It is 1 p.m., and just as I have done every Tuesday for the past eight months, I press the magnetic strip of my ID badge against the black plastic sensor outside the locked double doors of the Detox East Unit at Tarzana Treatment Centers. The locks click, and before the alarm sounds, I push open a door and find myself facing a long, ragged line of detox patients. Most are strangers to me, having arrived here within the past week. They look tired or restless as they eye me curiously.
“Are you taking us to the canteen?” one of them asks hopefully. “Nope,” I reply. “I lead the stress management group.” This is met with some grumbling, but one patient who has been here for a month on a methadone detox shakes her head and smiles. “So are we doing a tangerine meditation this week?”
“No tangerines; sorry,” I tell her. “But you’re in luck. I’ve got chocolate.” In a moment we are on our way to the lobby conference room, where for the next hour I’ll give them an experiential introduction to mindfulness meditation.
Since Jon Kabat-Zinn, PhD, and colleagues began the practice of mindfulness meditation with patients at the University of Massachusetts Medical Center’s Stress Reduction Program in 1979, the use of mindfulness meditation to treat a host of physical and psychological disorders has expanded to more than 240 hospitals and treatment centers throughout North America and Europe. (1) Over that same period, a growing number of research studies have demonstrated the therapeutic effects of meditation for physical ailments such as chronic pain, cancer, and AIDS, as well as for depression, anxiety, and borderline personality disorder. (2)
The work of G. Alan Marlatt, PhD, and colleagues has encompassed nearly 30 years of examining the positive effects of meditation on alcohol and drug abusers. (3) While my own work with detox patients is purely anecdotal, it has nevertheless affirmed my belief that mindfulness meditation is a practical tool that can be used for relapse prevention even at the earliest stages of recovery.
Although mindfulness meditation is free of any religious sectarian ideology, its roots may be traced back to Theravada and Mahayana Buddhism practiced in India around 500 BC.1 The practice of mindfulness meditation focuses on insight or vipassana, as it was called in a 5th-century text known as the Visuddhimagga (Path of Purification). The goal of this form of meditation is not to eliminate pain or stress or addiction but to use intentional, focused awareness to achieve a sense of nonjudgmental self-acceptance in the present moment.
Intentional awareness may be understood as putting one’s attention to one’s intention. It is through this willful, directed attention that the structure and chemistry of the brain begin to change, in what is now called neuroplasticity. (4) Just as a constant state of stress or the use of alcohol and drugs can dysregulate the components of the central nervous system, the daily regular practice of mindfulness meditation can enrich the brain’s neuronal structures, acting in effect like an antidepressant but without the accompanying side effects.
Achieving a state of nonjudgmental acceptance is, as the Buddhists say about meditation, “simple but not easy.” Patients new to recovery may be deeply self-judgmental, slinging arrows of guilt and shame at themselves for the destructive consequences of their addictive behaviors. In group, I hear stories of legal problems, financial ruin, damaged relationships, and physical and emotional self-destruction. Though some members have found a temporary peace by coming to detox, almost all feel trapped by the past and fearful for the future. To sit still in the present moment and simply breathe is difficult enough given their circumstances, but to cast off critical self-judgment seems nearly impossible.
Observing one’s thoughts
How, then, can the practice of mindfulness meditation possibly work with such a troubled population as patients in detox? Rather than target distorted thoughts with the goal of changing them, as in cognitive-behavioral therapy, mindfulness works through a mechanism that may be understood as metacognitive in nature. Mindfulness seeks to change our relationship to our thoughts without changing the thoughts themselves. (5)
I never directly challenge cognitions, but rather offer group members a means to detach themselves from the thoughts, feelings, and physical sensations that cause what Buddhists call dukkha or suffering. (6) I teach the concept of becoming a detached spectator or observer of one’s thoughts, in the sense that mindfulness allows us to recognize intrusive thoughts and feelings without asking us to act upon them. Pain may be chronic, but suffering is optional. Meditation allows us to respond rather than react. It reintroduces choice into our lives, and with that choice comes a renewed sense of self-efficacy.
In teaching mindfulness to detox patients, I have relied on imagery and metaphor to convey the concept of the detached spectator. I have asked the group to imagine staring up at the stars at night. As members breathe quietly, they may begin to observe certain objects: A satellite may glide across the quilt of stars or a meteor may blaze across the horizon. The blinking lights of a plane cross the sky more slowly, and the moon rises with its own deliberate speed. All these objects are like our thoughts, feelings, and physical sensations. Some flash for an instant, while others take hold of our attention for what feels like an eternity. Through mindfulness meditation, we accept that these objects exist, but without having to pay them more than passing attention. The detached observer notices the ebb and flow of his/her thoughts, accepts that these are occurring, and then lets them go, through the act of bringing attention back to breathing.
This notion of continually drifting from and returning to the present moment is essential to an understanding of how meditation works. The mistake most beginners make when trying to meditate is that of trying to clear their thoughts or push away negative thoughts and feelings in order to have a “good” meditation. This quickly becomes a futile exercise that leads to frustration and a sense of failure. On the contrary, the inevitable thoughts, emotions, and physical sensations that arise during meditation are exactly the material each of us needs to experience and release to make the meditation work. Each return to nonjudgmental self-acceptance —to self-compassion— is the healing, the practice, and the therapy of mindfulness.
This leads to the most crucial message I present to my patients in detox: Cravings and urges are a desire for things to be different from the way they are. Most addiction grows out of a conditioned response between attachment and aversion. Triggers cause cravings to be perceived as overwhelming. The subsequent bliss achieved through substance use creates its own attachment, which is compounded by an aversion to both the impermanence of the high and the suffering caused by withdrawal. (7) Suffering grows out of attachment to intrusive thoughts themselves, especially with regard to wanting physical states to be different. Just wishing for them to be different won’t make them different, however. Thus, relentless mind activity (ruminating, obsessing, etc.) causes at least as much suffering as the physiologic symptoms of addiction do.
Cravings and urges roll toward the addict like an insurmountable wave that threatens to destroy everything in its wake. But as anyone who has ever stood in the ocean and observed the waves as they break in the surf knows, even the largest wave flattens out as it makes its way to shore. If we can ride out the cravings, we can begin to understand their impermanence without needing to change or escape them. Marlatt and Kristeller call this “urge surfing,” (2) and it resonates well with my patients in detox because it suggests a means by which mindfulness meditation can help them hold off their cravings until they diminish.
Responding to resistance
Inevitably, some patients state their resistance to meditation. I treat their objections as a chance to model the flexibility that mindfulness teaches us. Chief among the complaints is that sitting and breathing is “boring” and that therefore it is impossible for them to meditate. This is where the chocolate comes in.
Mindfulness practice consists of both formal and informal meditations, in which everything from attention to breathing to mindful walking to the silent enjoyment of a meal becomes an opportunity for meditation. In my groups I have had patients talk about mindful showering, engine repair, drumming, fishing, and even making a bed. The chocolate meditation is especially helpful with detox patients because it allows them to respond to a benign craving by shifting their attention to the here-and-now.
After ascertaining whether anyone in the group cannot eat chocolate for health reasons, I distribute small chunks of dark chocolate. Our meditation consists of touching the chocolate, smelling it, and then placing it between our lips without putting it in our mouths. I ask the group members to focus on the thoughts and sensations this calls forth. Are their mouths salivating? Do they want to bite down on the chocolate? How hard is it to control the desire to slip the chocolate into their mouths? Then I ask them to shift their awareness from thoughts of chocolate to their breathing, focusing on each breath in and out. In this way, we begin to “urge surf,” letting go of our cravings as we turn our intention to breathing. Once this point is experienced and understood, we pop the chocolate into our mouths and savor the intensity of its flavors.
The detox unit is surprisingly a good place to begin the practice of meditation. Not only are patients feeling the painful physical effects of withdrawal, but they have become saturated with boredom, frustration, cynicism, fatigue, depression, and restlessness. My own mindfulness teacher, Jerome J. Front, has defined these as saturated states. Working with them allows detox patients the opportunity to begin to practice meditation when the iron is a little “hot.” Just as the time to weave your parachute together is not after you’ve jumped out of the airplane, the time to meditate for the first time is not in the midst of a superheated argument with your spouse, or during an overpowering urge to use when drugs are at hand. Within the safe confines of a locked detox unit, patients have the ability to focus on their own physical, emotional, and spiritual well-being.
Each group I run ends with a few minutes of processing. Some patients say they feel more relaxed after having meditated; others say they found themselves thinking of a peaceful place or holding onto a happy memory. To these patients I point out as gently as possible that this, too, is a desire for things to be different from the way they are. For those who remain cynical about their experience, I mention the Buddhist concept of “beginner’s mind,” of knowing what you don’t know, of opening your heart and mind to new possibilities.
All patients arrive at detox believing they have exhausted every other possibility for sobriety. They are stuck in detox without their drug of choice. What will we give them in return? Mindfulness meditation is a tool they can take with them that costs nothing more than a few minutes of their time each day. Yet every moment they live without intentionality is a moment lost forever. “This is your one precious life,” I tell them. “Are you going to show up for it or not?”
The reluctance to enter into a daily practice is perhaps the greatest resistance I face with my patients. To overcome this resistance and to kindle their motivation, I have relied on a powerful metaphor taught to me by Jerome Front. I lift up my hand and ask my patients to imagine that I am holding a glass beaker. Next, I ask them to think of all the toxins in their lives— their addictions, their depression, their pain, their most shameful secrets and self-destructive behaviors— and to pour these into this beaker, so that it is filled with a dense black liquid, like the ink of a squid. Then I ask them to imagine a large glass bowl on the floor beside me. I pour the noxious black liquid into the bowl. Now I ask them to imagine adding pure spring water to the bowl, drop by drop.
“How long will it take before that black grunge begins to dissipate and dissolve? How much water will we need to add for the gunk to disappear completely, as if it had never existed?”
I have their attention now. “Is there any less toxic liquid in that bowl than there was before?” Heads shake no. I can see their expressions brightening. “Right. It’s exactly the same. Only it’s no longer visible. Just clear fresh water. And that’s why we meditate every day.”
There are 10 minutes left before one of the detox techs will open the door to take the group back to the unit. I ask the members to settle into their seats comfortably, close their eyes, and focus their awareness on their breathing. I lift up a pair of Tibetan meditation bells to call us forth to the here-and-now. Eyes close, bodies settle into chairs, and a few group members sigh as they slow their breathing. I chime the bells together, and as their pure tone resonates throughout the room, we begin to meditate.
- Bishop S. What do we really know about mindfulness-based stress reduction? Psychosom Med 2002; 64:71-83.
- Marlatt GA, Kristeller J. Mindfulness and meditation. In: Miller W (ed.). Integrating Spirituality Into Treatment: Resources for Practitioners. Washington D.C.:American Psychological Association Books; 1999.
- Marlatt GA. Buddhist philosophy and the treatment of addictive behavior. Cognitive Behav Practice 2002; 9:44-9.
- Kabat-Zinn J. Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. New York:Hyperion; 2005.
- Segal Z, Williams J, Teasdale J Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York:The Guilford Press; 2002.
- Bien T, Bien B. Mindful Recovery: A Spiritual Path to Healing from Addictions. Hoboken N.J.:John Wiley and Sons; 2002.
- Bowen S, Parks GA, Coumar A, et al. Mindfulness meditation in the prevention and treatment of addictive behaviors. In: Nauriyal DK, Drummond M, Lal YB (eds.). Buddhist Thought and Applied Psychology: Transcending the Boundaries. London:Routledge Curzon; 2006.
Sidebar: Do Mindfulness and the 12 Steps Mix?
As most treatment programs either follow or encourage participation in a 12-Step program, patients often ask me whether the practice of mindfulness meditation is compatible with the 12 Steps. I point out that Step 11 speaks directly to meditation as part of recovery.
The Buddhist Four Noble Truths fit nicely with the Steps, and there are several books I recommend to patients in recovery who want to practice mindfulness within a 12-Step program. One Breath at a Time by Kevin Griffin, Mindful Recovery by Thomas and Beverly Bien, and The Zen of Recovery by Mel Ash are three of my favorites.
Originally published on Addictionpro.com on November 1, 2006.