Mindfulness, defined as the capacity to attend to the world around us on a moment to moment basis, non-judgmentally, and with accepting, relaxed awareness has become increasingly prevalent in the fields of mental health, pain management, stress reduction and most recently substance abuse treatment. Despite the fact that mindfulness techniques have been successfully used in both medical and behavioral health for over 30 years, and increasingly over the past 10 years in substance abuse treatment, there currently exists only a very general understanding of these techniques among the main stream of substance abuse practitioners, and their efficacy as stand-alone or adjunct interventions is not widely known or accepted. Mindfulness is still perceived by many as a “new-age” fad.
Admittedly, mindfulness is a vast and sprawling topic that is difficult to get our arms around. Any discussion of the topic could go off in any one of a thousand directions and go on for hours (or years). In an attempt to synthesize its vastness, perhaps it is best to start with a brief history of the evolution of mindfulness in clinical health settings.
The use of mindfulness in medical and behavioral health setting began in the 1970’s. Kabat-Zinn (1982) began demonstrating successful treatment of chronic pain with the use of mindfulness techniques in the 1970’s. The first studies on meditation and substance abuse came from practitioners of transcendental meditation (TM) (Benson, 1975; Marcus, 1974). The successes of these early interventions lead Marlatt et. al. (1984) to conduct a randomized study of three mindfulness techniques (TM, deep muscle relaxation and daily quiet recreational reading) in heavy drinking young adults. All three groups showed significant reductions in alcohol consumption with the TM group showing the most consistent reduction.
The application of mindfulness techniques has been used and proven effective with numerous psychological disorders. Kabat-Zinn (1990) developed mindfulness-based stress reduction (MBSR) for the treatment of anxiety disorders. Linehan (1993) integrated mindfulness into her revolutionary treatment dialectical behavior therapy (DBT) for the treatment of borderline personality disorder. Following the work by Kabatt-Zinn, Segal, Williams & Teasdale (2002) developed mindfulness-based cognitive therapy (MBCT) for the treatment of depressive disorders. All of these adaptations of mindfulness-based interventions support the hypothesis that meditation and other mindfulness techniques enhance awareness and the cultivation of alternatives to mindless, compulsive behavior. There exist a number of examples of successful adaptations and implementations of the aforementioned techniques to treat substance abuse.
But how and why does mindfulness work in the treatment of substance abuse? Substance abusers actively pursue oblivion, or at least attempt to continually alter their experience of each moment. They use words like “wasted” and “out of my mind”. Conversely mindfulness cultivates and encourages attention and acceptance of each moment as it is, often using phrases such as “being present” or “being here now”. Judging by the language you might consider these two ways of living as polar opposites, and as such mindfulness an unlikely adjunct to a successful treatment protocol. It would seem unlikely that the individual dedicated to the pursuit of oblivion would embrace a philosophy of being present. One way of reconciling this dichotomy is that, rather than viewing them as opposites, addiction (substance abuse) could be viewed as the absence of mindfulness, as darkness is the absence of light. This notion is supported by empirical study. Dakwar, Mariani & Levin (2011) demonstrated a significant “mindfulness impairment” in individuals seeking treatment for substance abuse disorders versus the general population.
So then, what specifically are we speaking of when we discuss “mindfulness techniques”? It is easy to encourage individuals to “stay in the moment”, “sit with your feelings”, “pay attention” , practice awareness”, etc… but these instructions are often too amorphous and vague to be actionable, particularly for those in early recovery. Tangible tools shown to be effective in cultivating mindfulness include:
Meditation / Attention to Breath – sitting or lying down with the attention centered on one’s own breath. The point of focus is personal; it might be air in and out of the nostrils, the rise and fall of the chest or belly, or the sound as breath passes in and out through the esophagus. The key is diligence; non-judgmentally discarding thoughts as they drift in and repeatedly returning to a simple observation of the breath.
Body Scan – sitting or most commonly lying down the attention is systematically directed to all the parts of the body; from the head to the toes, from the heart center out to the fingertips. Tension, tightness, pain, comfort & ease are all simply observed.
Mindful Hatha Yoga – mindfully moving through a series of seated, standing and supine postures while paying close attention to the breath and the sensations of the body, being careful to avoid judgments (positive or negative) of one’s own abilities or the abilities of those around them.
Walking Meditation – walking slowly (ideally in quiet, serene surroundings) and using all five senses to savior the experience through simple non-judging, non-analyzing observation: the physical sensation (feel) of the foot strike, the wind & the sun; the smell of nearby plant life; the sound of footsteps, birds, wind & silence; the view of surrounding architecture, earth, plants & sky.
Although a number of studies have shown mindfulness to be an effective stand-alone intervention for substance abuse, the bigger opportunity appears to be in the deeper integration of mindfulness techniques into the more widely practiced treatment modalities (Witkiewitz, Marlatt & Walker, 2005). Today most major treatment centers employ one or more of the following modalities as their primary treatment intervention; stages of change/motivational interviewing, cognitive behavioral therapy (CBT) & 12 step facilitation. There would appear to be significant opportunities for integration with each of these modalities. Becoming more mindful (of the consequences of substance abuse) would almost certainly speed the individual in the pre-contemplation phase toward a readiness for change. Mindfulness-based relapse prevention (MBRP) a relatively new treatment integrating over two decades of research on relapse prevention as a treatment for substance abuse with existing mindfulness based techniques such as MBSR and MBCT, is an a example of the integration of CBT and mindfulness. The 12 step model encourages meditation but offers little specific advice on technique. It encourages acceptance & non-judging but stops short of formal exercises to groom these skills. It is perhaps here, in the structured integration of mindfulness into the 12 step facilitation model that the biggest opportunity awaits.
Published - Together Arizona – March 2013 issue