Clinical Handbook of Mindfulness (83 page)

a way of moving through the earlier stages again as expeditiously as possi-

ble, without getting lost in feelings of guilt, shame, or hopelessness: facing

the unawareness of precontemplation, the ambivalence of contemplation,

the readiness of determination, formulation a plan of action, and develop-

ing skills to stay on track. Once the individual has established a stable, new

way of being in the world without the drug (or, alternatively, a stable state of

moderation), they may be thought of as having exited this process entirely.

Such an individual may no longer see herself as an addicted person, and may

not have to struggle very much to persist in the changed behavior. What

urges may arise from time to time are usually not very strong and are readily

dealt with.

It can be quite helpful to the person trying to change an addictive pattern

to be aware of these stages, and to understand the predictable processes and

potential difficulties. One of the difficulties about changing drug use, par-

ticularly where abstinence is the preferred goal, is that the addicted person

might be successful all day long, and succumb in one weak moment. For

this reason, the skills involved in mindfulness may be very helpful, teaching

the person to see thoughts and feelings as passing phenomena rather than

unalterable truth, changing the way the person relates to these inner pro-

cesses rather than struggling to alter their nature. Patients in therapy often

seem proud to report to me that they are not experiencing any relapse urges,

but I remind them that whether or not urges are present is actually of little

significance. Urges arise or fail to arise, and we are not in control of this pro-

cess. Since we are not in control, we deserve neither credit nor blame for

their occurrence or lack. What matters is how we handle the urge to relapse

when it does arise. Though it may seem counterintuitive, mindfulness sug-

gests that we are in fact better off being aware of the relapse thoughts and

feelings when they arise instead of trying to deny their arising.

Urge Surfing

In the urge surfing approach, one approaches the arising of relapse urges

with mindfulness
(Marlatt & Gordon, 1985).
Instead of struggling against them, which often increases the power of whatever we are trying to suppress, one seeks to ride these feelings out, like a surfer riding a wave. In this

approach, the necessity of the linkage between inner states and outer behav-

ior is challenged. Many of us, in point of fact, have often had feelings about

wanting to do something that we knew to be harmful, or wanting to avoid

doing something that we knew to be beneficial, while discovering that we

can still make the positive choice. On a dreary Monday morning, we may feel

that we would rather stay in bed than go to work, but most of us go to work

anyway.

Once the absolute link between inner states and behavior is challenged,

once we see clearly that we do not, in fact, need to act in accord with passing

Chapter 15 Paradise Lost

295

moods and emotions, we are then free to experience whatever arises with-

out fear that it inevitably means relapse. The onset of an urge, in its cog-

nitive, affective, and physiological dimensions, can be experienced clearly

without acting on it, especially since we also come to see all such inner

states as impermanent and transitory. Experience with meditation is help-

ful here, since in meditation one learns that every itch does not need to be

scratched, that we can think repeatedly of getting up from our cushion to

perform some “urgent” duty, while still remaining seated, looking into this

impulse calmly and clearly without succumbing to it. In such a way, the indi-

vidual experiencing a relapse urge learns to ask: “What thoughts are arising

in me about this?” It is not even necessary to challenge them as one might in

cognitive-behavior therapy: it is enough to see them clearly
as thoughts
, aris-

ing and passing away. In the same way one can ask, “What are the emotions

coming up for me attached to this urge?” and “What does this feel like in

my body?,” in each case inviting calm, accepting awareness of these passing

inner events. In urge surfing there is a meta-message that relapse thoughts

and feelings are not at all terrifying, since I can experience them without

giving in to them. Attempting to suppress such feelings, however, gives the

opposite kind of message: if we are afraid to even acknowledge such inner

states, they must be truly terrible, and if they are so dangerous, this can cre-

ate a state of chronic guardedness and anxiety rather than free-flowing, open

awareness.

Mindfulness of Life Problems

The relationship between addiction and problems in living is bi-directional:

a person may abuse drugs in a problematic way in part due to difficult life

circumstances, while the abuse itself also creates more problems. Once an

individual begins to change problematic drug use, life problems, often long

avoided, tend to surface. For the person to succeed in establishing a new

pattern of behavior, she must do more than quit. She must also establish a

satisfying and happy life and an adequate way of dealing with problems. If

such a way of life is created, then the temptation toward problematic drug

use will not be overpowering. If not, however, the pull may seem irresistible.

Often life problems are linked with inner states. The recovering person

may want to repair a relationship injured by unskillful speech and behav-

ior during years of drug use, but his anger feels overwhelming, and so he

says something that causes the relationship further injury. An unemployed

person may know she should begin the search for work, but anxiety about

interviewing may inhibit the active and energetic pursuit of this goal.

In order to face such life problems effectively, the individual needs ways

to take care of the emotional state underlying maladaptive behavior or avoid-

ance. Mindfulness is an ideal practice for this, since, as discussed above in the

context of urge surfing, one see through practice that there is no essential

connection between inner states and behavior, and since one experiences

clearly and repeatedly that all inner states, no matter how uncomfortable,

arise and eventually pass away, if not always as quickly as one might prefer.

In this way, one comes to see anxiety is a normal and natural event, some-

thing that all people will experience intermittently. One need not compound

296

Thomas Bien

the problem by becoming anxious about being anxious, but instead, one

can learn to experience anxiety with clarity while still pursuing desirable

life goals. Though anxiety may indeed arise in a job interview, this does not

mean that one has to avoid such situations. Not only would that create many

problems, financial and otherwise, but also, avoidance tends to increase the

anxiety. No one, for example, experiences as much anxiety as people who

have agoraphobia. If avoidance were effective, such individuals would have

extinguished the anxiety by staying within their zone of safety. Unfortunately,

even while doing so, they still experience a great deal of anxiety, probably

more than the person who accepts anxiety as a natural occurrence and faces

the world anyway. In this way, teaching patients to work mindfully with their

thoughts and feelings can have great value in helping them lean into their life

problems and face them effectively, instead of trying to avoid and evade, the

very processes that helped to create a pattern of drug abuse.

Mindfulness and the Therapist

I have suggested elsewhere
(Bien, 2006)
that the most important psychotherapeutic implication of mindfulness may lie not so much in techniques to

teach clients—though these may be valuable—but in the capacity of the

therapist to be truly present. Indeed, Siegel, Williams, and Teasdale (2002)

found, contrary to initial expectation, that teaching mindfulness to clients

was not really possible without practicing it themselves. Lambert and Simon

(2008), for example, report that 30% of the variance in therapeutic outcome

is attributable to common factors such as the therapeutic relationship, while

only 15% of the variance is attributable to specific therapeutic technique.

This is so despite the fact that therapists generally consider their specific

technique to be of greatest importance.
Miller, Taylor, & West (1980),
found that rankings of therapist empathy, one of the important factors in a therapeutic relationship, correlated highly (r=0.82) with therapeutic outcome.

Mindfulness, the practice of moment-to-moment, non-judgmental awareness,

would seem exactly the kind of attention needed to facilitate empathy and a

positive therapeutic relationship. And indeed, while more research is needed

in this area, some initial studies have supported the notion that mindfulness

practice increases empathy
(Aiken, 2006; Wang, 2006;
Shapiro, Schwartz, & Bonner
1998),
and improves the quality of the therapeutic alliance
(Wexler,

2006).
This may be particularly important with a stigmatizing disorder such as addiction, in which the quality of the interpersonal relationship with the

therapist (whether for example the therapist is empathic, on the one hand,

or lecturing on the other) is more determinative of client reactance than

any supposed trait of denial on the part of the client
(Miller & Rollnick,

1991).

A therapist who practices mindfulness may be more able to track the

moment by moment changes in a client’s emotional state, to be aware of what

stage of change the client is in (which may make minor swings even within

one clinical session), and to accept whatever the client presents as natural

and understandable including the very human tendency to resist change.

Chapter 15 Paradise Lost

297

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