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Mindfulness Implications For Substance Abuse And Addiction


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Mindfulness Implications For Substance Abuse And Addiction

  1. 1. Int J Ment Health Addiction DOI 10.1007/s11469-009-9199-z Mindfulness: Implications for Substance Abuse and Addiction Jonathan Appel & Dohee Kim-Appel Received: 16 November 2008 / Accepted: 28 January 2009 # Springer Science + Business Media, LLC 2009 Abstract Mindfulness is a concept that has taken quite a hold on the therapeutic world in recent years. Techniques that induce “mindfulness” are increasingly being employed in Western psychology and psychotherapy to help alleviate a variety of conditions. So while mindfulness has its conceptual roots in Buddhism it has been translated into a Western non- religious context. Mindfulness skills are now included as a technique for coping with urges to engage in substance use and relapse in addiction. The research at this date has not revealed the ultimate effectiveness of mindfulness for substance abuse and addiction. It might be that mindfulness is a helpful, but not a sufficient factor as a means to address substance abuse. The relationship between spirituality and mindfulness should be explored further. Keywords Mindfulness . Substance abuse . Addiction . Spirituality Instructions on mindfulness all point to the same thing: being right on the spot that nails us. It nails us to the point of time and space that we are in. When we stop there and don’t act out, don’t repress, don’t blame it on anyone else, and also don’t blame it on ourselves… we encounter our heart. Pema Chrodron (The Wisdom of No Escape) Mindfulness is a concept that has taken quite a hold on the therapeutic world in recent years. Mindfulness is a component that is a core concept within Buddhism, which is a 2500 year old tradition that began in India and spread and diversified throughout the Far East. Buddhism has been described as a philosophy, religion, and a spiritual practice that is followed by more than 300 million people and based on the teachings of the Buddha (Siddhartha Gautama). Mindfulness plays a central role in the teaching of the Buddha where it is avowed that “correct” or “right” mindfulness is an essential factor in the path to enlightenment, awakening, and liberation. It is the seventh element of the Noble Eightfold Path, which is a J. Appel (*) Department of Behavioral and Social Sciences, Tiffin University, Tiffin, OH 44883, USA e-mail: D. Kim-Appel Firelands Counseling and Recovery Services, Tiffin, OH 44883, USA e-mail:
  2. 2. Int J Ment Health Addiction system of practice designed to alleviate suffering. Mindfulness is a mental state, characterized by concentrated awareness of one’s thoughts, actions or motivations. Techniques that induce “mindfulness” are increasingly being employed in Western psychology and psychotherapy to help alleviate a variety of conditions. So while mindfulness has its conceptual roots in Buddhism it has been translated into a Western non-religious context. Kabat-Zinn (2003) suggests that mindfulness skills may be a helpful practice for a culture that may not wish to adopt Buddhism, but seeks techniques to relieve stress and adapt in healthier ways. Both metal health practitioners and researchers have been advocating mindfulness practice into mental health treatment programs and usually teach these skills without the religious and cultural traditions of their origins (Linehan 1993; Kabat-Zinn et al. 2002). While Mindfulness and meditation may have its roots in Buddhism, it may also be a component of other spiritual or religious traditions as well. In Christianity there are many practices, which can be viewed as forms of meditation or mindfulness practice. Christian meditation is often expressed in the form of prayer. Monastic customs often seek a turn inward and involve practices of intense prayer, rosary, and adoration of the Eucharist. Many have also compared the Eastern Orthodoxy tradition of the hesychast practice of focusing one’s attention on an individual object to a direct form of meditation or mindfulness. Philokalia can be seen as a form of a meditation of the heart, which leads towards Theosis, whose goal is to ignore the senses and achieve an inner stillness (Hierotheos 1998). It is also quite easy to recognize meditative practices in Judaism. There is ample evidence within the Tannach (the Hebrew Bible) that meditation was a key practice of the prophets (Ribner 1998). Kabbalah is also inherently a meditative field of religious or mystical study. One could also make the case that meditation is the core of Islam and Muslim mystical traditions (particularly in Sufism). The Muslim prophet Muhammad reportedly spent long periods in contemplation and meditation. It was during one such period of intensive meditation that Muhammad purportedly received revelations that formed the Holy Qur’an (Nigosian 2004). Meditation in Islam includes the concepts of “Tafakkur and Tadabbur,” which literally means “reflection upon the universe.” Thus, in many spiritual and religious traditions, meditative practices often provide a key access point to the divine. What is Mindfulness? But what is mindfulness? Mindfulness can be viewed as an effort to intentionally pay attention, non-judgmentally, to one’s present-moment experience and sustain this attention over time (Kabat-Zinn et al. 2002). Mindfulness is a cognitive strategy that develops a perspective that cultivates the recognition of thoughts and feelings as passing events created in the mind. By practicing the skills of moment-to-moment awareness, one seeks to gain insight into patterns in thoughts, feelings, and interactions with others, and then one can skillfully choose helpful targeted responses rather than automatically reacting in habitual, overlearned or unconscious ways (Teasdale et al. 2000). The aim of mindfulness is to cultivate consistent and non-reactive present moment awareness or directed attention. Our brains may be limited in the number of tasks we can do simultaneously. If one tries to do several tasks at the same time the brain may be limited in its efficiency. The classic example is the too often occurrence of talking on a cell phone while driving. This example like other multi-tasking events requires several different areas of the brain to be used. This multitasking can produce slower response times than if each task were done separately (Marois and Ivanoff 2005). Rather than double the amount of brain areas being activated, the amount of brain activity for each task is reduced considerably. Mindfulness allows for a more useful and
  3. 3. Int J Ment Health Addiction powerful use of directed brain activity. Mindfulness has also been shown to activate the medial prefrontal regions, which play a prominent role in two fundamental aspects of self-referential processing and perspective taking (Siegel 2007). Implications for this include an increase in empathy, a better sense of self, as well as a decrease in self obsession. Psychological suffering is generally associated with a heightened degree of self-focused attention. Mindfulness would perhaps help with the self/other in a balanced attention. Mindfulness meditation is different from “relaxation” meditation in a number of ways. As in relaxation meditation, one attends to the breath or bodily sensations, but in contrast, mindfulness meditation brings more of an acceptance to the distracting thoughts and emotions that emerge when one is still. Even when the experience is unpleasant, one is taught to observe or investigate the experience rather then try to dispel it. This type of response is referred to taking a “decentered” perspective or as “cognitive distancing” (Breslin et al. 2002; Hayes et al. 1999; Teasdale et al. 1995). But a common theme across meditation approaches is the desire to deepening one’s attention and awareness, refining them, and putting them to greater practical use in our lives. Meditation is intentional, systematic, human activity which is not about trying to improve yourself or go anywhere else, but to realize where you already are. Wherever you go—there you are! (Kabat- Zinn 1994). Mindfulness is but one of many of the approaches that may be available to us. Empirical Literature on Clinical Usefulness of Mindfulness If one reviews the current empirical literature on mindfulness, one can see that clinical interventions based on training in mindfulness skills are increasing at an escalating rate. Salmon et al. (1998) note that over 240 hospitals and clinics in the US and abroad were offering stress reduction programs based on mindfulness training. A search in the PsyInfo database of psychological peer-reviewed writings with “Mindfulness” as search term reveals that from 1980–2000 there were 83 articles/dissertations, while in the period of 2000 to the present there were 557 articles/dissertations on the topic. Mindfulness-based principles have also been infused and framed into a psychological intervention called “Acceptance and Commitment Therapy (ACT)” (Hofmann and Asmundson 2008; Eifert and Forsyth 2005; Hayes 2005). ACT is a branch of cognitive- behavioral therapy that uses acceptance and mindfulness strategies, with behavior change strategies, to increase psychological adaptability. Mindfulness training is also infused within dialectical behavior therapy—an empirically supported approach to the treatment of borderline personality disorder. Recent reworking of DBT includes it as an intervention for substance abuse (Dimeff et al. 2000). There is some empirical literature on mindfulness training which suggests that interventions infused with mindfulness practices may lead to an increased coping with a wide range of problems, including emotional regulation, stress, anxiety, depression, and pain management, and more recently substance abuse (Teasdale et al. 2000; Kristeller and Hallett 1999; Shapiro et al. 1998; Kabat-Zinn et al. 1992). Mindfulness and Substance Abuse Relapse prevention is a cognitive-behavioral skill approach that has been successfully used to treat and prevent substance abuse relapses (Marlatt and Gordon 1985). Mindfulness skills are now included as a technique for coping with urges to engage in substance use and relapse in addiction. Larimer et al. (1999) observe that mindfulness involves the acceptance
  4. 4. Int J Ment Health Addiction of the present moment, whereas addiction is the repeated desire to avoid the present moment, which contributes to the “urge” to use. Marlatt’s concept of “urge surfing” is used as a metaphor to help a client cope with the desire to use alcohol and drugs. Bowen et al. (2006) empirically tested the use of Vipassana meditation, “a Buddhist mindfulness-based practice” in an incarcerated population and found participants showed significant post- incarceration decreases in alcohol and drug related problems. Some initial data is supportive of a mindful relapse prevention approach, but more research is needed. While cognitive-behavioral approaches to alcohol and drug abuse disorders have been researched and empirically supported over the past few decades—substance and addiction treatment remains a heavy demand worldwide. As non-western countries adopt western influenced cultures-this demand may only increase. Drug abuse and drug trafficking have been increasing in India, Korea, Japan and China at alarming rates. The United Nations Office for Drug Control and Crime Prevention (UNODCCP 2003) recently reported that over 200 Million people worldwide are current users. The United Nations reports that, overall, the global drug problem continues to spread in geographical terms as more countries report increases rather than decreases in drug abuse. It is interesting to note that cultures that have originated mindfulness are the ones now having the largest increases in substance abuse problems. Further examination of this phenomenon would be warranted— if one is to understand worldwide trends, and how westernized thinking, as well as mindfulness could influence substance abuse on a global basis. Hopefully we are not importing cultural illnesses with our western practices. But perhaps these cultures have the potential to quickly address these personal and collective ills if they utilize their inherent and cultural wisdom that is at their access. Mindfulness as Separate from Spirituality? Carl Jung said: “Spirituality is an essential ingredient in psychological health.” Jung also wrote to Bill W, one of the founders of AA. “Your craving for alcohol was a spiritual thirst for wholeness, (an attempt at a) union with God.” Jung reminded us that “alcohol,” in Latin is spiritus, the same word for “spiritual experience” (Miller 1990). Many practitioners and recovering addicts have long believed that spirituality is an important part of a person’s life, and has great implications for health including substance abuse and dependence. It does appear that there is an increasing acknowledgement of this in the scientific research. Miller (2000) describes his journey of “coming out of the closet” as a psychologist interested in spirituality. But, there is a conceptual problem that currently exists in the literature. There is a confused understanding of the relationship between spirituality and substance abuse/dependence and a failure to distinguish spirituality from religiosity. These terms are often used interchangeably which results in construct merging and confusion. This same sort of construct confusion and overlap may be also occurring with mindfulness. Leigh, Bowen and Marlatt (2005) suggest that spirituality and mindfulness may be separate constructs. In their study of substance abuse, mindfulness and spiritual and substance abuse, they found substance using and abusing behaviors were negatively correlated with scores on a spirituality scale. As spirituality scores increased the use of alcohol and tobacco decreased. The found this relationship was not true for mindfulness. Thus, spirituality may be related to decreased substance use, not mindfulness. Alterman et al. (2004) in a study provided 8 weeks of mindfulness meditation (MfM) training and practice to a randomized group of 18 recovery house patients in addition to their standard
  5. 5. Int J Ment Health Addiction treatment. There was little indication that the MfM training resulted in more favorable outcomes than were found for a randomized group of 13 recovery house patients who received just standard treatment. It might be that mindfulness is a helpful, but not a sufficient factor as a means to address substance abuse. The relationship between spirituality and substance abuse should be explored further, as should the relationship and differentiation between the constructs of mindfulness and spirituality. Pardini et al. (2000) found that for those recovering from substance abuse, higher positive outcomes were achieved by clients that had higher levels of faith and spirituality. This study found that recovering individuals who rate themselves as being more spiritual than religious had better outcomes. The study suggests that spirituality contributes to a more optimistic life outlook whereas religious faith acts as a buffer to stress. However, the concept of spirituality and how it differs from religiosity remains an area that needs clarification. Addiction as Spiritual Emergency In light of viewing addiction through the lens of the transpersonal perspective, one can make better conceptual sense of what the connection of mindfulness, spirituality, and addiction might be. Grof and Grof (1993) argue that addiction is a manifestation of profound spiritual yearning—the “thirst for wholeness”. To escape the pain of this craving and fill the emptiness, Grof and Grof suggests, many people develop addictive behaviors, which only further drains one’s true self and soul. Grof (1993) also comment that for many addicts (as well as for other forms of addiction)—the real need is for wholeness, healing of the wounded psyche, and transcendence. Thus, substance abuse and addiction may be in many cases a form of spiritual emergency—thus representing the soul’s alarm clock—time to wake up! Of course many will hit the snooze button. Mindfulness and its role in a western treatment culture and context and its usefulness in this waking up process must be sorted out and identified further. Key questions still remain—mindfulness, while it might be a valuable clinical tool in the treatment of substance abuse—do we water down its potency by removing it from a spiritual context? Or does the removal of the spiritual connotations make it more beneficial in that it is now accessible and thus palatable to the masses? What is the relationship of mindfulness to spirituality? How are they alike or different? There is still much to learn about mindfulness, spirituality, and addictions—including whether spirituality and/or mindfulness will lead to a sustained decrease in substance abuse and addictions, and if so under what contexts do we maximize its effectiveness? Conclusion It is likely that spirituality and mindfulness has an important role in the development, treatment, and recovery from substance abuse and addiction. But, results to date are mixed, and more studies with sound methodology should be conducted to determine how mindfulness is distinct from spirituality. This must be done before one might be able to understand the full nature of this practice and its potentials and limitations. The fact that a serious scientific efforts to investigate spirituality in the addictions field are increasing is long overdue—and represents good news for mental health practitioners, researchers, and clients alike—and hopefully this search has the possibility to expand our vision of the present and future in a “mindful” way.
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