Treatment of Alcohol and Substance Dependence: An Introduction to a Mindfulness Based Approach to Assessment and Treatment
- 1. MD Psychiatrist, Providence, Rhode Island
CITATION
Ackerman BL (2017) Treatment of Alcohol and Substance Dependence: An Introduction to a Mindfulness Based Approach to Assessment and Treatment. J Subst Abuse Alcohol 5(1): 1053.
INTRODUCTION
Meditation/mindfulness based approaches offer a wealth of new ways to assess and intervene with those struggling with the challenges of substance use disorders. In this paper, I will introduce some of the core concepts and languages of a meditation /mindfulness based approach, and illustrate how they can be applied to assessment and treatment. I will introduce terms and conceptual frames, such, as cultivating awareness of our double nature, our dramatically shifting mental states, cultivating awareness of our over identification with our negative mental states, expanding the scope of toxicity awareness to include toxic thoughts and feelings and not just substances. In the context of toxicity, mindfulness is taught as essential filtering mechanism, a kind of mental dialysis to help to detoxify these toxic thoughts and feelings. Bringing to awareness toxic levels of shame and self-hatred, and helping our patients detoxify these insufferable mental states is as crucial to the success of treatment as exposing positive blood and urine levels of alcohol and substances. We also help our patients see that beyond toxic shame and states of self-hated, they need to detoxify the normative negative mental mind states as manifested by their vulnerability to reactivity, to irritability and anger, and to negative judgment of self or other. From the meditative/mindfulness perspective we help our patients to better self observe, and to simply witness how negatively reactive their minds are, and that however, unwittingly they have become identified with their negatively reactive minds. We then teach them ways, with this greater mind awareness that they can learn to better restrain or transform their reactivity. We also teach them that their noisy, reactive mind functions as a hindrance on their path, an obstacle blocking their access to their best and higher selves. Our therapeutic alliance with them, offers to join them and support them in their effort to free themselves from the noise in their heads. Access to silence and peacefulness thru meditation is juxtaposed to the domination of a noisy and distressed mind and drug usage is postulated to be a counterproductive attempt to self-medicate and to shut the noise off.
The first function of mindfulness, then, is to cultivate awareness of the noisy mind, learn how to, at least, quiet it down, if not shut off the noise in ways that are not harmful. The second function of mindfulness is to help gain more ready access to states of well-being. We teach our patients how to cultivate the capacity to be aware of their double nature and how to witness the two sides, to both lower self observe, and Higher Self observe cultivating a clear seeing nonjudgmental consciousness. A meditative/mindful approach helps our patients to be more self and Self aware and to better self restrain and Self pursue. Rather than buttressing their observing ego. We teach them how to actually observe the ego, to become curious about it, and gentle with it, as if they are witnessing an incredibly interesting wild animal at a watering-hole on safari and they are there, very alert, silently watching, witnessing. Meditation practice is designed to practice gaining access to and cultivating this alert, clearseeing, non judgmental, silently, witnessing consciousness. We call upon our patients to witness themselves; both their negative and positive selves, with the same alert, curious, silence. At first, they will learn to see their-negative shadows their feelings and thoughts of inadequacy, failure, feeling cheated, victimized, and misunderstood, as these kinds of feelings come to feed at the watering hole most often. But if they wait silently, patiently, they will begin to witness watering hole visits from a rather remarkable species their positive shadow feelings such as that they are-good at heart, and have a positive potential yearning for the light of day, to grow and blossom. This yearning can also be called a craving and we can suggest to them that their ‘drug cravings’ particularly those that persist or reoccur far after the window of withdrawal has passed, are nothing but disguised substitutes for their truer cravings for health and well being, and to love and be loved. Perhaps the term cravings should be restricted to that which we truly need, and the term urges for all else we might think we want. For example, we crave salt when salt-depleted, or thirst for water when we are dehydrated. It can also be said that we crave for health and wellbeing. We might have urges to use drugs, but we would not crave for something that is harmful to ourselves. A mindful approach helps us to make the distinction between our true cravings and the urges we have for a multitude of things that might entice us but which may be harmful to us.
Although each individual story of human suffering is compelling in its own right, a meditative/mindful approach steps back and takes a wider angled view on the nature of human suffering itself. The Buddha postulates, in his writings on the Four Noble Truths [1]that the source the source of human suffering desires mind it because it is always wanting and never satisfied, and, at best, can only be temporarily distracted. Some meditative teachings invite seeking a state of desirelessness, which I think makes the point about the desiring mind but ultimately becomes confusing and misleading because not all desires are created equal and not all come from the desiring mind. In my own meditative teachings, I suggest that our higher consciousness, too, has desires, but these higher desires are qualitatively different and can not only be satisfied, but that it is their very satisfaction that brings us incredible contentment and joy. A mindful approach then calls upon us to see beyond the desiring mind and see how our desiring mind functions to give us an obstructed view of our truest desires. The desiring mind often functions like a misguided GPS taking us to places that don’t truly provide the joy, contentment, and inner peace that we seek.
Finally, a mindful approach revisits the disease model of addiction, and finds that for most stages of the condition, the struggle with substances, it is the intense discomfort, the disease, if you will, which is the illness. A traditional disease model is more helpful for diagnosing and treating states of intoxication and withdrawal, but becomes confusing and misleading when dealing with other stages. While this patient population suffers a number and variety of different co or underlying maladies, one common drum beat is that substance users simply, more often than not, cannot stand the way they feel and are uncomfortable in their own skins. This is the core disease that needs to be treated. The treatment required is tantamount to having a psychological root canal
Neuroscience is helping to trail blaze the intersection between our neurochemistry and our mental states of mind, and the latest findings about neuroplasticity [2], may well suggest that both disease and dis-ease models are operating simulcast, that the psychological and neurochemical are interacting and interdependent. Neuroplasticity basically suggests that in an ongoing way we continue to form and deepen neurochemical channels in our brains. As a negative channel deepens, more negative associations flow through it and the more negative stuff that flows through it the deeper the channel gets. The most exciting news of neuroplasticity is our capacity to effectively dig new channels and change the flow pattern, so that we are learning to change not only our minds but also our brains. These neurochemical channels functions like irrigation channels for water around our houses helping to keep our basements from flooding. Meditative/ mindful approaches can be seen as functioning to harness this neuroplasticity by helping us dig new channels, making it easier for our positive associations to wellbeing and our desires for selfcare to flow. In this sense, meditation first acts as a sump pump to get the water out of our ever flooded minds. Then, it secondly functions to help prevent future flooding by digging new irrigation channels around our houses to divert the water and help prevent our mental basements from reflooding. Without these functions working, we are left to get the water out of the basement pail by pail, and all our life energy is diverted into this endeavor and we are exhausted by this flooding experience. But when our sump pump and landscaping are functioning properly, our life energy can be applied to the third function of meditation/mindfulness which is to access more directly and more frequently states of well-being and deepen the neurochemical channels which allows our positive feelings and aspirations to flow more readily. We teach our patients how to function like mental gardeners tending their garden, pulling the weeds that grow and sap the energy from the same soil that the fruits and vegetables that nourish us do. We teach our patients to identify with that, which is nutritious, and to identify but not be identified with the weeds. Once they see the potential of their garden for growth, we ask them to accept the responsibility to be weeders and growers and to see to it that their garden flourishes.
Meditation/mindfulness calls on us to be more aware of our varied mental states [3], and helps us learn how to facilitate the shift [4], from one mental state to another, more specifically from a negative, distressed state, to a more positive, more centered state of well-being. Like learning to drive a stick shift, mindfulness teaches us to be alert to when the engine is grinding calling on us to shift gears. Mounting feelings of impatience, irritability, depression and anxiety can become the sounds of that grinding that signal that it is time to shift gears, shift out of that uncomfortable state. Without a shift, the negative mental state often snowballs and becomes unbearable. While individual stories of substance dependence vary, one common theme is that users simply cannot stand the way they feel and use drugs in order to get relief from and alter their distressed states. Moreover, quite alarmingly, they are willing to risk liver damage, brain damage, and death to get that relief, however temporarily.
Meditative/mindfulness approaches help our patients to realize they have gotten too caught up in their heads and their mental anguish, and proceeds to teach them ways to help get out of their heads. Breathing techniques are commonly used and are fundamental to helping them of the shift out of the head into the greater body. But a breathing focus is far more than a technique. Meditation is taught as a means to free the mind of toxic thoughts and feelings. This mental dialysis is seen as essential to our well being as breathing is. All life is predicated on the ability to both take in what is needed and excrete what is not and especially that which is toxic. Breathing is also taught as a reminder to us of our aliveness and vitality and our essential connection to the universe and the air that surrounds us. The vastness and silence of the universe that surrounds us is contrasted with our noisy, obsessive pre-occupations. Meditation helps us find our inner silence our inner peacefulness, and we are called upon to find a perspective, a mental state that functions like the universe does, in that it can hold it all. The universe holds the earth, sun, moon, and other planets, all the chaos and the peacefulness, our joys and sorrows and we are called upon to be like the universe and cultivate a consciousness that can hold all the good, the bad, and the ugly. This holding capacity helps us reach a state of inner peace and equanimity, because this holding capacity remains relatively unperturbed by the disturbances.
We help our patients see how many filters we have built in order to live lungs to breathe in O2 and release CO2 , kidneys to free the blood of BUN (Blood Urea Nitrogen), digestive systems to take in nutrition and get rid of the rest. We also help them see it is part of the human predicament to discover that there is no built in filter for mental toxins, which have nowhere to go, stagnate, and pollute our state of well-being. We can begin to see that our very survival depends on our developing filtering mechanisms to free ourselves from the pollution. Meditation, sitting silently, quieting the mind, paying attention to our breathing is taught as an essential filtering tool, but we also encourage our patients to develop many additional filters exercise, having fun, playing games, laughter, music, dance, Tai Chi, reading, friends, support groups, all can help release the toxins.
Mindfulness teaches us that there is a way to reach more deeply gratifying states of well-being that has no risk of addiction or death, that if we dig deep enough into ourselves there is a buried reservoir of our well-being that is joyous, peaceful and filled with equanimity. The substance user seeks relief from their internal distressed states, by using a substance from the outside to cure or fix what is wrong inside them. To them, taking the drug is like taking an aspirin for a headache. A mindfulness/meditation approach acknowledges the intensity of the distressed state, validates the yearning to be free, if not freer from it, but tries to persuade the user that self medicating their distressed state is actually harmful, and that true relief can be found from by gaining more direct access to the reservoir of well being inside themselves, rather than from outside them.
Mindfulness/mindfulness approaches share much in common with standard therapeutic approaches, and can be used as an adjunct to, or complimentary, to more traditional approaches. There are also importance differences that are crucial to understand. A traditional therapy approach helps our patients identify the traumas they have experienced, get in touch with how they were affected by them, and helps them express and work through their feelings more constructively. A mindfulness approach sees and acknowledges the same emotional terrain, but takes a very different approach to it. It takes a wider angle picture of human suffering and postulates that even before we are subject to psychological traumas that our human nature is hard-wired, and soft-ware programmed to suffer that we are at our core-dual natured [5], caught in an arm-wrestle between our suffering nature and our well being nature. In this tug of war, the waves of their well-being are constantly pitted against the undertow of their angst, their dread, The cornerstone of our higher selves sense of lack, failure and deficiency. Mindfulness teaches us to be aware of both parts of our nature, and to recognize how the default setting of our minds, analogous to the set point on s thermostat, is unfortunately set to the negative, distressed, dissatisfied state, what mindfulness calls the normative mind set. The normative mind is contrasted to the most important dimension of our consciousness often referred to as our higher consciousness. Our true source of healing, recovery, and well-being comes from our higher consciousness and we teach our patients to get better access to this healing source. Mindfulness teaches that all people are afflicted with the relative dominance of the normative, suffering, negative mind over that the part of our consciousness that houses our well-being our Higher Consciousness. This, in turn, helps us to understand the purpose and function of meditation and mindfulness is to reverse this dominance. We empathize that this is no easy task, and is akin to teaching a right to be a lefty, but that the benefits more direct and consistent access to our well-being and self-worth, better self-care, better self-restraint to avoid toxins whether those be thoughts, feelings, or substances, makes the effort worthwhile. Another benefit of tying this mindfulness work to the core struggles of all human beings struggling to come to terms with the human nature is that it can help users lessen their feelings of being misfits, and to understand that their struggle to reverse this dominance is shared with all of humanity.
Most substance users will readily agree that their drug usage is a form of self-medicating their disease, and those of us who prescribe medications to help them have to admit that the medications we do prescribe them don’t work that well, and, in most cases, only offer partial relief. Prescribers, however, generally can make the case that the medications they prescribe are not that harmful, while the drugs of self-medication are taken with great risk, but because our medications do not work that well, it is important we offer our patients additional ways to reach well-being that are neither drug nor medication dependent.
On one level, we are helping our patients become aware that their wonder and party drugs are actually toxic to their brains, livers and minds. On another level, we are making the case to them that beyond clearing their brains and minds and bodies of chemical toxins that they also need to learn to clear their minds of mental toxins. The negative thoughts and feelings that swirl around in their minds on a rather constant basis and which are easily inflamed by life stresses. A clinical example illustrates this. Jessie, a 54 year old man, living in Rhode Island, with a 30 year history of alcohol abuse had spent his last 4 ½ years proud of his hard fought for sobriety, when he received a call from his biological father with whom he had an estranged relationship because of the father’s repeated physical and emotional abuse of him during childhood. His father was seeking his son’s support and he was having some new health problems. Jessie had some hesitation but his wish for a better relationship with his father overcame his hesitancy and he hopped on a plane to visit his father in N Carolina. The visit went terribly and his father and stepmother both became verbally and emotionally abusive to him, and by the end of the week when he left to fly home he was an agitated wreck. Then, his plane was delayed 5 hours at the Charlotte airport and before long he ‘wandered’ into an airport bar and 4 ½ years of sobriety went down the tubes. In talking with him about this relapse, I invited Jessie to become aware that his willingness to expose himself to a different ‘toxin’ his father was an equivalent to his willingness to expose himself to the toxin alcohol. He said he had never thought about it that way before. The next area of clinical work for Jessie was to help him be aware of the ‘toxic’ things he said to himself and the ‘toxic’ feeling she had both as a child and again during his most recent visit and help him get to work to free himself from these mental toxins as well as staying clear of alcohol.
We are also trying to help our patients realize more fully their drug usage is not only self-injurious, it is actually a disguised form of suicidality, in which the intensity of how negatively they feel about themselves leads them to think the world would be a better place without them. Some also harbor a homicidal rage toward someone who severely abused or neglected them. We want our patients to be aware of the intensity of their shame and self and/or other hatred, and help them realize their potential to live a life freer from such toxic feelings. The opposite of the willingness to expose oneself to toxins is the willingness to take responsibility for taking care of oneself. So many of our patients still yearn to be taken care of because their healthy dependency needs to be protected and taken care of as children were so frustrated. Instead of offering these parents yet another chance to get it right, we try to persuade our patients to learn to be the caring parents to themselves that they never had. We want them to think of themselves as worth taking care of.
One of the ways they explained away, in their minds, why they were so abused or neglected by their own parents, was to conclude that they were bad kids and caused their parents to act that way. By continuing to act out with substances they manage to continue the story line of their badness, and all the negative consequences that come with their substance use withdrawal seizures, black outs, DUI’s, jail time, as just more punishment for their badness. A mindfulness approach works to help them shift their focus from proving their badness to accessing their goodness. Many have never even thought they had goodness in them. One of my patients was subjected to severely sadistic parental abuse and claimed he had no positive memories from his childhood at all. I pressed him on this saying. I can understand how the horrible memories might dominate, but no positive memories whatsoever?? The next session he excitedly reported memories came back to him of riding his bike as a kid which he had completely forgotten about. We help our patients to recover positive memories buried in troubled pasts and even more importantly to access positive feelings they have about themselves often buried under layers of self-hatred. At times, this can feel like gluing the pieces of a shattered vase back together, but we align with our patient’s underlying yearning for wholeness, and make sure they know that we get it, that there is more to getting well than just refraining from drug usage.
Because of the remarkably high relapse rate with this population, we also need to direct our meditative/mindful approaches to relapse prevention, which starts with helping our patients to have greater awareness of the multitude of relapse triggers, whether that be a dirty look, a seemingly minor setback, the arrival of a pay check ($ for drugs), or something more significant like not getting accepted into a residential program, or death of a family member or friend. We want to help them anticipate these triggers and learn how to dance differently with them. One aspect of their vulnerability to triggers is that the mind is trigger happy, and human nature is wired to return to the reactive mind, as its default, operating system, which is like having a car that stalls every time it comes to a stop. To avoid this frustration, the astute driver learns to keep some light pressure on the gas pedal when stopping to avoid the stall. This vulnerability to return to this trigger happy state is one of the reasons, our patients feel so anxious and vulnerable, as if there is no one in charge, no part of them that they call on or rely on to restrain harmful reactions to the triggers, and they feel fragmented, on the edge of cliff anticipating falling off. When the mind is in charge it is like an immature baby sitter who is watching TV or talking on the phone and ignoring the baby. Because most of this patient population does not feel centered, and feel like they are held together by Scotch Tape, the slightest set back can set them reeling. Meditative/mindful approaches seek to help them to discover and uncover their more unflappable center and in some cases build a new center if they can’t seem to find theirs.
One last aspect of helping our patients understand their double natures that I will touch on here is helping them cultivate the awareness that their life story is being narrated, in their heads, as their life unfolds, by two very different narrators one positive, compassionate, describing the many obstacles they have had to face in their lives. I call this their Morgan Freeman narrator. They have to listen closely to hear this narrator, as it is most often drowned out by the other narrator their inner critic, which seems to relish every opportunity to chastise them, remind them of all their failures and proclaim they, will never amount to anything. At times, when there is no Morgan Freeman voice to be found, they have to learn to do a voice over of their inner critic.
The story lines of those who use drugs so often contain horrible stories of abuse and neglect. One, in particular, that I recall, is of a woman who as a young girl was used as a sexual object by her parents so they could get the money to support their drug habits. This is shockingly not that unusual. Our task as therapists is to acknowledge the multiple ways they have felt put down, suppressed, smeared, invalidated, humiliated, mocked, abandoned, lied about, stolen from, crucified and bruised and need to heal from this rather intense woundedness. One of the ways we help them heal, or at least carry their bruised hearts, is to help them move beyond these stories and write a new life chapter, not dominated by the past, one that is not only free of toxic substances, but free of toxic people and toxic memories as well. We also help them to become more aware of just how much they blame themselves for these traumas, and how they have replicated a sense of badness about themselves that was drilled into them when they were kids. A life of drugs serves to kill 3 birds by getting stoned, it internalizes the abusive rejecting, ignoring parent by continuing to neglect their most basic need for safety; it maintains the illusion that they and their badness is now and was then the root cause of their problems and it expresses the rage they feel for being so mistreated. I was raised so irresponsibly and you now expect me to take care of myself. By punishing themselves with drug usage and its consequences, they also punish the interjected abusive parents who wreak havoc in their present lives by occupying a significant part of the back of their minds, continuing to chastise them from behind the curtain.
A mindfulness approach helps these patients uncover their buried sense of goodness, and helps them release their feelings of badness. We invite them to live in the -here and now-not in the past, and if need be, imagine they have someone in their lives who truly advocates for, and truly cares about their welfare and teaches them how to invoke this ally to help guide them in their decision making and quest to make a better life for themselves.
A meditative/mindful approach does not treat all feelings as being equal and largely regards the negative spectrum feelings, irritability, impatience, boredom, anger, resentment, bitterness et.al.as foot soldiers of the mind and the more they are dominated by these feelings, the more they are held hostage by their minds. A mindful based therapeutic approach is not so much to get them to express these negative feelings as it is to be aware of them, and to be aware that holding on to them is tantamount to holding onto barbed wire. We then direct our efforts to helping them be more aware how holding on to these feelings hurts themselves, and then we help them to release them. When the distractions from the negative emotions are lessened, we then invite our patients to see if they can be more aware of their positive spectrum feelings, their gratitude, their compassion, their selfregard, their kindness. We are giving them permission to turn the TV off so that they can hear the voice on the telephone and this becomes a metaphor of developing the ability to shift out of agitated states and reach for communication and connection with higher centers.
In summary, a meditative/mindful approach to assessing and treating those challenged by substance use, offers a number of innovative approaches, some of which simply compliment traditional treatment strategies, and some of which are fundamentally different in conceptualization and treatment of the problem. In a mindful approach, we help our patients cultivate a non-judgmental, alert and witnessing consciousness that is able to see more clearly how dominated they are by their reactive minds [6], and the attendant emotional and cognitive foot soldiers of the mind. We teach them how to access their often buried reservoir of well-being and goodness and help them learn how to observe, witness, and restrain the mind in order to help bring out the best in themselves. We call upon them to expand their thinking about detoxification to include their toxic thoughts and feelings about themselves and encourage them to use meditation/mindfulness and other approaches to become more aware of just how polluted their minds are, and for which a filtering mechanism is required. Freer of this pollution, there is a calmer, more joyful consciousness that can better help them to restrain from relapse or nip it in the bud sooner. This frees them up to pursue healthier goals, the most essential of which is to learn to feel good about themselves, and to access and help bring to fruition their best selves.
