Mindfulness for Treating Addiction: A Clinician’s Guide

Mindfulness for Treating Addiction: A Clinician’s Guide

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An aspect of our scientific work relating to mindfulness involves investigating its applications for treating addiction. In this respect, we have a longstanding collaboration with Dr. Mark Griffiths who is Professor of Behavioural Addiction at Nottingham Trent University (UK) and is internationally recognised for his work in this field of study. Today’s post draws upon findings from our research using Meditation Awareness Training and provides ten recommendations on the psychotherapeutic use of mindfulness in addiction treatment contexts. These recommendations are primarily intended for mental health professionals, but individuals with addiction problems may also find them of interest. Although we have principally based our recommendations on insights gained from using mindfulness and meditation for treating behavioural addictions (e.g., gambling disorder, workaholism, sex addiction), we have also consulted the literature concerning the use of mindfulness for treating chemical addictions (e.g., substance- and alcohol-use disorders). Therefore, whilst we acknowledge that there are important differences between behavioural and chemical addictions (e.g., the physical signs of drug addiction are typically absent in behavioural addiction), we envisage that the following recommendations will be applicable to both addiction categories.

  1. Undertake a Thorough Assessment: Careful evaluation of the client’s history (e.g., clinical history, social history, education history, religious history, employment history, etc.) and presenting problems will come high on the list of any competent mental health clinician. However, we have chosen to include ‘thorough assessment’ as one of our specific recommendations because there appears to be a belief amongst a minority of mental health professionals that mindfulness is a one-stop cure for all mental health issues. As discussed in one of our peer-reviewed papers that was recently published in the British Medical Journal, the only psychopathologies for which the empirical evidence is robust enough to support the wide scale utilisation of mindfulness are specific forms of depression and anxiety. In other words, mindfulness is not a suitable treatment for every individual presenting for treatment. For example, we recommend that clinicians exercise additional caution (including taking into account their own experience with using mindfulness) before introducing mindfulness to clients whose addiction problem occurs in conjunction with psychotic features.
  2. Build Strong Meditative Foundations: Mindfulness is a practice to develop throughout one’s lifetime. It is a marathon and not a sprint. If an individual is to derive lasting benefit from mindfulness, it is essential that they establish strong meditative foundations. If we want to become aware of the subtle aspects of mind, we first need to become aware of the gross aspects of mind. And before we can do that, we need a method of calming, collecting and focussing the mind. This is why breath awareness is a vital feature of meditative development. Using the breath as a concentration anchor provides the client with a reference point – a place of safety to which they can return whenever their mind starts to run away with itself. The mental cravings that underlie addiction can be powerful and consuming, and without strong meditative foundations, it is unlikely that the client will be able to regulate these cravings as well as the withdrawal symptoms that they are likely to encounter during later treatment phases. Another important foundation of mindfulness is awareness of the body. At the early stages of treatment, clients should be taught how to sit with awareness, eat with awareness, walk with awareness and talk with awareness. Clients should be encouraged to adopt mindfulness as a way of life and not just a technique to apply when they are feeling low or susceptible to addiction-related urges.
  3. Make use of Psycho-education: In addiction treatment contexts, we suggest that psycho-education should be utilised at the early stages of treatment and should focus on two key areas: (i) educating clients in the science concerning the aetiology and symptom course of their particular addiction, and (ii) explaining the principles of mindfulness and a meditation-based recovery model. For a comprehensive and insightful academic resource that clinicians can draw upon in this respect, we recommend the chapter on mindfulness and addiction by Dr. Sean Dae Houlihan and Dr. Judson Brewer that features in our recent edited Springer volume on Mindfulness and Buddhist-Derived Approaches in Mental Health and Addiction (see further reading list below).
  4. Teach ‘Urge Surfing’: The term ‘urge surfing’ has been used in the scientific literature to refer to the process of mindfully observing the mental urges associated with addiction. The idea is that the client, having established themselves in awareness of breathing, takes craving as the object of meditation. They follow their breath and observe how craving dominates their cognitive-affective processes. The process of observing mental craving helps to objectify it and creates ‘mental space’ whereby instead of feeding the craving (i.e., by emotionally and conceptually adding to it), craving is allowed to exist ‘as it is’. It may appear as though urge surfing is concerned with controlling craving, but that’s not the case. Rather, the technique involves allowing craving to come and go such that it can progress through its natural cycle of birth, life and dissolution. When we teach this technique, we inform clients that if craving is manifest in the mind, that’s OK. We also inform them that if craving is not manifest, that’s OK too.
  5. Make use of Bliss Substitution: Substitution techniques are sometimes used in the treatment of both behavioural and chemical addictions. For example, studies have shown that some individuals with gambling disorder respond well to gradually substituting their gambling activity for recreational activities such as singing, learning computer skills, communication workshops, dance and music. Our own studies have shown that the substitution principle can also work well in the case of addiction treatments following a meditation-based recovery model. One of the key drivers of addiction is the mood modification (e.g., ‘feeling high’) that results from engaging with a particular substance or behaviour. Meditation may be particularly suitable as an addiction substitution technique because specific forms of meditation can induce blissful feelings. Effectively, the client learns to replace the ‘buzz’ or ‘high’ associated with a ‘negative addiction’ with the bliss and peace of meditation (i.e., a positive form of addiction). Eventually, clients should be encouraged to relinquish any dependency on meditation, but in the early stages of treating addiction, it can be a useful therapeutic technique.
  6. Employ Meditation Exposure Therapy: Exposure therapy is a method employed by various modalities of psychotherapy, and it can also be used as part of mindfulness therapy for individuals suffering from addiction. It is all very well teaching the client how to practise mindfulness from the safety of the psychotherapist’s consulting room, but at some point it is probable that they will encounter the stimuli that have previously caused strong mental urges to arise. Consequently, we encourage the psychotherapist to accompany (i.e., where it is safe and realistic to do so) the client in ‘real-world settings’ that are likely to induce relapse. For example, if the client is addicted to off-line gambling, consider accompanying them to a casino in order to demonstrate that it is possible for them to remain meditatively composed whilst surrounded by the object of their addiction. Meditation exposure therapy isn’t suitable for every client (or indeed for every mental health clinician), but where applicable, we generally recommend that it is used towards the end of the treatment course.
  7. Undermine the Value of the Addictive Object: This technique involves guiding the client to think about the ‘true nature’ of the object of their addiction. More specifically, it involves introducing the client – albeit at an elementary level – to the concepts of impermanence, interconnectedness and emptiness. Again, the clinician will have to assess on a case-by-case basis whether this technique is appropriate, but we have personally found it to be effective in addiction treatment contexts. By fostering meditative awareness of impermanence and the empty nature of all phenomena, the client can gradually begin to question and then undermine the intrinsic value that they have assigned to the object of their addition. For example, an individual suffering from sex addiction can use specific meditative techniques in order to better understand that (i) the individual components that comprise the human body are not particularly desirable in and of themselves (e.g., nails, hair, mucus, faeces, urine, pus, vomit, blood, sinew, skin, bone, teeth, flesh, sweat, etc.), (ii) the inevitable destiny of the body is that of ageing, illness and decay, and (iii) the body exists as a composite entity but does not exist intrinsically. If the client looks deeply using meditation, they can learn to see that in beauty and life, there is foulness and decay (and vice-versa). They can also learn to see that there is ‘other’ in ‘self’ and ‘self’ in ‘other’, and that when they practice kindness and respect towards themselves, they practise kindness and respect towards the entire world.
  8. Schedule Follow-up Sessions: Most of the available treatments that use mindfulness generally adhere to an eight-week treatment course. However, in the traditional Buddhist setting, a person would normally be required to engage in day-to-day mindfulness practice over a period of many years before being deemed to have gained a reasonable grounding in the practice. Consequently, it is important to schedule booster sessions and to meet with the client at regular (e.g., monthly) intervals following the initial programme of treatment. Ideally, clients should also be encouraged to make contact with mindfulness groups that are facilitated by competent teachers.
  9. Lead by Example: As discussed in a previous post where we offered guidelines on the general use of mindfulness in psychotherapy (i.e., not specific to treating addiction), it is important that the mental health clinician emanates a presence of meditative calm and awareness. This has to be natural and as indicated above, it can only arise after consistent daily practice over a period of many years. If the clinician merely ‘acts’ at being mindful, the client is likely (whether consciously or subconsciously) to pick up on this and it will inevitably act as an obstacle to recovery.
  10. Be Inspired: Mindfulness has been practised by spiritual traditions for thousands of years. When a clinician engages with the practice in a sincere manner, and when they wholeheartedly wish to help the client overcome their suffering, that clinician is bestowed with the blessings and wisdom of this ancient spiritual lineage. They become what is known in Buddhism as a Bodhisattva – a rare and beautiful being that conduct acts of kindness in order to alleviate the suffering of others. Skilled mental health professionals perform an invaluable role to society. They are inspired individuals who in turn help to inspire the clients they work with.

Ven Dr Edo Shonin and Ven William Van Gordon

 

Further Reading

Alavi, S. S., Ferdosi, M., Jannatifard, F., et al. (2012). Behavioral addiction versus substance addiction: Correspondence of psychiatric and psychological views. International Journal of Preventative Medicine, 3, 290-294.

Appel, J., & Kim-Appel, D. (2009). Mindfulness: Implications for substance abuse and addiction. International Journal of Mental Health Addiction, 7, 506-512.

Griffiths, M. D., (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M. D., Shonin, E., & Van Gordon, W. (2015). Mindfulness as a treatment for gambling disorder. Journal of Gambling and Commercial Gaming Research, 1, 1-6.

Houlihan, S. D., & Brewer, J. A. (2015). The emerging science of mindfulness as a treatment for addiction. In: E. Y. Shonin, W. Van Gordon and M. D. Griffiths (eds.), Mindfulness and other Buddhist-derived approaches in mental health and addiction (pp. 191-210). New York: Springer.

Iskender, M., & Akin, A. (2011). Compassion and internet addiction. Turkish Online Journal of Educational Technology, 10, 215-221.

Jackson, A. C., Francis, K. L., Byrne, G., et al. (2013). Leisure substitution and problem gambling: report of a proof of concept group intervention. International Journal of Mental Health and Addiction, 11, 64–74.

Rosenberg, K. P., Carnes, P. J., & O’Connor, S. (2014). Evaluation and treatment of sex addiction. Journal of Sex and Marital Therapy, 40, 77-91.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). The treatment of workaholism with Meditation Awareness Training: A Case Study. Explore: The Journal of Science and Healing, 10, 193-195.

Shonn, E., Van Gordon, W., & Griffiths, M. D. (2014). Cognitive Behavioral Therapy (CBT) and Meditation Awareness Training (MAT) for the treatment of co-occurring schizophrenia with pathological gambling: A case study. International Journal of Mental Health and Addiction, 12, 181-196.

Shonin, E., Van Gordon W., & Griffiths, M. D. (2014). Mindfulness as a treatment for behavioral addiction. Journal of Addiction Research and Therapy, 5, e122. DOI: 10.4172/2155-6105.1000e122.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). Mindfulness and the social media. Journal of Mass Communication and Journalism, 2014, 4: 5, DOI: 10.4172/2165-7912.1000194.

Shonin, E., Van Gordon W., & Griffiths, M. D. (2013). Buddhist philosophy for the treatment of problem gambling. Journal of Behavioural Addictions, 2, 63-71.

Shonin, E., Van Gordon W., & Griffiths, M. D. (2013). Meditation for the treatment of addictive behaviours: Sending out an SOS. Addiction Today, March, 18-19.

Shonin, E., Van Gordon, W. & Griffiths, M. D. (2013). Mindfulness-based interventions for the treatment of problem gambling. Journal of the National Council on Problem Gambling, 16, 17-18

Sussman, S., Lisha, N. & Griffiths, M. D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Witkiewitz, K, Marlatt, G. A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19, 211-228.

Shonin, E., & Van Gordon, W. (2013). Searching for the present moment, Mindfulness, 5, 105-107.

Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6, 1161-1180.

Van Gordon, W., Shonin, E., & Griffiths, M. (2015). Towards a second-generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49, 591-591.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice, 63, 654.

Shonin, E., & Van Gordon, W. (2015). The lineage of mindfulness. Mindfulness, 6, 141-145.

A Buddhist’s Guide to Safe Sex

A Buddhist’s Guide to Safe Sex

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In our capacity as Buddhist teachers we are sometimes asked questions regarding the role of sex in Buddhist practice. In the last few months, we have also received several requests for us to write a post on this subject. The nature of these questions and/or requests generally relate to misunderstandings as to the Buddhist teachings on this subject. Specifically, it appears that there is uncertainty over what appear to be conflicting Buddhist teachings regarding how a Buddhist practitioner should relate to sex so that it does not become an obstacle to spiritual awakening. Therefore, in today’s post we provide our perspective on the role of sex in Buddhist practice and provide five recommendations to help individuals contextualise and/or engage in sexual activity in a manner that is conducive to spiritual practice:

1. Have sex responsibly: The Buddha did not provide extensive details as to what constitutes having responsible sex and what sexual activity was acceptable or inappropriate. However, the sentiment of the Buddha’s teachings on sex (and on life more generally) were that nobody should ever be hurt or abused as a result of a sexual encounter. This not only includes the individuals having sexual intercourse but also includes anybody else that might be adversely affected. For example, before two people have sex together, they should ensure that an unwanted child will not be born as a result of their actions. Similarly, promiscuous sex should also be avoided because it invariably causes suffering for all concerned. We have always taught that sex within the context of a loving and stable relationship is the most ideal situation. However, if this is not possible then it is important to at least make sure that nobody is taken advantage of or hurt as a result of a sexual encounter.

2. Don’t turn sex into something it isn’t: We are not sure whether any credible research has been conducted to determine the average number of people per day in the world that have sexual intercourse. However, since there are credible estimates of the number of babies born each day in the world, then we can be fairly certain that at least twice this number of people in the world have sex on any given day. For example, current estimates place the birth rate at approximately 370,000 new born babies each day. This means that about nine months prior to this, approximately 740,000 people had sexual intercourse (this does not take into account babies that were born due to artificial insemination, premature births, or instances where twins or triplets were born). However, common sense tells us that in reality, the figure is much higher because not all acts of sexual intercourse result in the birth of a child. Some explanations for this might be that: (i) the act of sexual intercourse was between individuals of the same sex, (ii) contraception was used, (iii) one or both of the individuals had fertility issues, and (iv) there was a miscarriage or the foetus was aborted.

The reason for emphasising the fact that sex is very common is to help us see sex for what it is and not to assign it more importance than it warrants. As human beings, we have certain biological needs. We need to eat, drink water, sleep, and go to the toilet. At the point human beings reach the pubescent stage, the human body also has a biological need to discharge sexual energy. If any of the aforementioned biological needs are not addressed in one way or another, then sooner or later discomfort and pain arise. There are various ways an individual can deal with the build-up of sexual energy in the body, of which having sexual intercourse or masturbation are probably the most obvious (but there are also other means depending on a person’s level of meditative awareness and their familiarity with the various gross and subtle energies in their body). Nevertheless, the point is that just like eating or going to the toilet, sex is neither a wholesome nor an unwholesome act, and it is neither important nor unimportant. The way in which sex is viewed by an individual (and society) depends entirely on the level of importance and meaning they assign to it. The energy that is created and discharged during sex can be incredibly pleasurable, and sex is also necessary for bringing new life into the world. However, it seems to us that sex is afforded too much significance in modern society and this has actually cheapened this otherwise natural and neutral aspect of human behaviour. In other words, sex has become such a big part of peoples’ thoughts and conversation and has been given so much importance, that it has been debased and become unimportant.

3. Practice mindful sex: Research demonstrates that there are various health benefits associated with practising mindfulness. The Buddha did not teach that the idea was to practice mindfulness when engaging in some activities but not in others. Rather, he taught that mindfulness should be practised at all times. Therefore, when you are having sex, try to do so mindfully. We are not aware of a program of empirical research that has investigated whether mindful sex heightens sexual pleasure, but there are preliminary research findings indicating that mindfulness can improve sexual dysfunction (see further reading list below). The way to practice mindful sex is – as with all other forms of mindfulness practice – to be fully aware of one’s thoughts, feelings, bodily movements, and bodily sensations during and after sexual intercourse. In other words, mindful sex involves the individual becoming a participating observer. They fully participate in the act of having sex but allow a certain perceptual distance to be introduced between them and the psychosomatic experience of sexual intercourse. This prevents the act of sex and the powerful feelings and sensations that it produces from causing the spiritual practitioner to lose their meditative awareness and to succumb to mindless ways of thinking and behaving.

4. Don’t reject the experience of having sex:  Some Buddhist practitioners take vows of celibacy in relation to sexual activity. If, for example, a Buddhist nun or monk has taken a vow of celibacy, then it is very important that they honour that vow. However, for individuals that have not taken such vows, it is essential not to consider the act of having sex as something that happens outside of one’s spiritual practice. The Buddha taught that a mind intoxicated with desire for sensual and/or sexual pleasure is not conducive to spiritual awakening. Despite this, the Buddha certainly never implied that the act of having sex was wrong in and of itself. As we discussed in our post on False Spiritual Economy, the crucial point is not to become attached to any objects or experiences that we encounter – including sex. Attachment and/or desire are considered to be primary mental poisons in Buddhism and will definitely present an obstacle to spiritual growth. In fact, as our colleague and friend Professor Mark Griffiths has written extensively about on his own blog, it is actually possible for people to become so preoccupied with sex that they eventually become addicted to it.

The exact same principle applies to being averse to having sex as it does to being attached to it. If a person rejects the sexual feelings and energy that they experience, then they are effectively rejecting a part of their being and introducing a degree of conflict or resistance into their mind. It is for this reason that in place of the path of celibacy advocated by certain Buddhist monastic traditions, other (mostly tantric) Buddhist approaches advocate accepting sexual energy and using it as a means of making spiritual progress. The point in tantric Buddhism is for the spiritual practitioner to accept and work with sexual energy but in such a manner that they use it as a means of realising the inherent emptiness of all that exists (including feelings of sexual pleasure). However, it doesn’t take a genius to understand that the fairly graphic nature of some of the tantric Buddhist teachings means that they can be easily abused or misunderstood. The tantric teachings relating to sex and sexual energy are intended for experienced meditation practitioners that have already acquired advanced levels of spiritual insight and that are already well on the path to enlightenment. Despite this and due to not keeping their egos under control, some Buddhist practitioners and teachers automatically assume that they are already at an advanced stage of meditation practice and use these tantric teachings as an excuse to behave irresponsibly (i.e., they think they can go around sleeping with anybody and everybody and they lose sight of their original goal).

5. Enjoy the wonder of sex: As discussed above, the way in which we relate to sex largely depends on the level of meaning and importance that we assign to it. In other words, it is basically up to us whether sex and our thoughts and behaviours in relation to it becomes something that advances spiritual development or impedes it. Given this choice, it is completely within the power of every spiritual practitioner to turn sex into a wholesome practice and conduct. The way to do this is to load the act of having sex not just with mindful awareness but with positive and compassionate intentions. Sex can be a way for people to be intimate together, to be naked as human beings, and to show love and kindness. If one loads the act of having sex with such positive intentions and awareness, then it becomes a spiritual act. The same applies to everything we do. If a person eats or goes to the toilet with spiritual awareness and a compassionate intention, then these actions also become spiritually productive.

We sometimes observe Buddhist teachers attempt to side-step questions or requests for advice relating to sex. However, sex is a part of human existence and so we definitely don’t need to be afraid of it or steer away from talking about it just because we consider ourselves to be spiritual practitioners. Becoming comfortable with sex and knowing how to relate to it helps us to grow in wisdom and confidence as spiritual practitioners. In other words, if we are a person that wants to take spiritual practice seriously, we have to accept, love, and be comfortable talking and working with everything that we encounter in life. Therefore, if a Buddhist practitioner so wishes, they can certainly make use of sex as part of their spiritual practice. They can also fully enjoy and intricately experience the natural wonder of sex. This is very different than the person that becomes preoccupied with sex and uses it as an excuse to engender lustful, disrespectful, or smutty thoughts.

A great deal has been written about sex and Buddhism, including a lot of misinformation. The above suggestions are by no means exhaustive but we hope they will provide some food for thought for individuals seeking to make sense of this subject. The main thing to remember is to always have virtuous thoughts and intentions. If one can do this then having sex will certainly become an aid rather than a hindrance to spiritual awakening.

Ven Edo Shonin & Ven William Van Gordon

Further Reading

Barker, M. (2014). How social is your mindfulness? Towards a mindful sex and relationship therapy. In: Bazzano, Manu (ed). After Mindfulness: New Perspectives on Psychology and Meditation. Houndmills: Palgrave Macmillan, pp. 81-100.

Brotto, L. A., & Heiman, J. R. (2007). .Mindfulness in sex therapy: Applications for women with sexual difficulties following gynecologic cancer. Sexual and Relationship Therapy, 22, 3-11.

Laurent, H., Laurent, S., Hertz, R., Egan-Wright, D., & Granger, D. A. (2013). Sex-specific effects of mindfulness on romantic partners’ cortisol responses to conflict and relations with psychological adjustment. Psychoneuroendocrinology, 38, 2905-2913.

McCarthy, B., & Wald, L. M. (2013). Mindfulness and good enough sex. Sexual and Relationship Therapy, 28, 39-47.

Trungpa, C. (2011). Work, sex, money: Real life on the path of mindfulness. Boston: Shambala