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.

What Science Can Tell Us about How Mindfulness Actually Works

What Science Can Tell Us about How Mindfulness Actually Works

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Throughout recent decades there have been increasing attempts by scientists to understand how mindfulness actually works. However, because there are so many factors that could potentially exert an influence, coming to a definitive conclusion over the precise mechanisms of action that underlie the biological, psychological, or spiritual changes caused by mindfulness practice is not an easy task. Consequently, when scientists propose a mechanism in terms of how mindfulness causes change in individuals receiving mindfulness training, these proposals tend to be treated as just one piece of the larger jigsaw rather than as the final verdict. In today’s post, we summarise and discuss a selection – covering numerous remits of scientific enquiry – of the mechanisms of action that have been put forward to date.

  1. Perceptual Shift: Practising mindfulness is believed to create a perceptual shift in terms of how individuals respond and relate to thoughts, feelings, and sensory stimuli (e.g., sounds, sights, smells, pain, etc.). This greater perceptual distance is understood to help individuals objectify their psychological and somatic experiences and to regard them as passing phenomena.
  2. Increase in Spirituality: Some scientists (including ourselves) believe that mindfulness can increase spirituality and that this, in turn, acts as a buffer against feelings of loneliness as well as the various adversities we encounter in life. This growth in spiritual awareness is understood to help broaden an individual’s perspective on life and cause them to re-evaluate their life priorities.
  3. Reduced Autonomic and Psychological Arousal: It has been shown that mindfulness – and in particular conscious breathing – increases vagus nerve output which causes the heart and breathing rate to lower. Keeping the heart and breathing rate under control is understood to go hand in hand with remaining calm and being able to cope with stressful situations.
  4. Neuroplastic Changes: Neuroplasticity refers to changes in the brain neural pathways and synapses. Neuropsychological functional and structural imaging studies have demonstrated that mindfulness practice results in neuroplastic changes in various areas of the brain (including the anterior cingulate cortex, insula, temporo-parietal junction, fronto-limbic network, and default mode network structures). These neuroplastic changes are believed to improve an individual’s ability to regulate and remain in control of their choices, feelings, and behaviours.
  5. Increase in Self-Awareness: Mindfulness is understood to improve self-awareness which, in-turn, is believed to make it easier for people to identify and label negative mood states and thinking patterns. This relates closely to the above ‘perceptual shift’ mechanism because being able to accurately label mental processes makes it easier for people to objectify them.
  6. Addiction Substitution: One recently proposed mechanism of mindfulness (and other forms of Buddhist meditation) is that the peaceful/blissful states associated with mindfulness can be substituted for the highs and various forms of mood modification experienced by individuals with addictive behaviours. This particular mechanism was actually proposed by ourselves and it basically involves a ‘negative addiction’ (e.g., to drugs, alcohol, gambling, etc.) being substituted with a ‘positive addiction’ (i.e., to mindfulness/meditation).
  7. Urge Surfing: Another proposed mechanism of action (not by ourselves this time) relating to how mindfulness works as a treatment for addiction is that of ‘urge surfing’. Urge surfing basically refers to the process of an individual observing and not reacting to mental urges. In other words, they surf the urge and are therefore better able to regulate habitual compulsive responses.
  8. Letting Go: By mindfully observing the coming and going of thoughts and feelings (and other phenomena), it is believed that mindfulness practitioners cultivate a better understanding of the ‘transient’ nature of existence. This helps them to let-go of difficult situations and not to see things as fixed or permanent.
  9. Increase in Patience: Some scientists (including ourselves) believe that mindfulness increases an individual’s levels of patience. This is understood to reduce an individual’s desire for instant gratitude as well as their propensity for anger.
  10. Greater Situational Awareness: Outcomes from our own research have shown that mindfulness can help people feel more in touch with the physical and social environment in which they find themselves. This greater situational awareness is understood to improve decision-making competency, job performance, and the ability to pre-empt how a particular situation might unfold.

It is beyond the scope of today’s post to discuss every single mechanism of action that has been proposed in relation to how mindfulness causes somatic, psychological, or spiritual change. Nevertheless, the above overview represents a mixture of recently proposed mechanisms of action as well as those that are more established. As scientific enquiry continues, it is likley that new mechanisms of actions will be identified and that a more complete picture of ways in which mindfulness leads to positive change will emerge.

Further Reading

Dane, E. (2010). Paying attention to mindfulness and its effects on task performance in the workplace. Journal of Management, 37, 997-1018.

de Lisle, S. M., Dowling, N. A. & Allen, J. S. (2012). Mindfulness and problem gambling: A review of the literature. Journal of Gambling Studies, 28, 719–739.

Derezotes, D. (2000). Evaluation of yoga and meditation trainings with adolescent sex offenders. Child and Adolescent Social Work Journal, 17, 97-113.

Gillespie, S. M., Mitchell, I. J., Fisher, D., & Beech, A. R. (2012). Treating disturbed emotional regulation in sexual offenders: The potential applications of mindful self-regulation and controlled breathing techniques. Aggression and Violent Behavior, 17, 333-343.

Holzel, B., Lazar, S., & Gard, T., et al. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives in Psychological Science, 6, 537-559.

Howells, K., Tennant, A., Day, A., & Elmer, R. (2010). Mindfulness in forensic mental health; Does it have a role? Mindfulness, 1, 4-9.

Rungreangkulkji, S., Wongtakee, W., & Thongyot, S. (2011). Buddhist Group Therapy for diabetes patients with depressive symptoms. Archives of Psychiatric Nursing, 25, 195-205.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013). Mindfulness-based interventions: Towards mindful clinical integration. Frontiers in Psychology, 4, 1-4. DOI:10.3389/fpsyg.2013.00194. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629307/)

Shonin, E., Van Gordon W., Slade, K., & Griffiths, M. D. (2013). Mindfulness and other Buddhist-derived interventions in correctional settings: A systematic review. Aggression and Violent Behavior, 18, 365-372.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2015). Managers’ experiences of Meditation Awareness Training. Mindfulness, DOI: 10.1007/s12671-014-0334-y.

Toneatto, T., Pillai, S., & Courtice, E. L. (2014). Mindfulness-enhanced Cognitive Behavior Therapy for problem gambling: A controlled pilot study, International Journal of Mental Health and Addiction, 12, 197-205

Van Gordon, W., Shonin, E., Sumich, A., Sundin, E., & Griffiths, M. D. (2013). Meditation Awareness Training (MAT) for psychological wellbeing in a sub-clinical sample of university students: A controlled pilot study. Mindfulness, 5, 381-391.

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

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

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., 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.

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