A model of alcohol use that has been supported by a substantial
body of research is the self-medication hypothesis. (1) Based on this hypothesis, alcohol use often arises as a means of coping with or medicating other psychiatric problems, and individuals with psychiatric disorders use alcohol to reduce and manage their symptoms. (2) This may be explained in terms of negative reinforcement, which suggests that the reduction in aversive symptoms such as anxiety, following alcohol use, increases the likelihood of future use. (3,4) From this perspective, meditation may serve as a useful alternative to alcohol use and may result in some of the same positive consequences, including tension reduction and relaxation. In keeping with this, Glasser has described meditation as a "positive addiction" that may not be especially reinforcing in the short-run, but which is associated with long-term rewards such as greater psychological balance and wellbeing. (5) This is contrasted with "negative addictions," such as heavy drinking, which are immediately rewarding but related to a variety of negative consequences in the long run. (6) Meditation and mindfulness may also provide a useful antidote to the experience of craving, which is often characteristic of addictive behavior and is strongly related to relapse following a period of abstinence. (7) The heightened state of present-focused awareness that is encouraged by meditation may directly counteract the conditioned automatic response to use alcohol in response to cravings and urges. In addition, meditative awareness may be elicited as a response to the urge itself (6) and may create a pause in the individuals otherwise automatic and mindless chain of responses and reactions. Furthermore, meditation may encourage a greater understanding of the impermanence of all phenomena and an acceptance of one's current experience, even if this experience is one of tension or craving. This is in direct contrast to an addictive state of mind that is characterized by an inability to accept impermanence and a desire to alter one's current experience. (6) Greater awareness and acceptance of one's immediate experience may reduce the risk for relapse in a variety of ways. For instance, two factors that are strongly related to rates of relapse are negative emotional states and the tendency to attribute failure (to abstain) to personal weakness (abstinence violation effect). (6) A more accepting approach may not only encourage greater tolerance with regard to difficult emotional states but may also support a more compassionate and balanced evaluation of one's own actions, reducing the likelihood of spiraling into a relapse following a brief setback or a stressful event. In addition, continued meditation practice may increase self-efficacy, which may further reduce the likelihood of relapse and increase an individual's capacity to cope with stressful situations. (8) [ILLUSTRATION OMITTED] [ILLUSTRATION OMITTED] Finally, excessive drinking may also be conceptualized as a form of experiential avoidance, which is described as the unwillingness to remain in contact with one's experience (9) and is related to various forms of psychopathology. (10) Meditation counters experiential avoidance by encouraging direct, nonjudgmental, moment-to-moment contact with one's experiences without attempts at alteration and manipulation. A number of different meditation techniques have been utilized for reducing alcohol use and related problems, including transcendental meditation (TM), Vipassana meditation, and related mindfulness-based approaches. (11-13) In TM, the meditator is given a mantra (usually a spiritual word derived from Hindu philosophy) to repeat silently during two 20-minute periods each day, usually in the form of a morning and evening sitting practice with eyes closed. If the practitioner becomes distracted by thoughts or feelings during the meditation period, the instruction is given to gently return one's attention to the mantra. A clinical standardized form of TM has been published by Carrington and lists several mantras to choose from. (14) TM has also been described as facilitating a basic relaxation response that may underlie its clinical effectiveness. (15) Marlatt and Marques were among the first to apply the practice of TM as an intervention for high-risk college student drinkers. (16) The promising initial results led Marlatt and his research team to conduct a randomized trial comparing TM with two control vinyasa yoga groups (muscle relaxation and daily quiet recreational reading, each for two 20-min periods daily). Results showed that all three conditions reported significant reductions in alcohol use and associated drinking problems. (17) In a second randomized trial, meditation and daily aerobic exercise were found to be equally effective in reducing alcohol consumption, with both groups reducing their drinking significantly more than a no-treatment control group. (8) These findings are congruent with the definition of exercise and meditation as "positive addictions" that can substitute for "negative addictions" involving alcohol and other drugs. (5) Vipassana meditation is rooted in traditional Buddhist teachings. (11) This 10-day course consists of many hours of daily meditation (alternating sitting and walking meditation periods) that are held in silence, except for the oral instructions given by the teachers. Instead of using a mantra, Vipassana students focus their awareness on the breathing process and on physical sensations that occur throughout the body ("body-scan" meditations). The course also includes a series of hour-long evening discourses that cover basic Buddhist principles, including the "Four Noble Truths" associated with the cause and cure of human suffering and the misidentification of the "self" as a separate autonomous being. Researchers at The Addictive Behaviors Research Center at the University of Washington recently conducted a study to evaluate the effectiveness of Vipassana meditation as a standalone treatment program for alcohol and drug problems among inmates in a minimal-security prison located in Seattle. (18,19) Inmates were case-matched to a control group consisting of prison residents who did not choose to take the 10-day Vipassana course and were assessed for alcohol/drug problems at a 3-month follow-up following release from incarceration. Results showed that prisoners who self-selected the meditation course showed significantly less alcohol and drug use at follow-up, compared with inmates in the control group. (18,19) Vipassana meditation is one of several techniques that are designed to enhance "mindfulness," often described as a heightened sense of awareness that is open, present-oriented, and nonjudgmental (enhanced acceptance of the "here and now") in its experiential quality. (6) Mindfulness practice has also been shown to be effective in reducing chronic pain and reducing relapse among patients treated for depression. (20,21) Both of these programs consist of eight weekly outpatient group sessions lasting 2 to 3 hours, plus a weekend "retreat" that offers a more sustained opportunity to practice meditation and to apply it as an intervention for either pain or depression symptoms. As an extension of these mindfulness-based interventions for pain and depression, researchers in our lab are proposing the development of a new cognitive-behavioral treatment program for the treatment of addictive behavior, "Mindfulness-Based Relapse Prevention" (MBRP). The overall goal of MBRP is to develop awareness and nonjudgmental acceptance of thoughts, sensations, and emotional states through the practice of mindfulness meditation, and to practice these skills as a coping strategy in the face of high-risk trigger situations for relapse. (22) Teaching clients about the application of mindfulness skills to the experience of craving is an important tool in terms of promoting awareness and acceptance of physical reactions to substance withdrawal. In this 8-week outpatient group program, participants are taught specific relapse prevention strategies (enhancing self-efficacy to cope with high-risk situations for relapse, challenging positive outcome expectancies, and learning relapse management skills) in combination with setting up a regular mindfulness practice. Repeated exposure to being mindful in high-risk situations without giving into alcohol or drug use in the presence of substance-related cues should enhance self-efficacy and cognitive coping capacity. One example of how mindfulness meditation can be helpful in preventing relapse is known as "urge surfing." (23) In this procedure, clients are taught to visualize the urge or strong craving as an ocean wave that begins as a small wavelet that gradually increases in magnitude until it builds up to a large cresting wave. Using the awareness of one's breath as a 'surfboard,' the client's goal is to surf the urge by allowing it to first rise up and decline without being "wiped out" by giving into the urge. Clients are told that most urges are classically conditioned responses that are triggered by environmental cues and emotional reactivity. As with an ocean wave, the conditioned response grows in intensity until it reaches a peak level of craving. By successfully surfing the urge, the addictive conditioning is weakened along with an enhancement of the client's self-efficacy and acceptance. The process of incorporating a mindfulness practice and learning to accept and tolerate urges is compatible with the process of developing a repertoire of coping skills within relapse prevention therapy. The empirical literature on approaches that utilize some form of meditation is promising and may provide an efficacious, low-cost alternative or supplement to existing treatments for substance use problems. In addition, research suggests that these approaches are not only related to reductions in substance use, but may also lead to improvements in psychosocial functioning, and may extend the duration of treatment effects by providing the skills to prevent relapse. References 1. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry 1997;4:231-244. 2. Blume AW, Schmaling KB, Marlatt GA. Revisiting the self-medication hypothesis from a behavioral perspective. Cogn Behav Pract 2000;7:379-384. 3. Carey KB, Carey MP. Reasons for drinking among psychiatric outpatients: relationship to drinking patterns. Psychol Addict Behav 1995;9:251-257. 4. Chutuape MA, deWit H. Preferences for ethanol and diazepam in anxious indiviudals: An evaluation of the self-medication hypothesis. Psychopharmacology 1995;121:91-103. 5. Glasser W. Positive Addiction. New York, Harper and Row, 1976. 6. Marlatt GA Addiction, mindfulness, and acceptance. In: Hayes SC, Jacobson NS, Follette VM, et al. Acceptance and Change: Content and Context in Psychotherapy. Reno, Context Press, 1994, pp 175-197. 7. Sayette MA, Shiffman S, Tiffany ST, et al. The measurement of drug craving. Addiction 2000;95:189-210. 8. Murphy TJ, Pagano RR, Marlatt GA. Lifestyle modification with heavy alcohol drinkers: effects of aerobic exercise and meditation. Addict Behav 1986;11:175-186. 9. Hayes SC, Wilson KG, Gifford EV, et al. Experimental avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol 1996;64:1152-1168. 10. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, Guilford Press, 1996. 11. Hart W. The Art of Living: Vipassana Meditation: As Taught by S. N. Goenka San Francisco, Harper and Row, 1987. 12. Marcus JB. Transcendental Meditation: A new method of reducing drug abuse. Drug Forum 1974;3:113-136. 13. Marlatt GA, Kristeller JL. Mindfulness and meditation. In: Miller WR. Integrating Spirituality into Treatment: Resources for Practitioners. Washington, DC, American Psychological Association, 1999, pp 67-84. 14. Carrington P. Clinical Standardized Meditation. Kendall Park, Pace Educational Systems, 1979. 15. Benson MDH. The Relaxation Response. New York, William Morrow, 1975. 16. Marlatt GA, Marques JK. Meditation, self-control, and alcohol use. In: Stuart RB. Behavioral Self-Management. New York, Brunner/Mazel, 1977, pp 117-153. 17. Marlatt GA, Pagano RR, Rose RM, et al. Effects of meditation and relaxation training upon alcohol use in male social drinkers. In: Shapiro DH, Walsh RN. Meditation: Classic and Contemporary Perspectives. New York, Aldine, 1984, pp 105-120. 18. Bowen S, Witkiewitz K, Dillworth T, et al. Mindfulness meditation and substance use in an incarcerated population. Psychol Addict Behav 2006;20:343-347. 19. Marlatt GA, Witkiewitz K, Dillworth TM, et al. Vipassana meditation as a treatment for alcohol and drug use disorders. In Hayes SC, Follette VM, Linehan MM. Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition New York, Guilford Press, 2004. 20. Kabat-Zinn J. Full Catastrophe Living. New York, Delacorte, 1990. 21. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse New York, Guilford Press, 2002, pp 175-197. 22. Witkiewitz K, Marlatt GA. Mindfulness-based relapse prevention for alcohol and substance use disorders: the meditative tortoise wins the race. Journal of Cognitive Psychotherapy 2006;19:221-228. 23. Marlatt GA. Buddhist philosophy and the treatment of addictive behavior. Cogn Behav Pract 2002;9:44-50. In spite of the cost of living, it's still popular. --Kathy Norris G. Alan Marlatt, PhD, and Neharika Chawla, MS Addictive Behaviors Research Center, Department of Psychology, University of Washington. Reprint requests to Alan G. Marlatt, PhD, University of Washington; Addictive Behaviors Research Center, 210 Guthrie Annex III. Seattle, WA 98195. Email: [email protected] https://www.thefreelibrary.com/Meditationandalcoholuse.-a0162977433
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