Mindfulness for Treating Addiction: A Clinician’s Guide

Mindfulness for Treating Addiction: A Clinician’s Guide

Psychotherapy 1

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.

The Scientific Study of Buddhism and the Noble Eightfold Path: Dividing the Whole into Many

The Scientific Study of Buddhism and the Noble Eightfold Path:

Dividing the Whole into Many

eight steps

The Buddhist Noble Eightfold Path is sometimes referred to as the “eight steps to freedom”. This tends to give the impression of a graded approach to liberation – we begin at white belt and then progress through the various colours until we reach black belt. However, this is decidedly not the case with the Noble Eightfold Path. As the Mahãcattãrisaka Sutra (The Great Forty Sutra, Majjhima Nikãya, 117) explains, each of the eight factors that comprise the Noble Eightfold Path (i.e., right view, right intention, right speech, right action, right livelihood, right effort, right mindfulness, right concentration) are the individual parts that make up the whole. They are like the single strands that collectively make up a mountaineer’s rope – the rope is at its strongest when all of these fundamental strands are present and closely interwoven.

Rope strength

However, in certain scientific and medical contexts, the intricate and complex process of meditation has been dissected into the individual practices of  ‘mindfulness’, ‘concentrative meditation’, ‘insight meditation’, ‘self-compassion’, ‘compassion’, ‘loving kindness’, and so forth. Consequently, a growing number of scholars (including ourselves) have expressed concerns in the academic literature that by isolating these elements from one another, we may be taking unnecessary risks. Indeed, if we start to remove strands from a rope or work with only a single rope strand, there is a danger that the rope will snap. In this week’s post, we briefly attempt to highlight the deeply interconnected and interwoven nature of the Noble Eightfold Path, and of Buddhist meditation more generally.

Right view(Sanskrit: samyag-drsti / Pali: sammā-ditthi) essentially refers to the ability to see and understand the absolute nature of reality. Seeing that both we and reality are empty of inherent existence liberates us from suffering. However, in order to develop this clarity of vision, we first need to be able to give rise to a particular form of concentration. In this case we don’t just mean the ability to keep our attention placed on a particular task or object. Right concentration (samyak-samādhi / sammā-samādhi) refers to the meditative state whereby we have completely encompassed all mental activity within a single state of meditative calm. It means that we have effectively tranquilised the mind and in this state, we are profoundly aware of everything that is happening both internally and externally. The only problem with right concentration is that because this state is so blissful, we can forget that the blissful experience is also empty of inherent existence. Thus, although right concentration is a prerequisite for cultivating right view, we need the wisdom of right view to help us transcend any attachment and ignorance that remains when we are dwelling in right concentration.

Wisdom 5

If we want to develop meditative concentration, then we need to know when the mind is succumbing to attachment or aversion. If we are attempting to engulf the mind in tranquillity but we become attached to a particular thought or object, then this will interfere with our concentration and it may well cause us to lose awareness altogether. Consequently, we need to watch over the concentrating mind to ensure that it is in fact still in a state of meditative concentration. This is where mindfulness comes in. Right mindfulness (samyak-smrti / sammā-sati) allows the mind to remain fully concentrated in the here and now. If the mind becomes too excited or too drowsy and begins to drift out of its state of concentration, mindfulness observes that this is happening, so that we gently loosen or tighten our concentration as required.

mind 2

As you can imagine, until we reach a certain level of awakening, constantly being mindful of the mind requires a lot of determination. So right effort(samyag-vyāyāma / sammā-vāyāma) is needed to continuously remind ourselves to be mindful. However, it is not just with regard to right mindfulness where we require right effort – right effort essentially underlies and fuels every other element of the Noble Eightfold Path. For example, right effort is required to cultivate right speech (samyag-vāc / sammā-vācā), right action (samyak-karmānta / sammā-kammanta), right livelihood (samyag-ājīva / sammā-ājīva) and so forth. Likewise, an active and focussed effort is required to cultivate right view and to see all phenomena exactly as they are – empty of intrinsic existence. Thus, as with every other aspect of the Noble Eightfold Path, right effort cannot be treated in isolation.

Right speech, right action and right livelihood are basically concerned with our ethical conduct. Everything we think, say and do in this present moment will create the next present moment – not just for ourselves but also for others. In other words, before we open our mouths we should stop and ask ourselves “is what I am about to say going to cause me or anybody else harm”? If we are not very nice to other people or to ourselves, then this is actually going to cause us a lot of worry and a lot of bother. We are constantly going to be involved in internal and external squabbles. If we get caught up in things it is extremely difficult for the mind to relax and find peace. It becomes difficult to establish right effort and, therefore, it becomes difficult to establish right mindfulness. Without maintaining mindfulness of our mental processes, it is impossible to rest in meditative concentration and – in turn – cultivating right view and meditative wisdom becomes a very distant prospect.

Ethics

Thus, it is absolutely essential for effective spiritual and meditative development that we infuse all of our actions with gentleness, awareness, and compassion. This is where right intention (samyak-samkalpa/sammā sankappa) comes in. Right intention means that we live our whole life with the primary goal of helping ourselves and others to develop spiritually. Right intention should permeate each of the other seven aspects of the Noble Eightfold Path. For example, when we are practicing mindfulness, we should be practicing with others’ long-term wellbeing in mind. Some people have told us that they practice mindfulness in order to overcome a medical problem or to get ahead in their career. However, this doesn’t embody the meaning of right intention and so actually, these individuals are not practicing mindfulness at all.

Because we allow right intention to completely pervade our being, everything else falls nicely into place. By having the right intention, the spiritual path becomes very enjoyable and progress happens automatically. As we discussed in our recent post on the ‘Top Ten Mistakes Made by Buddhist Meditation Practitioners’, it is because people don’t have the right intention that their spiritual practice fails to bear fruit. Some people sit in meditation for hours each day and/or they diligently study the teachings for many decades. But right intention is something that comes from within – it can be learned but it is actually quite intuitive. You either really want to evolve spiritually or you don’t. You’re either willing to subdue your ego or you’re not. It is quite simple. In a nutshell, right intention means that due to knowing all phenomena are impermanent and our time here is limited, we are ready to work hard in order to leave suffering behind.

To summarise, each aspect of the meditative journey is intrinsically connected to every other aspect. We need to practice all of the components of the Noble Eightfold Path at the start of our journey, and we need to practice them all at the end. If we only focus on one component of the path, things will be unbalanced. We will end up like one of those people who only works on their biceps when they go to the gymnasium – they end up with huge arms stuck onto a matchstick body. If we dissect the individual elements of the spiritual path and we treat them as isolated units, then we are basically misconstruing the Buddha’s instructions of how to practice and apply the teachings. By getting caught up in categorising and analysing things – it is a sign that we are becoming attached to the teachings. No doubt some people find this very interesting, but it basically means that we are moving things from the spiritual to the academic plane. At this point, the practice is no longer going to be of any long-term benefit. The Buddha explained that the Buddhist teachings are rather like a raft or a boat that we can build and use in order to cross the ocean or a wide and turbulent river. We are born on one shore of this turbulent river (life) and in order to get to the other shore, we build ourselves a boat. When built, we set sail with joyful effort, great diligence, and equanimity. However, when we arrive on the other shore, we don’t lift the boat onto our shoulders and carry it around with us. We let go of the raft, we let go of the teachings.

 Ven Edo Shonin & Ven William Van Gordon

Further Reading

Bodhi, B. (1994). The Noble Eightfold Path: Way to the End of Suffering. Kandy, Sri Lanka: Buddhist Publication Society.

Bodhi, B. (Ed.). (2009). Majjhima Nikaya: The Middle Length Discourses of the Buddha (4th ed.). (Bhikkhu Bodhi, & Bhikkhu Nanamoli, Trans.) Massachusetts: Wisdom Publications.

Buddharakkhita (Trans.). (1966). Dhammapada: A Practical Guide to Right Living. Bangalore: Maha Bodhi Society.

Chah, A. (2011). The Collected Teachings of Ajahn Chah. Northumberland: Aruna Publications.

Dalai Lama. (1995). The Path to Enlightenment. New York: Snow Lion.

Shonin, E., Van Gordon W., & Griffiths, M. D. (2014). The emerging role of Buddhism in clinical psychology: Towards effective integration. Psychology of Religion and Spirituality, 6, 123-127.

Shonin, E., & Van Gordon, W. (2013). The consuming mind. Mindfulness, DOI: 10.1007/s12671-013-0265-z.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). The top ten mistakes made by Buddhist meditation practitioners. The Buddhist Voice, 1(5), 22-24.

Suzuki, D. T. (1983). Manual of Zen Buddhism. London: Rider.

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