Day 5 - Mind and Life XXVII - Craving, Desire and Addiction

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The point of this summary is not to replace the complete video and nor is it fully comprehensive, but rather the intention is to give a brief overview of proceedings so as to assist the reader in determining which sessions they would like to watch in full. 

Day Five of Mind and Life XXVII - Sarah Bowen discusses the Application of Contemplative Practices in Treatment of Addiction

DAY 5 AM - Sarah Bowen
Application of Contemplative Practices in Treatment of Addiction

Dr Bowen presented an exploration of contemplative practice in the treatment of addiction. She explains the key practices and treatment targets, has a look at what the data says and where do we go from here?

One of the core features is the relapsing nature of addiction. There are approaches based on 12-step approaches and CBT, but still 60% in first year of treatment will relapse. Studies have looked at causes of relapse, and negative emotions are a primary cause, with craving, social issues and low self-efficacy (self trust as Marc has spoken about).

She described behavioural models of relapse, there is a trigger which leads to discomfort which leads to a craving which leads to use, and there is then a temporary alleviation, but soon there is more shame. Many addicts will describe this as almost automatic:

What they are trying to do is create an awareness that could lead to the ability to make a choice. The aim is to bring some level of curiosity, rather than avoidance, to the craving or discomfort. This takes some compassion.

Dr Bowen referenced Alan Marlatt's work in relapse prevention, as well as John Kabat-Zinn and Zindel Segal in the area of mindfulness. This informs mindfulness-based relapse prevention. It is working with patients who have completed initial treatment and consists of an 8 week out-patient program, 2 hours a week. It is group based. Each session has:
  • Formal meditation skills
  • Informal mindfulness practice
  • CBT skills
The intention is to have a progressive awareness. It starts with a very tangible external object. They start with eating a raisin as a first step - they explore the raisin using all senses. They then move towards intangible sensations such as breath, and then to thoughts and emotions.They move towards a more compassionate response. Finally they create an awareness of the relapse state:

In the course they dismantle craving, understanding what it is - just a thought, feeling or emotion. They look at the urge to react, and what they are projecting onto the object of desire. Can we pause and shift our focus in the midst of craving? This is what is being attempted.

The first session examines the sensation of eating a raisin. They then ask the patient to bring that level of attention to some other activity - brushing teeth, or putting on a shoe, for example. They also teach the body scan, so as to be more aware of the internal experience. This then moves to breath, thoughts and emotion. They use the mountain meditation for example so as to create a sense of groundedness and dignity. They also focus on kindness and self. This meta practice is extremely difficult to send kindness to self, so they tend to start with kindness for someone easy. Forgiveness is also integrated into this process.

They are attempting to examine the relationship between direct experience and reactions stories and judgement, so they can discern the difference between reality and perception. Within the group setting, people see that this is just how the mind works - it is not personal.

Dr Bowen explained the SOBER practice:
  • Stop
  • Observe
  • Breath
  • Expand
  • Respond
 She then went on to explain urge surfing. This explores experiencing craving, recognising it and "surfing" the wave of something that is transient. By learning to "ride" the wave of craving, we promote self-efficacy, and over time the experience of craving reduces.
Patients are encouraged to identify relapse thoughts. These are analyzed ahead of time and dealt with. Eventually patients can track the whole course of their process and can map this using a worksheet, and create alternative pathways.

Dr Bowen then discussed how they are putting this into practice, and the feedback that they had been getting. She discussed some of the outcome studies that they have been doing. There are about 24 studies across the field, and main outcomes suggest reduced substance use. Perhaps one of the reasons why is because of the changed relationship with the substance. It is still a fairly young field of study, and studies are small and have limitations.

The questions they needed to look at were:
  • How do we train clinicians and implement these programs
  • Who are they for and what are the mechanisms
  • How can they be adapted for other populations and settings
  • Motivation for treatment and practice

Dr Davidson asked about follow-up. Dr Bowen said that in the most recent study they had followed people over a year. They found in one study that 84% practiced outside sessions, and 2-4 months later over 50% were still practicing.

Dr Davidson asked HH for his reflections. HH said that this was perhaps more a painkiller, than the preventative - it was best to tackle the problem before it arose. He said it should be left to the experts, who could monitor, research and adapt. HH said that even in difficult circumstances our approaches and mental attitude is protective. He spoke about the human capacity to maintain compassion and peace of mind using examples of those who had been incarcerated in Chinese prisons.

Dr Bowen spoke about how they were expanding their research to, for example, problem gambling, impulsivity, anxiety and the like. In multi-problem groups, the individuals recognise commonalities.

HH pointed out that underlying craving is desire. Desire is not good or bad. What makes desire dysfunctional? It is often the object of desire. Awareness of the true nature of things is important. What is helpful, what is not. If you have a greater awareness, you have the ability to exercise choice. And this protects us from addictive use. Investigation and skepticism is vital. People who do not pay attention into the inner world of the mind get stuck - or habituated.

HH raised a very important point that we must keep a broader perspective. Dr Volkow emphasized that our knowledge is indeed limited, and we need to seek further understanding.

Diana Chapman Walsh raised the possibility that these approaches, rather than being a headache tablet, could be the doorway to change - in the way that Rosa Parks became uncomfortable with the duality of segregation and sat on a different seat in the bus. Sarah's approach may create the glimpse of another way of living.

Dr Ricard spoke how the surfing is a very useful image that can be used to reduce the levels of craving over time. The conversation continued around teaching the teachers and means of delivering these services.

I response to a question from Dr Berridge HH pointed out that these techniques need not be based in Buddhism, but rather in the common experience. Science is unifying. There is no right or wrong, but merely what is or isn't. Buddhism is a kind of inner science that seeks to understand the mind. Ultimate reality is the absence of independent existence.

Dr Davidson wondered how analytic meditation could be brought into play. HH said that scientists use analytical meditation all the time - their just needed to be a focus toward inner world.

Dr Lewis brought up the question as to whether addiction is a disease? Dr Davidson brought the session to a close before the question could be discussed - much to my disappointment!

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