Mindfulness in Addiction Therapy

In my practice, I work with many clients whose addiction may be construed as a maladaptive response to “discomfort of unknown origin.” A patient will tell me: “I’m not sure how to describe it. I was feeling something. And before I knew it I had picked up.” Using mindfulness can help such clients explore, define, and overcome these painful feeling states so that alternative, non-addictive ways of responding can be employed.

Mindfulness is “in” right now. “Be mindful.” “Follow your breath.” “Accept the moment.” “Just breathe.” Research has shown that practicing mindfulness can indeed have a positive impact on affect regulation, concentration, impulse control, decision-making and self-care. The process of becoming nonjudgmentally aware of the different aspects of a compulsion weakens its power. That is why increasing numbers of clinicians are eagerly incorporating mindfulness into the treatment of substance use disorders, eating disorders, sex addiction and other compulsive behaviors.

At the same time, however, you have a responsibility to be mindful of exactly how to present the practice to a client. What expectations and assumptions are we inadvertently expressing? What values and goals are we implicitly communicating? And how can we tailor this approach to meet the unique needs of each client? Such an inquiry differentiates the “mindfulness” of pop culture from the mindfulness that deeply improves the quality of a life. Through my clinical practice and my own meditation practice I have found that being very cautious and thoughtful is crucial in applying mindfulness to the practice of psychotherapy.

Jon Kabat-Zinn, PhD, founding director of the Center for Mindfulness in Medicine at the University of Massachusetts Medical School, defines mindfulness in his book Full Catastrophe Living as “paying attention in a particular way: on purpose, in the present moment and nonjudgmentally.” To me, the fundamental aspect of mindfulness is the capacity to witness your internal experience in the moment rather than instantly reacting to it. But how do you teach clients how to be “mindful”?

With substance users, I often introduce mindfulness before we have fully determined a treatment plan or goal (for example, abstinence or moderation). Mindfulness can provide both the client and me with valuable information about what is unfolding inside. This is another benefit of mindfulness: the cultivation of curiosity about how our thoughts, feelings and body convey important information. More “data” can help promote greater understanding and healthier decision-making.

One of the first things I do is teach a client to slow down and note the mental “chatter” or “noise” that typically occurs nearly continuously with little awareness. The content is often harsh, critical self-talk that triggers discomfort that, in turn, activates the habitual, automatic response of substance use and other risky behaviors. Mindfulness can help clients become more aware of these patterns and develop the capacity to choose from a greater repertoire of responses.

Mindfulness drives at the root of compulsive behaviors by undermining the assumption that inner experience is intolerable and requires immediate relief through substance use.

I frequently work with clients who state that they consume more alcohol or other substances than intended. They are often unaware of the internal process leading up to this increased use. In addition, there may be feelings of shame, along with fears associated with being able to sustain long-term changes. Guiding attention back to the present moment in order to catch these mental habits as they occur, including the tendency toward shame and doubt, is key.

Here is a case study (based on a composite of several clients) that exemplifies my application of mindfulness to individual therapy:

My client Joan tells me, “I don’t know what happened. I started feeling uncomfortable, and before I knew it, I had three glasses of wine and don’t remember what I said during the rest of the evening or how I got home. Now I’m even more embarrassed and worried that I said something stupid. This is hopeless.”

Initially I try to model mindfulness through guided retrospection. I tell her, “Let’s try to relive that night: what you were thinking, how you were speaking to yourself, how your body was feeling, what sensations you noticed, and what led to the decision to have another glass of wine.”

I use careful questioning to unravel the specific details. Joan recalls that entering the social situation, she automatically compared herself to others and assumed that she did not measure up in some way. This thought process was associated with subtle changes in her body, including chest tightening, shortness of breath, and tension in shoulders and neck, and finally a holistic mind/body reaction that “this is intolerable.” For this client, like many others, this wholesale aversive appraisal triggers the desire for relief along with powerful cravings for substance use. All too soon it is the morning after and my client finds herself hung over and ashamed.

In our mindfulness work together, we practice noting this entire habitual pattern, and we explore the assumption that the only route of escape from the “intolerable” feeling is to have another drink. By now, Joan has become authentically curious about the ways in which wanting her thoughts and feelings to be other than they are in the moment can generate cravings for substances. While this practice is focused on remembering a specific moment in a risky situation, it helps prepares for future stressful moments.

Over time, we practice breathing exercises so that she can begin to notice her breathing during these moments. As she catches her breath becoming more constricted as her mind spinning toward self-criticism, she can slow down her breathing in order to tap into a sense of stability and groundedness. From there, Joan can shift her focus to her senses and re-attend to the holistic experience of the stressful situation and take thoughtful action.

An often-overlooked aspect of utilizing mindfulness in mental health is the assumptions that clinicians bring to the practice. As long as a collaborative, fine-tuned approach evolves out of a moment-by-moment understanding of where the client is, I find that people at many different stages of ambivalence, substance use, and recovery can benefit. Often, a therapist’s prerequisites to practicing or having specific goals about a desired outcome can be an obstacle. All you need is a curious, compassionate style of relating to experience.

Jenifer Talley, PhD, is a clinical psychologist in New York City. She is the assistant director of the concentration in Mental Health and Substance Abuse Counseling at the New School for Social Research. She is also a psychologist at New York City’s Center for Optimal Living, an addiction treatment center based on principles of integrative harm reduction psychotherapy. Her email address is talleyj@newschool.edu.

The author would like to acknowledge Sam Koval for his contributions to this article.

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