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Buddhist Approaches to Addiction Recovery Dr Paramabandhu Groves Consultant Psychiatrist Islington Specialist Alcohol Treatment Service Clinical Director, Breathing Space London Buddhist Centre From craving arises sorrow and from craving arises fear. If a man is free from craving, he is free from fear and sorrow. (Dhammapada, 216) Buddhist therapeutic approaches Addiction in early Buddhism Approaches to addiction in countries with established Buddhist cultures • Thai detoxification • Naikan Contemporary western approaches • Mindfulness • Non-theistic 12 step • Integrated approaches Buddha exhorted disciples to avoid intoxicants Untoward effects of intoxicants: • loss of wealth • increased quarrelling • susceptibility to disease • losing a good reputation • indecent exposure of the body and • weakening of intellect Dangers of gambling • the winner makes enemies • the loser grieves for his losses • loss of wealth • his word is not trusted in assemblies • he is despised by friends and associates • he is not in demand for marriage, since he would not be seen to be able to afford to maintain a wife Behavioural interventions Thai detoxification • Response to heroin epidemic • One month detox using herbal medicine & religious rites • 20-30% abstinent at 6 months • Some go on to enter monasteries Naikan • Based on Shinshu Buddhism • Used since 1960s to treat alcoholics • One week of intensive meditation with reflections on family & friends • Less intensive meditation encouraged subsequently • Support owing to cultural congruence Mindfulness • Translation of ancient Pali word “sati” “awareness” – direct, open-hearted “knowing” • Traditionally cultivated by meditation practices – Learning to pay attention • Moment by moment • Intentionally • With curiosity and compassion Applications of mindfulness in the addictions • Mindfulness-based Relapse Prevention (MBRP) / Mindfulness-based Addiction Recovery (MBAR) • Dialectical Behavior Therapy (DBT) • Acceptance & Commitment Therapy (ACT) ABC of Mindfulness-Based Approaches • Develop Awareness • Learn to Be with experience • Making skilful Choices Bowen et al (2011) MBRP programme eight 2 hour sessions, each including: 1. formal mindfulness practices 2. exercises and skills designed to bring these practices into daily life, specifically into situations in which an individual is at high risk for relapse. SOBER Breathing Space Stop – step out of automatic pilot mode Observe – what is happening for you Breath – focus simply on your breathing Expand – be aware of mind, body & situation Respond – notice that you can respond with awareness. Bowen et al’s MBRP Session Structure 1) 2) 3) 4) 5) 6) 7) 8) Automatic Pilot and Relapse Awareness of Triggers and Craving Mindfulness in Daily Life Mindfulness in High Risk Situations Acceptance and Skilful Action Seeing Thoughts as Thoughts Self-care and Lifestyle Balance Social Support and Continuing Practice Research Evidence • Review by Chiesa & Serretti (2014) • 21 studies; 14 RCTs • 10 compared with waiting list, 9 with active intervention & 2 with non-specific intervention • Reduction of substance use • Some showed a reduction in craving and increased mindfulness • No adverse effects • Methodological limitations Alberto Chiesa & Alessandro Serretti (2014) Are Mindfulness-Based Interventions Effective for Substance Use Disorders? A Systematic Review of the Evidence. Substance Use & Misuse, 49:492–512 Research Evidence (2) • Review by Zgierska (2009) • High patient satisfaction • Between half and 80% continued to practise mindfulness after the programme had finished Parents under Pressure • RCT 64 methadone maintained patients • Parenting intervention including mindfulness v conventional parenting programme v tau • Improved parenting, child behaviour and dose of methadone • Dawe et at (2007) Playful, happy, creative thought Mindfulness training associated with enhanced activity in left prefrontal cortex Davidson et al 2003, Barnhofer et al. 2007 Left prefrontal cortex associated with feeling happy and more optimistic outlook EEG Studies Decrease in alpha and theta brain waves reported in meditators Chiesa and Serretti, 2010 Decreased alpha and theta waves are associated with heightened attentional activation and focus Attention and awareness Long-term mindfulness practice enhances activity in brain regions related to introspection and attention Lazar et al. 2005, Holzel et al 2008 Areas related to visceral awareness (i.e bodily sensations) also show heightened activity Lazar et al. 2005 Mindfulness for dual diagnosis? • Mindfulness appears to help depression, anxiety, stress, poor emotional regulation & avoidance coping • Helps cope with risk factors to relapse (e.g. depression) • Commonality of rumination & stress vulnerability DBT • Developed by Linehan for borderline personality disorder, subsequently adapted for substance misuse treatment • Mindfulness is part of package of treatment • Mindfulness is used to encourage acceptance and to extinguish automatic avoidance of emotions ACT • Developed by Steven Hayes • Based on relational frames theory • Not consciously drawn from Buddhism • Key components are accepting difficult mental states & committing to positive action Buddhism and the 12 steps Reasons for adapting / modifying 12 steps: 1. Seeking further spiritual support / sustenance 2. Rekindled earlier or complemented concomitant interest in Buddhism 3. Deeper levels of attachment to addiction not being addressed 4. Language off-putting or applied in dogmatic way 5. Group experienced as having evangelical Christian flavour Overlaps between Buddhism and the 12 steps • Meditation – 11th step (meditation and prayer) • śīla or ethics – 4th & 5th step (fearless moral inventory) Buddhism and the 12 steps Alternative formulations based on: Buddha The Three Jewels Vajrasattva Mutual aid Integrated Buddhist approaches • Refuge Recovery • Eight Step Recovery Based on Four Noble Truths & Eightfold Path First: addiction creates suffering Second: repetitive craving is the cause of addiction Third: recovery is possible Fourth: path of ethics, meditation and wisdom Step One: Accepting that this human life will bring suffering. Step Two: Seeing how we create extra suffering in our lives. Step Three: Embracing impermanence show us that our suffering can end. Step Four: Being willing to step onto the path of recovery, and discover freedom. Step Five: Transforming our speech, actions and livelihood. Step Six: Placing positive values at the center of our lives. Step Seven: Making every effort to stay on the path of recovery. Step Eight: Helping others to share the benefits I have gained. Thank you