Mindfulness: Implications for Substance Abuseand 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 inrecent years. Techniques that induce “mindfulness” are increasingly being employed inWestern psychology and psychotherapy to help alleviate a variety of conditions. So whilemindfulness 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 toengage in substance use and relapse in addiction. The research at this date has not revealedthe ultimate effectiveness of mindfulness for substance abuse and addiction. It might be thatmindfulness 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 thatnails us. It nails us to the point of time and space that we are in. When we stop thereand don’t act out, don’t repress, don’t blame it on anyone else, and also don’t blame iton 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 oldtradition that began in India and spread and diversified throughout the Far East. Buddhismhas been described as a philosophy, religion, and a spiritual practice that is followed by morethan 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

Int J Ment Health AddictionDOI 10.1007/s11469-009-9199-z

J. Appel (*)Department of Behavioral and Social Sciences, Tiffin University, Tiffin, OH 44883, USAe-mail: Appelj@tiffin.edu

D. Kim-AppelFirelands Counseling and Recovery Services, Tiffin, OH 44883, USAe-mail: Dohee64@yahoo.com

system of practice designed to alleviate suffering. Mindfulness is a mental state, characterizedby concentrated awareness of one’s thoughts, actions or motivations. Techniques that induce“mindfulness” are increasingly being employed in Western psychology and psychotherapy tohelp alleviate a variety of conditions. So while mindfulness has its conceptual roots inBuddhism 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 toadopt Buddhism, but seeks techniques to relieve stress and adapt in healthier ways. Bothmetal health practitioners and researchers have been advocating mindfulness practice intomental health treatment programs and usually teach these skills without the religious andcultural 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 acomponent of other spiritual or religious traditions as well. In Christianity there are manypractices, which can be viewed as forms of meditation or mindfulness practice. Christianmeditation is often expressed in the form of prayer. Monastic customs often seek a turninward and involve practices of intense prayer, rosary, and adoration of the Eucharist. Manyhave also compared the Eastern Orthodoxy tradition of the hesychast practice of focusingone’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 isalso quite easy to recognize meditative practices in Judaism. There is ample evidencewithin 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 mysticaltraditions (particularly in Sufism). The Muslim prophet Muhammad reportedly spent longperiods in contemplation and meditation. It was during one such period of intensivemeditation 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 religioustraditions, 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 payattention, non-judgmentally, to one’s present-moment experience and sustain this attentionover time (Kabat-Zinn et al. 2002). Mindfulness is a cognitive strategy that develops aperspective that cultivates the recognition of thoughts and feelings as passing events createdin the mind. By practicing the skills of moment-to-moment awareness, one seeks to gaininsight into patterns in thoughts, feelings, and interactions with others, and then one canskillfully choose helpful targeted responses rather than automatically reacting in habitual,overlearned or unconscious ways (Teasdale et al. 2000). The aim of mindfulness is tocultivate consistent and non-reactive present moment awareness or directed attention. Ourbrains may be limited in the number of tasks we can do simultaneously. If one tries to doseveral tasks at the same time the brain may be limited in its efficiency. The classic example isthe too often occurrence of talking on a cell phone while driving. This example like othermulti-tasking events requires several different areas of the brain to be used. This multitaskingcan produce slower response times than if each task were done separately (Marois and Ivanoff2005). Rather than double the amount of brain areas being activated, the amount of brainactivity for each task is reduced considerably. Mindfulness allows for a more useful and

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powerful use of directed brain activity. Mindfulness has also been shown to activate themedial prefrontal regions, which play a prominent role in two fundamental aspects ofself-referential processing and perspective taking (Siegel 2007). Implications for this includean 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-focusedattention. 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 andemotions that emerge when one is still. Even when the experience is unpleasant, one istaught to observe or investigate the experience rather then try to dispel it. This type ofresponse 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 attentionand awareness, refining them, and putting them to greater practical use in our lives. Meditationis intentional, systematic, human activity which is not about trying to improve yourself or goanywhere 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 clinicalinterventions 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 wereoffering stress reduction programs based on mindfulness training. A search in the PsyInfodatabase of psychological peer-reviewed writings with “Mindfulness” as search termreveals that from 1980–2000 there were 83 articles/dissertations, while in the period of2000 to the present there were 557 articles/dissertations on the topic.

Mindfulness-based principles have also been infused and framed into a psychologicalintervention called “Acceptance and Commitment Therapy (ACT)” (Hofmann andAsmundson 2008; Eifert and Forsyth 2005; Hayes 2005). ACT is a branch of cognitive-behavioral therapy that uses acceptance and mindfulness strategies, with behavior changestrategies, to increase psychological adaptability.

Mindfulness training is also infused within dialectical behavior therapy—an empiricallysupported approach to the treatment of borderline personality disorder. Recent reworking ofDBT includes it as an intervention for substance abuse (Dimeff et al. 2000).

There is some empirical literature on mindfulness training which suggests thatinterventions infused with mindfulness practices may lead to an increased coping with awide range of problems, including emotional regulation, stress, anxiety, depression, andpain management, and more recently substance abuse (Teasdale et al. 2000; Kristeller andHallett 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 usedto treat and prevent substance abuse relapses (Marlatt and Gordon 1985). Mindfulness skillsare now included as a technique for coping with urges to engage in substance use andrelapse in addiction. Larimer et al. (1999) observe that mindfulness involves the acceptance

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of the present moment, whereas addiction is the repeated desire to avoid the presentmoment, which contributes to the “urge” to use. Marlatt’s concept of “urge surfing” is usedas 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-basedpractice” in an incarcerated population and found participants showed significant post-incarceration decreases in alcohol and drug related problems. Some initial data is supportiveof a mindful relapse prevention approach, but more research is needed.

While cognitive-behavioral approaches to alcohol and drug abuse disorders have beenresearched and empirically supported over the past few decades—substance and addictiontreatment remains a heavy demand worldwide. As non-western countries adopt westerninfluenced cultures-this demand may only increase. Drug abuse and drug trafficking havebeen increasing in India, Korea, Japan and China at alarming rates. The United NationsOffice for Drug Control and Crime Prevention (UNODCCP 2003) recently reported thatover 200 Million people worldwide are current users. The United Nations reports that,overall, the global drug problem continues to spread in geographical terms as morecountries report increases rather than decreases in drug abuse. It is interesting to note thatcultures that have originated mindfulness are the ones now having the largest increases insubstance abuse problems. Further examination of this phenomenon would be warranted—if one is to understand worldwide trends, and how westernized thinking, as well asmindfulness could influence substance abuse on a global basis. Hopefully we are notimporting cultural illnesses with our western practices. But perhaps these cultures have thepotential to quickly address these personal and collective ills if they utilize their inherentand cultural wisdom that is at their access.

Mindfulness as Separate from Spirituality?

Carl Jung said: “Spirituality is an essential ingredient in psychological health.” Jung alsowrote to Bill W, one of the founders of AA. “Your craving for alcohol was a spiritual thirstfor wholeness, (an attempt at a) union with God.” Jung reminded us that “alcohol,” in Latinis spiritus, the same word for “spiritual experience” (Miller 1990).

Many practitioners and recovering addicts have long believed that spirituality is animportant part of a person’s life, and has great implications for health including substanceabuse and dependence. It does appear that there is an increasing acknowledgement of this inthe scientific research. Miller (2000) describes his journey of “coming out of the closet” asa psychologist interested in spirituality. But, there is a conceptual problem that currentlyexists in the literature. There is a confused understanding of the relationship betweenspirituality and substance abuse/dependence and a failure to distinguish spirituality fromreligiosity. These terms are often used interchangeably which results in construct mergingand confusion.

This same sort of construct confusion and overlap may be also occurring withmindfulness. Leigh, Bowen and Marlatt (2005) suggest that spirituality and mindfulnessmay be separate constructs. In their study of substance abuse, mindfulness and spiritual andsubstance abuse, they found substance using and abusing behaviors were negativelycorrelated with scores on a spirituality scale. As spirituality scores increased the use ofalcohol and tobacco decreased. The found this relationship was not true for mindfulness.Thus, spirituality may be related to decreased substance use, not mindfulness. Alterman etal. (2004) in a study provided 8 weeks of mindfulness meditation (MfM) training andpractice to a randomized group of 18 recovery house patients in addition to their standard

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treatment. There was little indication that the MfM training resulted in more favorableoutcomes than were found for a randomized group of 13 recovery house patients whoreceived just standard treatment.

It might be that mindfulness is a helpful, but not a sufficient factor as a means to addresssubstance abuse. The relationship between spirituality and substance abuse should beexplored further, as should the relationship and differentiation between the constructs ofmindfulness and spirituality. Pardini et al. (2000) found that for those recovering fromsubstance abuse, higher positive outcomes were achieved by clients that had higher levelsof faith and spirituality. This study found that recovering individuals who rate themselves asbeing more spiritual than religious had better outcomes. The study suggests that spiritualitycontributes to a more optimistic life outlook whereas religious faith acts as a buffer tostress. However, the concept of spirituality and how it differs from religiosity remains anarea that needs clarification.

Addiction as Spiritual Emergency

In light of viewing addiction through the lens of the transpersonal perspective, one canmake better conceptual sense of what the connection of mindfulness, spirituality, andaddiction might be. Grof and Grof (1993) argue that addiction is a manifestation ofprofound spiritual yearning—the “thirst for wholeness”. To escape the pain of this cravingand 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 manyaddicts (as well as for other forms of addiction)—the real need is for wholeness, healing ofthe wounded psyche, and transcendence. Thus, substance abuse and addiction may be inmany cases a form of spiritual emergency—thus representing the soul’s alarm clock—timeto wake up! Of course many will hit the snooze button. Mindfulness and its role in awestern treatment culture and context and its usefulness in this waking up process must besorted out and identified further.

Key questions still remain—mindfulness, while it might be a valuable clinical tool in thetreatment of substance abuse—do we water down its potency by removing it from aspiritual context? Or does the removal of the spiritual connotations make it more beneficialin that it is now accessible and thus palatable to the masses? What is the relationship ofmindfulness to spirituality? How are they alike or different? There is still much to learnabout mindfulness, spirituality, and addictions—including whether spirituality and/ormindfulness will lead to a sustained decrease in substance abuse and addictions, and if sounder 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 howmindfulness is distinct from spirituality. This must be done before one might be able tounderstand the full nature of this practice and its potentials and limitations. The fact that aserious scientific efforts to investigate spirituality in the addictions field are increasing islong overdue—and represents good news for mental health practitioners, researchers, andclients alike—and hopefully this search has the possibility to expand our vision of thepresent and future in a “mindful” way.

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