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Buddhist Philosophy and the Treatment o f Addictive Behavior

G. A l a n M a r l a t t , University o f W a s h i n g t o n The purpose of this paper is to provide an overview of how Buddhist philosophy can be applied in the treatment of individuals with substance abuse problems (alcohol, smoking, and illicit drug use) and other addictive behaviors (e.g., compulsive eating and gambling). First I describe the background of my own interest in meditation and Buddhist psychology, followed by a brief summary of my prior research on the effects of meditation on alcohol consumption in heavy drinkers. In the second section, I outline some of the basic principles of Buddhist philosophy that provide a theoretical underpinning for defining addiction, how it develops, and how it can be alleviated. The third and final section presents four principles within Buddhist psychology that have direct implications for the cognitive-behavioral treatment of addictive behavior: mindfulness meditation, the Middle Way philosophy, the Doctrine of Impermanence, and compassion and the Eightfold Noble Path. Clinical interventions and case examples are described/or each of these four principles based on my research and clinical practice with clients seeking help for resolving addictive behavior problems.

FIRST b e c a m e interested in the clinical applications of m e d i t a t i o n in 1970, while I was teaching at the University of Wisconsin. AS an assistant professor faced with the publish-or-perish stress o f academic life, I was diagnosed with b o r d e r l i n e hypertension. My physician reco m m e n d e d that I first modify my lifestyle in an a t t e m p t to lower my b l o o d pressure, i n c l u d i n g diet modification (less salty fast food), regular exercise (walking, biking), a n d increased relaxation. After he discovered that I h a d never tried any specific relaxation technique, he advised m e to enroll in a Transcendental Meditation (TM) course. His advice was based on review of the hypertension t r e a t m e n t literature showing that TM a p p e a r e d to be an effective intervention for some patients. I was at first skeptical a b o u t signing u p for a course that a p p e a r e d to be based on a mystical, Eastern philosophy, with its emphasis on training the "mind" to relax. T h e p h i l o s o p h y e m b r a c e d by TM practitioners was in sharp conflict with my training as a b u d d i n g behavioral psychologist, in which overt behavior was c o n s i d e r e d m o r e scientifically objective than anything to do with subjective mental states, m u c h less the "mind." After walking out of the i n t r o d u c t o r y TM lecture presented by white m e n in black suits (in sharp contrast with the informal dress favored by everyone else living in Madison, Wisconsin, d u r i n g this era of Vietnam protests on campus), I r e t u r n e d to my lab a n d the academic safety o f my Ivory Tower office. O n e of my graduate students asked, "Well, d i d you try TM?" After I r e p l i e d that I left the i n t r o d u c t o r y lecture in frustration before trying the
Cognitive and Behavioral Practice 9, 4 4 - 5 0 , 2002 1077-7229/02/44-5051.00/0 Copyright 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

m e d i t a t i o n technique, she said, "Well, I t h o u g h t you were an e m p i r i c i s t - - s h o u l d n ' t you at least try it once before you reject it o u t o f hand?" Reflecting on h e r wisdom, I ret u r n e d to the TM c e n t e r a n d registered to take the meditation course. D u r i n g my first m e d i t a t i o n experience, I was given a Sanskrit m a n t r a a n d asked to r e p e a t it silently d u r i n g the 20-minute m e d i t a t i o n period. After meditating for a b o u t 10 minutes, I was surprised to find myself feeling m o r e relaxed, b o t h mentally a n d physically, than I h a d ever felt before. Feeling m o r e motivated a n d encouraged by this experience, I b e g a n to meditate on a regular basis (two 20-minute periods daily). T h e results were impressive, even for a behavioral empiricist: I felt m o r e relaxed a n d c e n t e r e d d u r i n g this period, a n d my b l o o d pressure d r o p p e d to the p o i n t that my physician d e c i d e d that I would n o t n e e d any hypertension medication. "Sometimes m e d i t a t i o n works b e t t e r than medication," he said, pleased with the results. I c o n t i n u e d to practice TM for the next year or so, a n d my ability to relax in the face of c o n t i n u e d a c a d e m i c pressure i m p r o v e d considerably. I also b e g a n r e a d i n g the developing research literature d o c u m e n t i n g that the practice o f meditation elicited a physiological "relaxation response," d e f i n e d by Benson (1975) as a d e e p hypometabolic state associated with decreased reactions o f somatic stress ( d o c u m e n t e d by drops in stress h o r m o n e levels, synchronized EEG responding, etc.). As a scientist, I was impressed with the empirical findings s u p p o r t i n g m e d i t a t i o n as a practical m e t h o d of i n d u c i n g relaxation a n d r e d u c i n g stress. As a clinical psychologist, however, I f o u n d myself d i s a p p o i n t e d with the lack o f theory in the TM literature a b o u t m e d i t a t i o n as a t e c h n i q u e to alter psychological a n d behavioral problems. My disappointm e n t d i s a p p e a r e d one day in the fall o f 1971, when a friend a n d colleague gave m e a copy of a book, e n t i d e d

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Meditation in Action, written by the Tibetan Buddhist

t e a c h e r Chogyam T r u n g p a (1968). TM continues to be practiced worldwide a n d has gene r a t e d considerable research, i n c l u d i n g studies docum e n t i n g the effectiveness o f TM in the t r e a t m e n t o f addiction p r o b l e m s ( O ' C o n n e l l & Alexander, 1994). My own interest in m e d i t a t i o n was stimulated even further by my i m m e r s i o n in the works o f T r u n g p a a n d a d e v e l o p i n g u n d e r s t a n d i n g o f basic Buddhist philosophy. As I continu e d my reading, I b e c a m e aware that the Buddhist literature offers considerable insight into the basic nature of addiction, how addictive behavior develops, a n d how m e d i t a t i o n can be used as a m e t h o d o f t r a n s c e n d i n g a wide variety o f a d d i c t i o n problems. After moving to the University o f Washington in 1972, several o f my graduate students a n d I b e g a n c o n d u c t i n g p r e l i m i n a r y studies designed to investigate the effectiveness o f m e d i t a t i o n as a preventive intervention for high-risk drinkers (Marlatt & Marques, 1977). In o u r first study (Marlatt, Pagano, Rose, & Marques, 1984), we r a n d o m l y assigned college s t u d e n t volunteers who m e t o u r screening criteria as heavy drinkers to o n e o f three relaxation techniques: m e d i t a t i o n (a mantrabased m e d i t a t i o n t e c h n i q u e similar to TM), d e e p muscle relaxation (based o n J a c o b s o n ' s t e c h n i q u e as used in systematic desensitization), o r daily p e r i o d s o f quiet recreational reading. C o m p a r e d to those in the control g r o u p (self-monitoring o f daily d r i n k i n g only), participants in all t h r e e relaxation conditions showed a significant reduction in daily alcohol c o n s u m p t i o n . Those in the meditation group, however, showed the most consistent a n d reliable reductions in d r i n k i n g over the 6-week intervention p e r i o d (with an average decrease o f 50% in daily alcohol c o n s u m p t i o n ) . These findings were replicated in a subsequent study, also c o n d u c t e d with heavy drinkers, that c o m p a r e d m e d i t a t i o n with aerobic exercise. T h e results showed that b o t h m e d i t a t i o n a n d exercise were associated with significant d r o p s in daily alcohol consumption (Murphy, Pagano, & Marlatt, 1986). These findings p r o m p t e d m e to include m e d i t a t i o n a n d exercise as potential alternatives to addictive behavior in h e l p i n g clients develop a "balanced lifestyle." Lifestyle balance later b e c a m e an integral c o m p o n e n t in the d e v e l o p m e n t of o u r relapse prevention m o d e l (Marlatt, 1985). In the years that followed, I b e c a m e increasingly interested in studying Buddhist p h i l o s o p h y as a m o d e l o f und e r s t a n d i n g b o t h the roots o f a d d i c t i o n a n d its r e m e d y t h r o u g h m e d i t a t i o n practice. As the i m p a c t o f cognitive psychology on behavior therapy increased t h r o u g h o u t the 1980s, I b e c a m e m o r e aware o f the parallels between Buddhist teachings a n d the e m e r g i n g field o f cognitivebehavioral therapy. As a means o f directly observing the "behavior o f the mind," m e d i t a t i o n offered many advantages as a t e c h n i q u e for self-monitoring thoughts a n d

feelings in an a t m o s p h e r e o f acceptance a n d n o n j u d g mental objectivity. E n c o u r a g e d by my reading, I m a d e a c o m m i t m e n t to take additional m e d i t a t i o n training by att e n d i n g a series o f 10-day Buddhist m e d i t a t i o n retreats. Participation in these courses requires intensive meditation practice (both sitting a n d walking m e d i t a t i o n ) for many hours each day. These retreats are usually h e l d in total silence, e x c e p t for b r i e f talks by the teachers, who provide both meditation instructions a n d evening d h a r m a talks (based on the B u d d h a ' s teachings) to h i g h l i g h t the essentials of Buddhist philosophy. B e g i n n i n g in 1978, I a t t e n d e d a series o f these 10-day retreats based on Vipassana meditation, a Buddhist practice that dates back to the B u d d h a ' s original teachings some 2,500 years ago. T h e retreats ! a t t e n d e d were dir e c t e d by o u t s t a n d i n g Buddhist teachers, i n c l u d i n g Ruth Denison, S. N. Goenka, J o s e p h Goldstein, and, most recently, P e m a C h o d r o n (a f o r m e r s t u d e n t o f the late Chogyam T r u n g p a a n d a u t h o r o f the influential Buddhist text When Things Fall Apart;, C h o d r o n , 1998). I also a t t e n d e d a 5-day retreat taught by the r e n o w n e d Vietnamese Buddhist t e a c h e r a n d author, T h i c h N h a t H a h n , on the topic o f integrating m e d i t a t i o n a n d psychotherapy practice. I will always r e m a i n i n d e b t e d to these teachers for o p e n i n g my m i n d to the d h a r m a a n d the practice o f Buddhist meditation. At the e n d o f o n e retreat, I asked my teacher, S. N. G o e n k a (influential for his teaching o f Vipassana) a b o u t the n a t u r e o f addiction. I first told him that in the U.S., a d d i c t i o n is usually d e f i n e d as a biological disease, based on genetic i n h e r i t a n c e a n d o t h e r biomedical vulnerabilities. H e smiled when I asked h i m how Buddhists view the p r o b l e m o f addiction. "Yes, a d d i c t i o n is a d i s e a s e - - a disease of the mind." According to G o e n k a a n d o t h e r Buddhist teachers, the roots o f a d d i c t i o n are in the mind, even t h o u g h the consequences o f a d d i c t i o n often include considerable d a m a g e to the body, including such disease states as cancer (from smoking), cirrhosis o f the liver (from d r i n k i n g ) , o r even AIDS (via transmission o f HIV by s h a r e d needle-use a m o n g injection d r u g users). T h e following section provides a m o r e detailed a c c o u n t o f the Buddhist m o d e l o f addiction.

The B u d d h i s t M o d e l o f A d d i c t i o n
T h e following material is based o n a review article by Groves a n d F a r m e r (1994), "Buddhism a n d Addictions." These authors p o i n t o u t that from the Buddhist perspective, a d d i c t i o n represents a "false refuge" from the p a i n a n d suffering o f life. In a c c o r d a n c e with the First N o b l e Truth, as o u t l i n e d by K u m a r (2002), "suffering is ubiquitous" a n d is e x p e r i e n c e d in multiple ways as pain, misery, a n d the anxiety associated with life c h a n g e o r existence in general. In a d d i t i o n to the actual here-and-now experience o f suffering, Groves a n d F a r m e r also include the

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Marlatt e x p e r i e n c e o f "potential suffering, the fear that something may h a p p e n to m a r c u r r e n t happiness or cause some future displeasure, perhaps worry over where the next 'fix' will c o m e from" (p. 184). A c c o r d i n g to this perspective, e n g a g i n g in d r u g use or o t h e r addictive behaviors is a "false refnge" because it is motivated by a strong desire o r "craving" for relief from suffering, despite the fact that c o n t i n u e d involvement in the addictive behavior increases pain a n d suffering in the long run. T h e immediate consequences o f e n g a g i n g in addictive behavior provide only a t e m p o r a r y refuge by e n a b l i n g the user to avoid o r escape suffering a n d o t h e r negative e m o t i o n a l states. Addictive behaviors provide " t e m p o r a r y refuge" because o f their promise for relatively i m m e d i a t e relief from suffering, either by e n h a n c i n g positive e m o t i o n a l states (the positive r e i n f o r c e m e n t o f getting "high") a n d / o r eliminating negative e m o t i o n a l states (the negative r e i n f o r c e m e n t of escaping o r avoiding feeling "low"). T h e potential for a d d i c t i o n is e n h a n c e d to the e x t e n t that the individual b e c o m e s increasingly d e p e n d e n t on o r "attached" to the behavior that appears to offer refuge a n d relief from suffering. As this a t t a c h m e n t to the addictive behavior o r substance grows, the individual is likely to e x p e r i e n c e increased "craving" for the anticipated relief associated with e n g a g i n g in the addictive behavior. Craving can be e x p e r i e n c e d either as a desire to continue or p r o l o n g a pleasant e x p e r i e n c e (continue the "high") or to avoid o r escape an unpleasant state (alleviate the "low"). Because craving is d i r e c t e d toward the future (anticipation of i m m e d i a t e positive or negative reinforcem e n t ) , the addict b e c o m e s t r a p p e d in his or h e r attachm e n t o r "clinging" to the addictive behavior as the only source of relief from p r e s e n t or potential suffering. T h e a d d i c t e d m i n d b e c o m e s fixed on the future ("~qaen will I get my next fix?"), a n d the individual is less likely to accept what is h a p p e n i n g in the p r e s e n t m o m e n t . As one e x p e r i e n c e d m e d i t a t o r e x p l a i n e d to a skeptical novice, "In meditation, n o t h i n g h a p p e n s next. This is it!" B u d d h i s m provides an alternative to the moral or disease m o d e l s o f addiction. It is assumed that the individual is t r a p p e d in this "false refuge" because o f their "ignorance" or lack o f u n d e r s t a n d i n g of how the d e p e n d e n c y d e v e l o p e d a n d how to b e c o m e free o f its grasp o f attachment. As stated by Groves a n d F a r m e r (1994, p. 187): A c c o r d i n g to B u d d h i s m p e o p l e resort to false refuges n o t o u t of sinfulness, but r a t h e r out of i g n o r a n c e - - t h e y believe they will make t h e m h a p p y whereas in reality they t e n d to lead to m o r e suffering. Thus p e o p l e are not to be blamed; rather B u d d h i s m p r o m o t e s an attitude of compassion which may be helpful when working with p e o p l e with p r o b l e m s of addiction. T h e F o u r Noble Truths can be a p p l i e d to u n d e r s t a n d i n g b o t h the roots o f addiction a n d the pathway to recovery a n d eventual e n l i g h t e n m e n t . Suffering a n d pain, essential to the life e x p e r i e n c e (First Noble Truth), are caused by craving a n d a t t a c h m e n t (Second N o b l e Truth). Addiction is viewed n o t as a physical disease, b u t as a particularly intense form of the a t t a c h m e n t process, which in turn is based on an incorrect u n d e r s t a n d i n g (ignorance that the addictive behavior is only a t e m p o r a r y o r "false" refuge). T h e T h i r d Noble Truth states the possibility o f the cessation o f suffering, based on "the c o m p l e t e fadingaway a n d extinction of this craving, its forsaking a n d a b a n d o n m e n t , liberation fi'om it, d e t a c h m e n t from it" (Groves & Farmer, 1994, p. 186). T h e pathway out o f craving, addiction, a n d suffering is spelled o u t in the F o u r t h Noble Truth, which describes the Eightfold Noble Path leading toward e n l i g h t e n m e n t : right vision, c o n c e p t i o n , speech, conduct, livelihood, effort, mindfulness, a n d c o n c e n t r a t i o n (Kumat; 2002). Meditation provides the vehicle to follow this pathway from the heavy b u r d e n o f addiction to the f r e e d o m of e n l i g h t e n m e n t . I g n o r a n c e can be r e p l a c e d by a c o m b i n a t i o n o f " r i g h t c o n c e p t i o n or u n d e r s t a n d i n g " as to the true nature of a d d i c t i o n a n d the d e v e l o p m e n t of new c o p i n g skills (right conduct, o r "skillful means"). As such, the practice o f m e d i t a t i o n a n d following the Eightfold Path offers a clear a n d distinctive alternative to the 12-steps a p p r o a c h a n d the disease m o d e l of addiction: Buddhism offers a spiritual b u t non-theistic alternative to the theism implicit in the 12-steps a p p r o a c h . This may be i m p o r t a n t for n o t j u s t Buddhists with an addiction p r o b l e m , b u t also the many addicts who reject a theistic a p p r o a c h . Also unlike the disease model, p e o p l e are seen as having the ability to choose a n d take responsibility for their actions. T h e a t t e m p t to change, unlike m u c h c o n t e m p o r a r y therapy, is n o t primarily p r o b l e m orientated. T h e main focus is creating well-being t h r o u g h practicing skillful behavior a n d cultivating skillful m e n t a l states. (Groves & Farmer, 1994, p. 191)

Clinical Applications
In my work with clients with addictive behavior problems (in the context of individual private practice), I often draw u p o n my knowledge a n d e x p e r i e n c e o f Buddhist p h i l o s o p h y and meditation. In some cases, I have taught clients how to m e d i t a t e using awareness o f the breath as the c e n t e r of attention. In my practice, I offer clients a m e n u of stress-management options as part o f the lifestyle balance intervention (Marlatt, 1985). A typical choice includes meditation, muscle r e l a x a t i o n / y o g a , walking a n d aerobic exercise. All techniques are recomm e n d e d on the basis o f their relative empirical s u p p o r t

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a n d practicality in terms of the client's b a c k g r o u n d a n d c u r r e n t lifestyle. Meditation a n d yoga are described as effective in terms of e n h a n c i n g a "positive psychology" approach associated with Buddhist teachings (Levine, 2000). For clients who c o n t i n u e to utilize a n d benefit from the practice of meditation, I describe how it links to certain Buddhist principles that might be helpful in managing their addictive behavior. In the section that follows, I describe four topic areas that provide a clear link between basic Buddhist principles a n d their application to cognitive-behavioral interventions. A more detailed acc o u n t of how m e d i t a t i o n can be used as a n adjunct to psychotherapy is provided elsewhere (Marlatt, 1994; Marlatt & Kristeller, 1999).

Mindfulness Meditation
The practice of meditation is an antidote to addiction because it e n h a n c e s mindfulness, or awareness of the behavior of the mind. As described by Kumar (2002), mindfulness is described as a "nonjudgTnental, present-centered awareness . . . . This awareness is directed toward all thoughts, feelings, a n d sensations that occur d u r i n g practice" (p. 42). O t h e r s have described m i n d f u l n e s s as "attentional control" (Teasdale, Segal, & Williams, 1995) in which the meditator develops a metacognitive state of detached awareness. The goal of mindfulness training is n o t to change the c o n t e n t of thoughts (as in cognitive therapy), b u t to develop a different attitude or relationship to thoughts a n d feelings as they occur in the mind: Unlike CBT [cognitive behavior therapy], there is little emphasis in MBCT [mindfulness-based cognitive therapy] o n c h a n g i n g the contents of thoughts; rather, the emphasis is o n c h a n g i n g awareness of a n d relationship to thoughts . . . . The focus of MBCT is to teach individuals to become more aware of thoughts a n d feelings a n d to relate to them in a wider, d e c e n t e r e d perspective as "mental events" rather than aspects of the self or as necessarily accurate reflections of reality. (Teasdale et al., 2000) Mindfulness meditation is similar to the traditional behavioral technique of self-monitoring (Thoresen & Mahoney, 1974) or, in this case, "thought monitoring." Meditation practice helps clients with addictive behavior problems to develop a detached awareness of thoughts, without "overidentifying" with them or reacting to them in an automatic, habitual manner. Urges a n d cravings can be m o n i t o r e d a n d observed without "giving in" a n d engaging in the addictive behavior in an impulsive manner. Meditation creates a space of m i n d f u l awareness a n d e n h a n c e s the cultivation of alternatives to mindless, compulsive behavior. As stated by Groves a n d Farmer (1994), "In the context of addictions, mindfulness might m e a n b e c o m i n g aware of triggers for c r a v i n g . . , a n d choosing

to do something else which might ameliorate or prevent craving, so weakening this habitual response" (p. 189). O n e of my clients, a w o m a n who sought help for her co-occurring problems of alcohol d e p e n d e n c e a n d depression, described the effects of mindfulness m e d i t a t i o n as follows: "I still have urges to d r i n k excessively, b u t when this t h o u g h t occurs, I tell myself that I do n o t have to be dictated to by my thoughts. I j u s t accept that the urge is occurring, b u t I d o n ' t have to act o n it automatically. I j u s t focus o n my breath until the urge passes." I r e m i n d e d her that the term "addiction" has the same Latin origin (decere, translated as "diction") as the term "dictation" or "dictator." She r e s p o n d e d by saying that she was b e g i n n i n g to feel a new form of f r e e d o m a n d was no longer subject to the dictation of her addictive thoughts a n d feelings. O t h e r clients have described the successful use of "urge surfing" as a mindfulness technique (Marlatt, 1985, 1994). Clients are taught to visualize the urge as a n ocean wave that begins as a small wavelet a n d gradually builds u p to a large cresting wave. As the urge wave grows in strength, the client's goal is to surf the urge by allowing it to pass without b e i n g "wiped out" by giving into it. I tell clients that urges are often c o n d i t i o n e d responses triggered by cues a n d high-risk situations. Like a wave, the c o n d i t i o n e d response grows in intensity until it reaches a peak level of craving. Giving in to the urge when it peaks only serves to further reinforce the addictive behavior. Not acting on the urge, o n the other hand, weakens the addictive c o n d i t i o n i n g a n d strengthens acceptance a n d self-efficacy. Like any skill, l e a r n i n g how to "urge surf" takes practice a n d improves over time as the client attains greater balance o n the mindfulness surfboard.

The Middle Way

In the description of the historical origins of Buddhism, K u m a r (2002) notes that Siddharta G a u t a m a was "born a n d raised in a sheltered life of luxury a n d ease" until he later was "confronted by the ubiquity of suffering evident in the forms of poor, sick, aged, a n d dying people" (p. 41). In response to this realization, the future B u d d h a resolved to r e n o u n c e his worldly life a n d spent the next 6 years as a w a n d e r i n g ascetic who e n g a g e d in extreme forms of self-mortification (self-starvation a n d avoidance of all bodily pleasures). It was only after his experience of e n l i g h t e n m e n t u n d e r the banyan tree that he gave u p both the extremes of self-indulgence o n the o n e hand, a n d ascetic self-mortification o n the other, a n d adopted a "middle-way" position. This middle way represents a position of m i n d f u l balance or m o d e r a t i o n between the otherwise polarized extremes a n d c o n t i n u e s to be a centerpiece of the dharmic teachings. T h e addiction field is also marked by a polarization between opposites. In traditional t r e a t m e n t programs, cli-

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Marlatt ents are told that they have a choice between total abstin e n c e or giving in to the clutches of an irreversible, progressive, a n d ultimately fatal disease. F r o m this polarized perspective, there is no r o o m for the m i d d l e way o f m o d e r a t i o n . This d i c h o t o m y between abstinence (success) a n d relapse (failure) often contributes to the client's b e i n g caught in a vicious cycle o f restraint (control) a n d d r u g use (loss o f control), l e a d i n g to a revolvingd o o r p a t t e r n o f abstinence a n d relapse. T h e inability to maintain total abstinence often pushes clients to the o t h e r e x t r e m e o f u n c o n t r o l l e d relapse, especially if they b l a m e themselves for their failure (as in the "abstinence violation effect"). For clients who are unable to maintain abstinence, it is helpful to distinguish between a single episode o f the addictive behavior (defined in the relapse prevention m o d e l as a "lapse") a n d a full-blown relapse. In this terminology, e x p e r i e n c i n g a lapse can be viewed as a middle-way alternative between total abstinence a n d u n c o n t r o l l e d relapse. Clients can be taught c o p i n g skills to regain balance a n d recover from lapses before they escalate into a greater p a t t e r n o f relapse. T h e middle-way philosophy is also c o n g r u e n t with a harm-reduction a p p r o a c h for clients who are unable or unwilling to a d o p t an abstinence goal. H a r m reduction techniques are designed to reduce the harmful consequences of addictive behaviors (Marlatt, 1998). O n e such m e t h o d involves teaching clients how to successfully moderate their alcohol or d r u g use in o r d e r to reduce the risk o f adverse or harmful effects. In o u r own research, we have successfully a p p l i e d a cognitive-behavioral moderation training p r o g r a m for young adults who have e n g a g e d in frequent binge d r i n k i n g behavior, often associated with a wide range o f harmful consequences (i.e., injuries, accidents, blackouts, sexual assault a n d violence). Although the majority o f these high-risk drinkers reject abstinence as a personal choice, they show significant i m p r o v e m e n t in r e d u c i n g excessive drinking a n d its negative consequences t h r o u g h their participation in a brief harmreduction prevention p r o g r a m (Baer et al., 2001; Dimeft, Baer, Kivlahan, & Marlatt, 1999; Marlatt et al., 1998). For many of o u r clients, h a r m reduction offers an attractive middle-way alternative between either abstinence or continuing to d r i n k in a chaotic a n d u n c o n t r o l l e d m a n n e r T h e Doctrine o f I m p e r m a n e n c e A d d i c t i o n can be d e f i n e d as an inability to accept imp e r m a n e n c e . At o n e level, the addict seeks a p e r m a n e n t high. As stated by K u m a r (2002), "It is in trying to h o l d on to the stability o f a passing m o m e n t . . . we struggle against the natural i m p e r m a n e n c e of all p h e n o m e n a . . . . " (p. 41-42). T h e i m p e r m a n e n c e o f all p h e n o m e n a needs to be contextualized in the i m p e r m a n e n c e o f life itself. AS stated earlier, clients with addiction p r o b l e m s are fixated on the future ("When will I get my next fix?") a n d are often dissatisfied with the here-and-now o f o r d i n a r y life experiences. D e p e n d e n c e on the addictive behavior locks the individual into a state o f a t t a c h m e n t to an activity o r substance m a r k e d by an anticipation o f c o n t i n u e d a n d future satisfaction. W i t h o u t c o n t i n u e d access to the addictive substance, the e x p e r i e n c e o f o n g o i n g activities in the p r e s e n t m o m e n t is r e n d e r e d unsatisfactory, a reaction that may be e x a c e r b a t e d by withdrawal symptoms a n d / o r exposure to stressful situations previously associated with d r u g use. As a result, the a d d i c t e d client desires to p r o l o n g the high, to make the addictive e x p e r i e n c e last as long as possible. A l o n g with this desire for a p e r m a n e n t high, clients have little patience for e n d u r i n g negative e m o t i o n a l states without e n g a g i n g in the addictive behavior as a form o f escape or avoidance. T h e practice of mindful m e d i t a t i o n helps the client accept the basic i m p e r m a n e n c e of all h u m a n experiences. In observing the m i n d ' s behavior, the m e d i t a t o r comes to realize that thoughts, feelings, a n d images are constantly changing. Pleasant thoughts arise a n d pass away, as do negative thoughts a n d emotions. N o t h i n g remains the same over time in this a t m o s p h e r e o f constant change. Clients who gain this knowledge of i m p e r m a n e n c e are often liberated from their psychological dep e n d e n c y on the addictive behavior as a means o f regulating o r controlling their m o o d . As o n e client told me, "If things are always changing, my negative m o o d s will also c h a n g e over time. Meditation helps m e to let go a n d allow these natural changes to occur, without worrying a b o u t how I will try to control t h e m t h r o u g h my d r u g use. The same goes for feeling high. I c a n n o t stay high all the time, so I get caught in p l a n n i n g where a n d when I will be able to get high again. T h e truth is, I'll never achieve perm a n e n t satisfaction. Just knowing that things are always c h a n g i n g is a big load off my mind." For this client, the practice o f meditation allowed him to accept the basic i m p e r m a n e n c e of existence a n d facilitated his acceptance o f the here-and-now of daily life experiences. As stated by Groves a n d F a r m e r (1994): An i m p o r t a n t right view a n d a central t h e m e in Buddhism is the o m n i p r e s e n c e of i m p e r m a n e n c e - all things change, be they trees, mountains, p e o p l e o r relationships, which opens u p the possibility o f beneficial change. Similarly c h a n g e is an i m p o r t a n t c o n c e p t in explaining a n d altering addictive behavi o r . . . . IT]he stress on potential for change shifts emphasis from overly static concepts of personality which can lead to t h e r a p e u t i c nihilism in the addictions field. (p. 187)

Compassion and the Eight-Fold Path

Buddhist philosophy holds that the pathway to liberation and e n l i g h t e n m e n t lies in following the N o b l e Eight-

Buddhism and Addiction Fold Path. Progress along the path involves the developm e n t o f a new set o f attitudes o r beliefs as well as engaging in behaviors that h e i g h t e n awareness a n d balance Several steps along the p a t h refer to d e v e l o p i n g the "right" attitude toward all life experiences, including right vision, right c o n c e p t i o n , a n d right mindfulness a n d concentration. O t h e r steps focus m o r e on behavior, such as "right speech, right conduct, right livelihood, a n d right effort" (Kumar, 2002) Each o f these steps refers to various aspects o f the d h a r m a a n d essentials of Buddhist p h i l o s o p h y (e.g., right mindfulness). For example, und e r s t a n d i n g the c o n c e p t o f i m p e r m a n e n c e is c o n s i d e r e d an essential c o m p o n e n t o f right c o n c e p t i o n (or right und e r s t a n d i n g ) . Spiritual seekers are e n c o u r a g e d to follow these principles in o r d e r to attain e n l i g h t e n m e n t , b u t they are also useful guidelines for directing the progress o f therapy Right mindfulness is also linked with an attitude o f compassion toward the suffering e x p e r i e n c e d by oneself a n d others. As stated by K u m a r (2002): Compassion involves cultivating an attitude of universal, unconditional acceptance. With this attitude, essentialist boundaries that define self a n d o t h e r tend to dissipate as one develops compassionate equanimity toward all living b e i n g s . . . . . I n d e e d , m i n d f u l n e s s a n d c o m p a s s i o n are frequently discussed as two intertwined aspects o f practice in Buddhist literature . . . . (p. 42) T h e d e v e l o p m e n t o f m i n d f u l compassion is helpful for b o t h the client a n d therapist in addiction treatment. Clients can foster an attitude o f a c c e p t a n c e toward themselves a n d their behaviors. Therapists who show compassion a n d e m p a t h y for their clients are m o r e likely to succeed than those who a d o p t a critical a n d confrontational a p p r o a c h (Miller & Rollnick, 1991) Recent advances in the cognitive-behavioral t r e a t m e n t o f addictive behaviors are consistent with a m o r e compassionate app r o a c h than many traditional "intervention" approaches T h e m o r a l model, as exemplified by the c u r r e n t War on Drugs, is particularly lacking in compassion. F r o m the Buddhist perspective, several new a n d e m e r g i n g t r e a t m e n t p r o g r a m s offer clients a compassionate a n d pragmatic alternative In h a r m r e d u c t i o n therapy (Denning, 2000; Marlatt, 1998), therapists a t t e m p t to m e e t clients "where they are at" in terms o f their c u r r e n t addictive behavior to provide e m p a t h i c a n d u n d e r s t a n d ing s u p p o r t for any positive changes in the client's behavior. Small steps to reduce harmful consequences are e n c o u r a g e d (e.g., participation in a needle-exchange program, e n r o l l m e n t in a m e t h a d o n e p r o g r a m , training for m o d e r a t e drinking, etc.) r a t h e r than insisting u p o n total abstinence as the first step. H a r m r e d u c t i o n is characterized by compassionate pragmatism, an a p p r o a c h that is also c o m p a t i b l e with Buddhist teachings. As Groves a n d F a r m e r conclude, " . . . the B u d d h a ' s attitude to the relevance o f his teaching was one o f p r a g m a t i s m - - i f it helped, t h e n use it" (p. 191). T h e i m p a c t o f right effort, or right motivation, in the Eight-Fold Path is also implicit in the influential stages-ofc h a n g e m o d e l o f addictive behavior c h a n g e p r o p o s e d by Prochaska, DiClemente, a n d Norcross (1992) Clients often move t h r o u g h these various stages d e p e n d i n g o n their motivational level, from little o r n o motivation to c h a n g e ( p r e c o n t e m p l a t i o n ) , to ambivalent o r conflicted motivation ( c o n t e m p l a t i o n ) , before e n t e r i n g the action stage o f taking specific steps to c h a n g e their addictive behavior. Again, therapists who m a t c h their intervention strategies to the client's c u r r e n t stage o f c h a n g e a p p e a r to be m o r e successful than those who insist on "action" (comm i t m e n t to abstinence) when clients are n o t ready o r able to benefit from a confrontational a p p r o a c h . In recent years, motivational e n h a n c e m e n t therapy (MET) has b e e n increasingly used as a m e t h o d o f e n h a n c i n g movem e n t through these motivational stages (Miller & Rollnick, 1991). MET is characterized by an attitude o f compassion a n d acceptance on the part o f the therapist as the client is g u i d e d t h r o u g h the stages-of-change process

49

Conclusion
Buddhist p h i l o s o p h y has m n c h to offer the addictions t r e a t m e n t field. T h e parallels between the d h a r m a a n d cognitive-behavioral t r e a t m e n t a p p r o a c h e s suggest that these two disciplines have m u c h in c o m m o n . Traditional t r e a t m e n t p r o g r a m s are based o n the disease m o d e l (i.e., that addiction is a disease o f the brain). This a p p r o a c h is based on the assumption that a d d i c t i o n is r o o t e d in biological factors b e y o n d the individual's control. T h e 12step p h i l o s o p h y requires acceptance o f personal "helplessness" a n d that abstinence a n d the n e e d to rely u p o n an external H i g h e r Power are the only means o f resolving the p r o b l e m . In contrast, Buddhist p h i l o s o p h y teaches us that a l t h o u g h addiction can have debilitating disease consequences (e.g., cancer, cirrhosis, central nervous system disorders), the roots o f a d d i c t i o n are in the mind. Meditation a n d o t h e r Buddhist practices are essential to u n d e r s t a n d i n g how the m i n d behaves a n d how thoughts a n d expectations can e i t h e r facilitate or r e d u c e the occ u r r e n c e o f addictive behavior.

References
Baer,J. S., Kivlahan, D. R., Blume, A. W., McKnight, E, & Marlatt, G. A. (2001). Brief intervention for heavy-drinking college students: 4year follow-up and natural history. American Journal of Public Health, 91, 1310-1316. Benson, H. (1975). The relaxation response. New York: William Morrow. Chodron, E (1998). Whenthings fall apart: Heart advicefor difficult times. Boston: Shambhala.

50

Robins

Denning, E (2000). Practicing harm reduction psychothoapy/. New York: Guilford Press. Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief

Alcohol Screwing and Intervention fi)r College Students (BASICS): A ha~vn reduction approach. New York: Guilford Press. Groves, E, & Farmer, R. (1994). Buddhism and addictions. Addiction Reseatch, 2, 183-194.
Kumar, S. M. (2002). An introduction to Buddhism for the cognitivebeha~ioral therapist. Cognitive and Behavioral Practice, 9, 40-43. Levine, M. (2000). The positive psycholo~ of Buddhism and yoga. Mahwah, NJ: Lawrence Erlbaum. Marlatt, G. A. (1985). Lifestyle modification. In G. A, Martatt &J. R. Gordon (Eds.), Relapse prevention (pp. 280-348). New York: Guilford Press. Marlatt, G. A. (1994). Addiction, mindfulness, and acceptance. In S. C. Hayes, N. S.Jacobson, V. M. Folette, & M.J. Dougher (Eds.), Acceptance and change: Content and context in psychothera]o' (pp. 175-197). Reno, N%1:Context Press. Marlatt, G. A. (Ed.). (1998). Harm reduction: PragmaticstmtegiesJbr mana~ng high-risk behaviors. New York: Guilford Press. Marlatt, G. A., Baez;J. S., Kivlahan, D. R., Dimeff, L. A., Larimel; M. E., Quigley, L. A., Somers,J. M., & Williams, E. (1998). Screening and brief intezwention for high-risk college student drinkers: Results from a two-year tollow-up assessment. Journal of Consulting and Clinical Psychology, 66, 604-615. Marlatt, G. A., & gJ'istellei; J. (1999). Mindfulness and meditation. In W. R. Miller (Ed.), Integrating spirituality in treatment: Resourcesfor practitioners (pp. 67-84). V~:ashington,DC: American Psychological Association Books. Marlatt, G. A., & Marques, J. K. (1977). Meditation, selfcontrol, and alcohol use. Ill R. B. Stuart (Ed.), Behavioral self-management: Strategies, techniques, and outcomes (pp. 117-153). New York: Brunner/ Mazel. Marlatt, G. A., Pagano, R. R., Rose, R. M., & Marques, J. K. (1984).

Effects of meditation and relaxation training upon alcohol use in male social drinkers. In D. H. Shapiro & R. N. Walsh (Eds.), Meditation: Classic and eontemporary perspectives (pp. 105-120). New York: Aldine Press. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change. New York: Guilford Press. Murphy, T.J., Pagano, R. R., & Marlatt, G. A. (1986). Lifestyle modification with hea~T alcohol drinkers: Effects of aerobic exercise and meditation. Addictive Behaviors, 11, 175-186. O'Connell, D. E, & Alexander, C. N. (Eds.). (1994). Self-recovery: 7?eat-

ing addictions using 7?anscendental Meditation and Maharishi AyuT: Veda. New York: Haworth Press.
Prochaska,J. O., DiClemente, C. C., & Norcross,J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114. Teasdale,J. D., Segal, Z. V., & Williams,J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? BehaviourResean:h and Therapy, 33, 25-39. Teasdale, J. D., Segal, Z. V., Williams,J. M. G., Ridgewa); V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in m~:jor depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623. Thoreson, C. G., & Mahoney, M. H. (1974). Behavioralself-control. New York: Holt, Rinehart & Winston. Trungpa, C. (1968). Meditation in action. Boston: Shambhala. Address correspondence to G. Alan Marlatt, Ph.D., University of Washington, Department of Psychology, Box 351525, Seattle, WA 98195; e-mail: marlatt@u.washington.edu.

Received: January 10, 2000 Accepted: l~br'uary 20, 2001

Zen Principles and M i n d f u l n e s s Practice in Dialectical Behavior Therapy

C l i v e J . R o b i n s , D u k e University

Dia&ctical behavior therapy (DBT; Linehan, 1993a) was developed as a treatment for borderline personality disorder (BPD). It involves a dialectical synthesis of the change-oriented strateg4es of cognitive-behavioral therapy with more acceptance-oriented principles and strategies adapted primarily Ji'om client-centered therapy and from Zen. In this p a p ~ I note both .similarities and contrasts between co~zitive-behavioral therapy and Zen. I then highlight the role of Zen principles in DBT's assumptions about patients, theory of BPD, selection of treatment targets, and treatment strategies. Finally, the article describes the value of mindfulness practice for patients with BPD, how mindfulness skills are taught to patients in DBT, and benefits of mindfulness practice for therapists.

EHAVIOR THERAPY a n d B u d d h i s t t h o u g h t m i g h t app e a r to b e radically d i f f e r e n t , p e r h a p s e v e n c o n t r a dictory, in t h e i r a p p r o a c h e s to u n d e r s t a n d i n g a n d c h a n g i n g behavior. F o r e x a m p l e , b e h a v i o r t h e r a p y t r a d i t i o n a l l y has f o c u s e d o n o v e r t b e h a v i o r a n d o t h e r o b s e r v a b l e variables a n d t h e W e s t e r n scientific m e t h o d o f a d v a n c i n g

k n o w l e d g e , w h e r e a s B u d d h i s t t h o u g h t a n d m o s t o t h e r religious t r a d i t i o n s have b e e n c o n c e r n e d p r i m a r i l y with m e n t a l a n d spiritual p h e n o m e n a a n d p r o p o s e a n e x p e r i e n t i a l p a t h to u n d e r s t a n d i n g a n d c h a n g i n g b e h a v i o r . H o w e v e r , as this series attests, t h e r e is g r o w i n g i n t e r e s t among behavior therapists and cognitive behavior therapists in t h e p o t e n t i a l c o n t r i b u t i o n s o f spiritual t r a d i t i o n s , particularly Buddhism. A t least o n e f o r m o f b e h a v i o r t h e r a p y , d i a l e c t i c a l beh a v i o r t h e r a p y (DBT; L i n e h a n , 1993a) f o r p e r s o n s diagn o s e d with b o r d e r l i n e p e r s o n a l i t y d i s o r d e r (BPD), ex-

Cognitive

and

Behavioral

Practice

9, 50-57,

2002

1077-7229/02/50-5751.00/0 Copyright 2002 by Association for Advancement of Behavior Therapy. All right.s of reproduction in any form reserved.