “anecdotal data.” Data from a sample size of one does not provide sufficient information from which a generalization can be made about a group or population. Principles believed to account for outcomes from inspirational individual stories, practitioner wisdom, or theories based on logic, cannot be safely applied to others without first subjecting those principles to rigorous research.

Medical care is the first line of treatment recommended by the medical professionals and researchers who authored Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health. Medications approved by the FDA for treating substance use disorder are listed here. Currently, no licensed treatments are available for stimulant use disorder.

Terms not used in this guide:

Addict and alcoholic. The complexity of human identities defies the limits of definition by trait or condition. This guide, as does the new edition of the Associated Press style manual, uses the terms “person with addiction” and “person with alcoholism.”

Substance abuse. “Abuse” means to wrongly maltreat. “Self-abuse” is a pejorative term for masturbation. “Sexual abuse” and “child abuse” are heinous acts. Use of the term “substance abuse” conflates addiction with sexual acts and violation, misrepresents the medical illness of addiction, perpetuates stigma, and needs to be jettisoned from any reference to addiction.

Disease. Although carefully defined by NIDA, the term “disease” used to explain addiction can be unhelpfully misunderstood by laypeople. Scientists and researchers may decide other terms may be more accurate. Terms used in this guide include “disorder,” “condition,” and “illness.”

Dopamine. The neurotransmitter dopamine is conflated with “pleasure.” But dopaminergic pathways involve reward-related cognitions that include incentive salience (desire or “wanting”), pleasure (“liking”), and positive reinforcement, i.e. a desired event occurs. Most laypeople are not qualified to discuss addiction at this level. Addiction is more complicated than simply stating, “It’s all about dopamine.”

Enablingcodependency, “hit bottom,” and “tough love.” People with medical illnesses that can result in premature death need care, support, and treatment, especially when their symptoms are severe and life-threatening. For further reading:

Trading one addiction for another. Use of substances, for any reason, prescribed or not, where behavior does not persist despite negative consequences is not addiction.

. . . . .

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
– National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), 2014

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
Nora Volkow, M.D., Director of NIDA, 2015

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt, Ph.D., 2004

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”, 2016

“It’s my life. Don’t you forget.”
– “Talk, Talk,” The Music Machine

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. However, when treatment is scarce or denied, people with addiction must take treatment matters into their own hands. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Addiction Recovery: Realities and Possibilities

The goal of an evidence-based treatment plan for the medical illness of addiction would be to assist individuals in living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society.

A glass half fullHowever, society’s primary measure of recovery from addiction – and its measure of merit to receive continued treatment for addiction – is negative urine drug screens for illicit and non-prescribed substances. Secondarily, society measures addiction recovery progress in terms of reduced contact with 1) the criminal justice system, 2) emergency health care services, 3) child protective services, and 4) social services programs.

Achievement of legal negative urine drug screens requires abstaining from illicit and non-prescribed substances. (The illogic and injustice of citizens with a medical illness being required to prove they are asymptomatic of that illness to receive treatment for it is beyond the scope of this post.)

After medical care for the medical condition of addiction, this is what research suggests helps most people, most of the time, better than other ways, and better than nothing, to increase the likelihood of abstaining from substances:

Maintain a state of stability: physically, emotionally, cognitively, relationally, spatially, geographically, financially. Practice on-going awareness and, if any factors become unstable, adjust until they’re stable again.

Regulate emotions. Without judging feelings, adjust the “volume” on the intensity to a stable state while providing self-acceptance, self-reassurance, and self-soothing.

Sort thoughts, without judging them, into the categories of “helpful” and “unhelpful.” Focus on the “helpful” thoughts. Recognize and accept that opposing thoughts – for example, “I want to use” AND “I don’t want to use” – may both be true.

Consult your inner wisdom, your “Wise Mind.” Having given your attention to the truth of what you’re feeling, thinking, and sensing, what is your inner wisdom’s guidance?

Manage attention. Become aware and stay aware. Monitor your needs and wants. If you can become aware, in the moment, of what you are giving your attention to, what you are feeling, what you are thinking, and what physical sensations you are experiencing – and do so without judgment and without alarm – you can use this information to help yourself decide what would be most helpful for you to say or do next – or not say or not do.

Monitor environmental cues. Limit or eliminate exposure to items, individuals, locations, and situations that may produce a longing to return to use.

In addition:

Over time, identify the purpose and meaning of substances and substance use in your life.

Over time – acknowledging that no one source, perhaps even combinations of sources, might ever equal the complete experience substances offered – identify possible practices, activities, and conditions that might serve in place of substances.

Do research, consult with others, and discover evidence-based, therapeutic modalities recommended for any mental illness you might have. Help yourself with any trauma you may have experienced. Do self-paced therapeutic exercises, or receive counseling for that particular disorder. Examples: cognitive behavior therapy for depression; dialectical behavior therapy for bipolar disorder.

Attune to yourself, learn your preferences, and attach to yourself.

Attune to others to increase the possibility of connection, closeness, attachment, and bonding.

. . . . .

Here is a shortened version of this post as a printable handout. (.pdf opens in a new tab.)

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. However, when treatment is scarce or denied, people with addiction must take treatment matters into their own hands. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

When Replacing Substances, Good Enough Will Have to Do

When the rung on the bottom shelf of my refrigerator broke, I bought a roll of white duct tape and, as carefully as I could, cut short lengths of duct tape to hold it back in place. I will not win a repair design contest. It’s not “good as new.” The shelf can no longer hold heavy items. But I treasure sandwiches for lunch. Plastic jars of yellow mustard and light mayo reside there reliably. Good enough will do.

Good enough will do

Similarly, if I need to abstain from problematic substances, if I can figure out what purposes substances served for me – what needs and wants they filled for me – I might be able to find replacements for them. Since addiction is a brain condition requiring medical care, this effort is unlikely to have a direct, immediate effect on my brain’s functioning. Figuring out the needs and wants that substances assisted me with may not cover the full scope of, or explanation for, my initial or repeated substance use prior to developing addiction. But understanding what substances did for me may help me with my self-care efforts.

Since substances can magnify experience beyond what the brain naturally experiences, I’m unlikely to find identical, snap-in substitutes. Given the interrelated neurocircuitry of love and addiction, this reality creates a deep loss to grieve. While no analogy is perfect, the idea of finding good-enough, duct tape-like replacements might be helpful.

What did substances do for me? Answering that question feels overwhelming! But analyzing my last return to use may help get me started. Let’s break it down.

First, here’s the usual information to gather when seeking self-understanding:

What was I giving my attention to, what was I feeling, what was I thinking, and what physical sensations did I experience?

Many people cannot remember what they were feeling and thinking just prior to use, so that data is usually missing.

Let’s try different time frames – 24 hours, 1 week, 1 month.

Answering these questions might be useful:

1. ATTENTION:  What was getting – perhaps splitting – my attention prior to my last return to use? 24 hours before? 1 week before? 1 month before?

2. FEELINGS: What was I feeling prior to my last return to use? 24 hours before? 1 week before? 1 month before?

3. THOUGHTS: What was I thinking prior to my last return to use? 24 hours before? 1 week before? 1 month before?

4. PHYSICAL SENSATIONS:  What physical sensations was I experiencing prior to my last return to use? 24 hours before? 1 week before? 1 month before?

5. AWARENESS OF NEEDS AND WANTS THEN: Having become aware of 1) what I was giving my attention to, 2) what I was feeling, 3) what I was thinking, and 4) what physical sensations I was experiencing, what needs and wants did I seem to have prior to my last return to use? 24 hours before? 1 week before? 1 month before?

6. SELF-KINDNESS AND SELF-CARE: AWARENESS OF NEEDS AND WANTS NOW: What needs and wants do I have now? What might I do to kindly and supportively help myself meet these needs and fulfill these wants?

7. What insights have I had as a result of doing this exercise?

8. In what ways can I continue to customize and individualize my treatment plan to help get my needs and wants met? Some good-enough, duct tape-like replacements, perhaps, may decrease the likelihood of my return to use.

The idea is this: If I can become aware, in the moment, that I have unmet needs and wants, strong feelings, intense thoughts, or physical sensations similar to those I experienced prior to past returns to use, I might be able to help myself with them without substances.

. . . . .

Here is a version of this post in the form of a printable handout. (.pdf opens in a new tab.)

If different substances served different needs, printing out multiple copies of the handout and answering the questions for one substance at a time might be helpful.

Last revised 12/7/17

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

About Abstaining

Rightly or wrongly, society wants people with substance use disorders to abstain.

Many factors interfere with abstaining from substances.

Art by Jesi Pace-BerkeleyAddiction is a brain condition, not a moral or criminal one. What an individual is supposed to do with his or her brain to abstain right here, right now, is unknowable. For most individuals and scientists alike, the brain is a black box of mystery.

Substances serve purposes. When the substances are absent, the purposes aren’t served. This absence is experienced as stress, distress, and suffering.

Humans need social connection to survive and thrive. Due to the brain’s automaticity with regard to environmental cues, abstaining usually requires cutting oneself off from anyone or anything that may trigger a return to use. Isolation is experienced as pain.

The brain has evolved to withdraw the being it inhabits from pain. Abstinence requires fighting the brain’s automatic function to relieve pain by returning to substances.

Negative consequences don’t work. Punishing an individual with negative consequences for returning to use – or an individual on his or her own trying to fear negative consequences to prevent a return to use – doesn’t work. That’s because the primary symptom of addiction is the brain’s drive to return to use despite negative consequences.

Addiction is a chronic illness. Who wants to chronically treat a chronic illness? Most people with chronic illnesses drop out of treatment, even quit filling their prescriptions for meds, and their symptoms return.

Humans naturally, normally, wondrously seek pleasure and avoid pain. Denying oneself substances can feel like self-inhumanity.

In sum, for people with acute substance use disorders, abstaining is nearly impossible, especially long-term. Relapse rates can be are high, similar to those for other chronic conditions. People with substance use disorders can be considered to be at risk for 5 years.

(Note that I didn’t even mention physical withdrawal from substance dependence. A mere annoyance compared to the anguish of the other factors.)

What tools can be helpful to people who need or want to abstain?

  • Stop putting energy into things that, according to research, don’t work for most people, most of the time, better than other treatments, better than no treatment.
  • Other than some medications for some substance use disorders, shrug your shoulders and accept that what directly results in abstinence is unknown. Indirect, imperfect means are all we know to try.
  • Use periods of successful abstinence to attempt to identify, personally and individually, what did work for you.
  • Jettison this punishing mindset: “I must make myself not use.” Research suggests that direct attempts are very unlikely to work, even help.
  • Adopt this generous mindset: “I can help myself not use.” Research offers a bounty of possibilities for practices that can, however indirectly and imperfectly, help people not use.
  • Learn additional methods and practices that help people abstain, experimentand find the ones that work for you.

Art by Jesi Pace-Berkeley

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.