MINDFULNESS AND ADDICTION: SENDING OUT AN S.O.S
Research exploring the effectiveness of mindfulness as a treatment for addictive gambling shows very promising demonstrable outcomes, as do clinical case studies, report Edo Shonin, William Van Gordon and Mark D Griffiths of the International Gaming Research Unit at Nottingham Trent University.
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Mindfulness is a spiritual or psychological faculty described in the healthcare literature as an intentional engaging of a non-judgmental awareness of the present moment. The practice of mindfulness derives from Buddhism and has been used for over 2,500 years to reduce ‘craving’. Throughout the last decade, there has been growing scientific interest into the potential utility of mindfulness as a treatment for addictive behaviours. In what follows and using gambling addiction as an exemplar, we explore the practice of mindfulness in terms of its relevance to clinicians working in the field of addiction recovery.
PROBLEM GAMBLING: THE PROBLEM
The most recent British Gambling Prevalence Survey published in 2011 reported that just under 1% of UK adults meet the diagnostic criteria for problem gambling. This was a statistically significant increase of 50% since the previous BGPS study published in 2007. Gambling addiction is linked with a broad range of health problems including substance-use disorders, mood disorders, anxiety disorders and sleep disorders. Also, problem gamblers account for at least 30% of gambling spend and are particularly at-risk for debt and bankruptcy. Problem gambling has serious medical, social and economic implications: UK charity GamCare estimates £3.6billion as the cost to our economy.
MINDFULNESS INTERVENTIONS: A THIRD WAVE APPROACH
‘Second-wave’ cognitive behavioural therapies have in recent times been regarded as the ‘intervention of choice’ for treating problem gambling. Cognitive-behavioural approaches share a common mechanism of therapising via the restructuring of maladaptive core beliefs. In effect, clients are empowered to control and modify ‘faulty’ cognitions and to ‘self-intervene’ at the level of individual thoughts and feelings.
CBT has cautiously been advocated for the treatment of problem gambling, but relapse rates for problem gamblers can be as high as 75% and there is a scarcity of high-quality CBT trials reporting long-term follow-up data.
Over the past decade, mindfulness has been integrated into ‘third-wave’ cognitive behavioural approaches. Rather than a deliberate attempt to control and modify distressing thoughts and emotions – as happens in traditional second wave CBT approaches – third wave approaches operate via a mechanism of acceptance and transformative present-moment awareness.
Research exploring the potential utility of mindfulness as a treatment for addictive gambling has shown that higher levels of mindfulness are associated with reductions in severity of (i) gambling involvement, (ii) overconfidence and risk willingness, (iii) reward and sensation seeking and (iv) thought suppression. Clinical case studies also demonstrate that problem gamblers who receive mindfulness training show reductions in gambling urges, frequency and expenditure.
Demonstrable outcomes also include improvements in levels of depression and anxiety, along with greater awareness and regulation of gambling-related feelings and thoughts. These outcomes are consistent with findings from studies assessing the effectiveness of mindfulness for people with substance-use disorders (where interventions such as mindfulness-based relapse prevention have been shown to reduce craving).
MECHANISMS OF ACTION
Proposed mechanisms for effects of mindfulness on problem gambling and addictive behaviour centre on the acceptance, non-reactive awareness and ‘unfiltered present-moment-experiencing’ of mental urges, sometimes referred to as ‘urge surfing’. Paying attention to the ‘here and now’ enables clients to ‘surf’ cravings for euphoric states that are a means of ‘escaping’ from the present moment.
Another proposed mechanism is that of spiritual development. It is well known that 12–step programmes such as Gamblers Anonymous and Alcoholics Anonymous are founded on spiritual principles. Spirituality has been shown to increase subjective wellbeing and attainment of abstinence in those with a diagnosis of pathological gambling. From the Buddhist perspective, all forms of addictive behaviour can be viewed as maladaptive ‘spiritual coping strategies’.
Mindfulness can also help to reduce relapse and temper withdrawal symptoms via a form of substitution effect. Substitution techniques are already used in other problem gambling and substance-use interventions. ‘Bliss’ is often referred to in meditation literature as an outcome of certain concentrative forms of meditation. So it is feasible that ‘bliss substitution’ could be used to maximise the maintenance of beneficial outcomes in people with addiction disorders who have treatment using mindfulness techniques.
A THERAPIST-LED TECHNIQUE: SENDING OUT AN S.O.S
To exemplify how these principles can be applied in the therapist-client setting, the following outlines a technique used as part of a meditation and mindfulness intervention known as Meditation Awareness Training. MAT is a non-religious intervention in which participants attend weekly two-hour meetings over an eight-week period. Participants also attend one-to-one therapeutic support sessions in the third and seventh weeks of the programme, and receive a CD of guided meditations to facilitate daily self-practice. MAT is the subject of research we are conducting to assess its effectiveness as a treatment for problem gambling and other addictive behaviours.
During the guided meditations which are part of MAT, participants are instructed to rest their awareness on the in-breath and out-breath. Any forced breathing is discouraged such that the breath follows its natural course and is allowed to slow and deepen of its own accord (ie, as a regular consequence of it being mindfully observed).
While sitting on a chair or meditation cushion, a stable but relaxed posture is assumed. The analogy used in MAT for the appropriate meditation posture is that of a mountain. A mountain has a definite presence, it is upright and stable yet at the same time it is without tension and does not have to try too hard to hold its posture – it is relaxed, content and deeply-rooted in the earth. Thus, participants are instructed to adopt the posture of a mountain with both their bodies and minds.
Just as the mountain observes and is un-phased by seasonal change unfolding across its landscape – harsh winters give way to the relative warmth and serenity of spring, etc – those engaging in the intervention are instructed to nonjudgmentally observe the changing landscape of their minds, their changing thoughts and feelings. More specifically, clients are guided to acknowledge and recognise any addictive urges, a necessary step if they are to ‘let them go’.
This applies irrespective of whether their thoughts and feelings are deemed to be ‘positive’ or ‘intrusive’ (eg, craving-related). In this manner, a certain ‘perceptual distance’ is created. Thoughts become objectified and thus free to ‘self-liberate’ in the expanse of mindful-awareness. As with all psychotherapeutic change, the technique requires sustained practice and participants are discouraged from seeking ‘immediate’ results.
To account for difficulty in cultivating meditative concentration in people without prior meditative training, MAT employs techniques that can be used as gentle reminders or ‘meditative-anchors’. The ‘SOS’ technique is one such example for when intrusive or craving-related thoughts arise (during or outside formal meditation practice):
The three-step SOS technique for clients –
2. Observe the breath
3. Surf the urge.
The SOS three-step process serves to disrupt ruminative and/or intrusive thoughts and is intended to assist clients in regulating craving by re-focussing their attention on the present moment.
Although clinical evaluation is at an early stage, preliminary findings suggest that mindfulness approaches might be promising standalone or adjunctive treatments for addictive behaviours. But there are potentially impeding factors such as the relative reluctance of westerners to participate in introspective or contemplative practice.
Other integration issues relate to inadequate provision of dedicated addiction treatments by service providers. For example, in the UK only 3% of the 327 Primary Care Trusts, Foundation Trusts, and Mental Health Trusts provide a service – specialist or otherwise – for treating people with gambling problems. Likewise, only 20% of GPs report being able to access mindfulness-based interventions for their patients.
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