The practice of mindfulness can be a powerful tool in preventing relapse and supporting recovery, says Dr Paramabandhu Groves.
Mindfulness has been a cornerstone of Buddhist practice for about two and a half thousand years. The essence of mindfulness is paying deliberate attention to our experience as it unfolds moment by moment, with an attitude of friendliness and curiosity.
In the late 1970s Jon Kabat-Zinn in Massachusetts started using mindfulness as a therapeutic modality, especially for people with chronic pain, but also for people with anxiety and stress. He developed an eight-week course called mindfulness-based stress reduction (MBSR) using mindfulness meditation and simple yoga. His work showed that about two thirds of people with chronic pain benefited, and benefits were maintained at four-year follow-up. In particular, people benefited if they continued to practise mindfulness, even if only informally (as oppose to formal sitting meditation).
Mindfulness-based cognitive therapy (MBCT) for depression was based on Kabat-Zinn’s work, incorporating some ideas from cognitive therapy. Depression has a high relapse rate, and the aim was to develop a maintenance form of cognitive therapy that could keep people well after they had recovered from an episode of depression. Although initially work began as cognitive therapy with some elements of mindfulness added in, it ended up being primarily a mindfulness meditation course. A three-centre trial showed that it reduced the risk of relapse in those with three or more episodes of depression, and subsequently it was included in the NICE guidelines for preventing recurrent depression.
MBSR and MBCT have generated a wide interest in using mindfulness for a range of conditions. A review in 2013 reported that there had been 209 randomised controlled trials involving mindfulness. Given the relapsing nature of addiction, the work on MBCT suggested mindfulness might also be helpful for use in addiction. Mindfulness-based relapse prevention (MBRP) is an adaptation of MBCT for preventing relapse into addictive behaviour.
Relapse prevention
The key components of MBRP are threefold (in a handy ABC). The first part is developing awareness. This is done through sitting meditation, a body scan, mindfulness of everyday activities such as walking or eating, and a ‘breathing space’ – a mini-meditation that can be done anytime during the day. Bringing awareness to simple activities like eating, we start to recognise that frequently our mind is not fully attending to what we are doing. Often our minds are caught up in worrying about the future or going over the past, rerunning arguments or playing out fantasies – a condition referred to as automatic pilot.
The sitting meditations provide an opportunity for watching the mind in more depth. For example, in the mindfulness of breathing meditation the breath is used as a focus. Inevitably the mind frequently wanders off from the breath, and in acknowledging where the mind has gone we can develop awareness of habitual thoughts and emotions. By recognising what is going on, we step out of automatic pilot, with its danger of running off down relapse-predisposing mental habits. Triggers and unhelpful mental patterns are recognised earlier, when it is easier to choose something other than an addictive behaviour. The second stage is learning to ‘be’ with experience. The emphasis is to not push away unwanted experiences, but instead find a way of letting them be. This helps to avoid suppression or unhelpful habitual reaction. It can also lead to a change in perspective so that thoughts and emotions are not over-identified with: thoughts are just thoughts, not (necessarily) facts.
The third stage is making skilful choices. On the basis of greater awareness and when not acting out of habitual reactions, it is possible to make wiser decisions about how best to act.
Is mindfulness effective?
Preliminary work suggests that MBRP may be helpful in preventing relapse into substance use. To date there have been eight randomised controlled trials. Two showed no difference from controls, but the others showed reduced substance use. Some studies also showed improvements in other areas, such as enhanced psychological and social adjustment, and reduced craving.
Mindfulness is being used with other therapeutic modalities. In developing dialectical behaviour therapy (DBT) for borderline personality disorder, Marsha Linehan included mindfulness as part of the package. Mindfulness is used to encourage acceptance and to extinguish automatic avoidance of emotions, and DBT has been adapted for substance misuse treatment.
Acceptance and commitment therapy (ACT) emphasises accepting difficult thoughts and emotions in the service of moving towards goals that are in line with a person’s values. Although ACT was not developed from the mindfulness tradition, mindfulness practices are now often used to enable the acceptance part of ACT. It has been used to help with a wide variety of disorders including substance misuse, for which there is a growing interest in its application.
Mindfulness appears to be helpful for a range of psychological disorders, as well as improving well-being and psychological functioning. For the future, rather than focusing just on relapse prevention (MBRP), mindfulness courses – referred to as mindfulness-based addiction recovery (MBAR) – may be seen as a support to the broader journey of recovery.
Dr Paramabandhu Groves is an NHS consultant psychiatrist at Camden and Islington NHS Foundation Trust, specialising in addictions, and clinical director of Breathing Space, www.breathingspacelondon.org.uk