Clinical Handbook of Mindfulness (82 page)

difficulties. Drug addiction would not be so great a problem if this were

not the case. If this were not the case, no one would be very tempted by

addictive substances. It is precisely because they work so effectively, in this

sense, that drugs are so compelling.

I emphasize, however, that the effect is short term. On the one hand, one

may take a drug initially to enhance a positive experience. The individual

finds herself with friends, and wants to really let go and have fun with them.

Or she wants to celebrate a success. On the other hand, she may use drugs

to turn off pain. A friend said something insensitive. The anticipated salary

increase was not offered. She uses to turn off the pain for a while. But as

the tendency to use a drug for such purposes gradually increases, the drug

at the same time comes to lose its positive effects. Because of physiological

and psychological tolerance, she tries to use more and more of the same

substance to try to get back to that original, appealing state of mind, that

effortless and paradisiacal feeling that made the drug so attractive in the first

place. But ultimately, this is a matter of quenching thirst with salt water, and

the effort fails. Paradise cannot be re-entered in this way.

What is considered problematic use varies considerably across cultures.

What Americans would consider serious alcoholism evokes puzzled looks

from Australians, who might consider such a level of consumption at most

heavy, social, nonproblematic drinking. Traditional Jewish culture incorpo-

rates wine into family rituals such as the Passover Seder, and Jews are

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traditionally low on rates of alcoholism until perspective on what constitutes

normal wine drinking, while eastern Europeans are known for their love

of vodka. But the clinical key to determining what constitutes problematic

drinking within a cultural context is the impact it has on one’s life, health,

well-being, and life functioning.

However, the diagnosis is made of what constitutes abuse or dependence,

once the pattern of dependence is established, drug use is far from a benignly

altered state in which one takes temporary respite from one’s problems or

enhances a celebratory mood. Instead, as one seeks the drug with increasing

frequency, one’s life becomes centered on maintaining supply, the rituals of

drug use, and recovering from the episodes of use. There are few resources

left to invest in solving life problems. Work and relationships are neglected

and financial resources are wasted. Increasingly, when the addicted person

tries to cope with life, the life he encounters is one that is painful and out of

control. In the face of these difficulties, he has only the one highly developed

and overpracticed response: use.

At this point, drug use has little to do with pleasure. Many individuals who

have been addicted for a long time report that there is actually very little that

remains enjoyable any more about using their drug. One reason for this may

be that the body becomes conditioned to anticipate introduction of the drug

at certain times and places or under certain conditions. In the case of alcohol,

for example, the body prepares for the introduction of the depressant drug

by an anticipatory homeostatic adjustment in a direction opposite from the

drug’s effects. That is, whereas alcohol slows heart rate and respiration, and

lowers blood pressure, for example, the body anticipating the introduction of

alcohol raises heart rate, respiration and blood pressure even before the drug

is introduced. Once such conditioning is established, the addicted person

requires more of the drug to achieve the same effect.

When the pleasure of use is gone or at least largely diminished, what is

left is simply a compulsive pattern. In terms of conditioning, it is now almost

exclusively a matter of negative reinforcement or avoidance. Instead of using

to enhance pleasurable states, now it is a matter of avoiding pain or discom-

fort, including the discomfort of physiological withdrawal. But even more

important is avoiding the pain of a life that has deteriorated on all important

fronts.

The destructive downward spiral is captured in the story of the Tippler in

Saint-Exupery’s
The Little Prince
(1943):

“Why are you drinking?” demanded the little prince.

“So that I may forget,” replied the tippler.

“Forget what?” inquired the little prince, who already was sorry for him.

“Forget that I am ashamed,” the tippler confessed, hanging his head.

“Ashamed of what?” insisted the little prince, who wanted to help him.

“Ashamed of drinking!” The tippler brought his speech to an end, and shut

himself up in an impregnable silence.

If then drug abuse is an avoidance paradigm, if it is about forgetting, then

it stands to reason that the solution lies in the direction of non-avoidance, of

remembrance. An approach which helps a person to remember rather than

to forget, to be more aware rather than less, which increases one’s capacity to

face the truth of the present moment, even in its unpleasant elements, might,

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Thomas Bien

prima facie, be the essence of cure. Mindfulness is just such an approach.

Mindfulness teaches us to be present, even with what hurts. And indeed,

when we learn to do this fully, we encounter many positive elements of the

present as well, elements that we miss when we are so intent on avoiding

pain. In this sense, mindfulness can ultimately be a way to re-enter paradise,

to acquire the state of profound psychological balance which Buddhists call

nirvana
.

But it is not so easy for the addicted individual to see the trap that she

has fallen into with sufficient clarity to change it. For one thing, the psychol-

ogy of learning teaches us that we are more controlled by the immediate

consequences of our behavior than by the longer term consequences. In the

laboratory paradigm, if a hungry rat presses a lever, and the food pellet drops

almost immediately, the rat quickly learns to do lever presses. But if that food

pellet drops more slowly—if it drops, for example, an hour later—learning

does not take place so readily. Likewise, it is precisely the early stages of drug

use that are generally the most pleasant. The first two drinks feel very good.

The initial rush of cocaine feels nice. Unfortunately, the unpleasant sequelae

are less determinative of subsequent behavior.

A further complication here is that drug use affects memory. In the case of

alcohol, memory problems occur across a continuum that begins with acute

effects, such as a vagueness of fuzziness in the recall of events, increasing to

actual alcoholic blackouts, in which the memory for an entire period of time

is missing, and reaching the extreme and chronic effect of Korsakov’s syn-

drome, in which no new information can be assimilated
(Miller & Saucedo,

1983).
A Korsakov’s patient can be introduced anew to the same therapist day after day without remembering him, or may ask why a former political

leader, long dead, is no longer in the papers, since the ability to remember

new information ceases at the point of onset of the disorder.

But even in the less extreme cases, the negative consequences of drug

use remain less salient since they are not remembered clearly if they are

remembered at all. The user remembers the pleasant buzz and sense of well-

being, but forgets the nasty confusion or anger or stupor or even, in some

cases, arguments and physical violence which follow later.

Mindfulness of the Process of Change

If addiction involves unawareness and avoidance, then it stands to reason that

what is needed is an increase in awareness and in the capacity to experience

life clearly, as it is, with calmness and clarity, and without evasion. Mind-

fulness is just such a practice. It is a non-judgmental, moment-by-moment

openness to experience. The role of the therapist then is to help facilitate a

shift in awareness, to make the negative consequences of use more salient.

This is particularly challenging, however, given the memory effects noted

above, in addition to powerful conditioning effects.

The type of awareness required varies with the stage of change. Prochaska

and DiClemente
(1986)
conducted factor analyses of the stages people go

through in changing an addictive behavior
.1
In the full six factor model, these 1 Subsequent research by these two revealed that these same stages are found in all

kinds of change in human behavior they have investigated and not just addiction.

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293

stages are:
precontemplation, contemplation, determination, action, main-

tenance
, and
relapse
. Understanding these stages, and knowing where the

client is in this regard, can help the therapist be present in a helpful way,

facilitating the kind of awareness required for progress. The procedures for

helping the addicted individual through these stages of change have been

detailed by
Miller and Rollnick (1991)
in a process they call
motivational
interviewing
. For our purposes here, motivational interviewing is the art of

increasing a person’s awareness in a specific kind of way, making it a process

of increased mindfulness

Precontemplation
means unawareness. At this stage, a person simply does

not know there is a problem. This is not to say they are in denial, since denial

connotes that the individual knows, at some level, that a problem exists,

but refuses to recognize it. If asked whether they have a substance abuse

problem, people in this stage will express genuine surprise. For this reason,

people in this stage of change are not often found in treatment, unless a

spouse or concerned other has insisted on it. What is needed for people at

this stage is clear evidence that there is a problem. The therapist’s job here is

not to lecture and convince, but to draw out whatever evidence is available

to this person that a problem exists. A spouse’s concern, for example, is

reframed in this procedure to indicate that the person’s drug use is causing

relationship difficulties—without arguing about whether the perception of

the spouse is veridical.

Contemplation
. In this stage, the individual may be thought of as engaged

in an inner dialog about whether or not the problem is real. “Well, I am

spending a lot of money on cocaine, and I know it’s not good for me
. . .
but,

look at George, he does even more than I do, and he seems okay.” Once

again, the therapist working with someone in this stage seeks to make the

problematic aspects of the individuals experience more salient, overcoming

the normalizing effects of memory distortion and social context (drug users

associate with drug users), taking care always to draw the concerns from the

individual rather then telling them what they
should
be concerned about.

For as every experienced therapist knows, lecturing elicits reactance rather

than behavior change.

Determination
is a stage that does not always emerge from factor analysis,

but remains useful heuristically. In this stage, the person is ready to change.

In order to move on into the next stage, the individual must perceive that

there are options that make change possible. If the individual has heard about

a support group, or about a useful book, or about a therapist who offers help,

then she can move into the next stage. But if she has come this far, has rec-

ognized that there is a problem, and is ready to change, but sees no possible

way to go about it, she is likely to return to the precontemplation stage.

The
action
stage is where the individual takes the actual steps involved in

change. He might attend a group, seek out therapy, read a book, or make a

plan of his own. Such a plan can involve elements such as setting a date to

quit, disposing of the drug and paraphernalia, informing significant others

about his plan, avoiding high risk situations, and so on. The action stage,

however, involves skills differing from those required for the subsequent

stage of
maintenance
, however, and this is in fact one of the most signif-

icant implications of the model. Put colloquially, quitting is different from

staying quit. For this reason, it is important for the therapist to know which

stage the client is in, and offer strategies appropriate to that stage. Staying

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Thomas Bien

quit involves skills such as anticipating difficult situations that may be com-

ing up (such as a wedding where alcohol will be available), explaining the

change of behavior to friends, managing stress without using, and so on. All

of this requires a heightened awareness and clarity.

Most people are unsuccessful in their first attempt to alter addictive behav-

ior, and thus enter the stage of
relapse
. In this stage, the individual requires