Mindfulness and Recovery: Theory and Mechanisms

woman practicing mindfulness by the seaThe practice of mindfulness is no longer considered an experimental approach in the treatment of mental health and substance abuse disorders. Once a novelty without much data or evidence to verify its benefits, research into the mechanisms and efficacy of mindfulness practices on health and wellness began in the 1970s, gained momentum in the 1980s and 1990s, and surged in the 2000s. Between 2000 and 2010, the sheer volume of mindfulness studies published in peer-reviewed scientific journals piqued the attention of the traditional medical establishment and forced a shift in the way doctors, therapists, and health scientists view techniques once considered interesting but unverified fluff. Since 2010, wide-ranging surveys and meta-analyses have addressed and verified the scientific basis for mindfulness. The current consensus is that practices such as meditation, yoga, taiji, and basic breathing exercises are practical and effective components in the treatment of mental health disorders of all sorts, and substance abuse disorders in particular.

This article offers a brief history of mindfulness in the U.S., a discussion of the neural mechanisms mindfulness training targets, and a general theory to explain why mindfulness plays an important role in any treatment and recovery plan for individuals struggling with substance abuse and addiction disorders.

Mindfulness in the U.S.

While a majority of the population may view mindfulness as a relatively new phenomenon, history tells a different story. Mindfulness arrived in the U.S. over a century ago, when renowned Indian guru Swami Vivekananda addressed the Parliament of World Religions in Chicago in 1893. Vivekananda represented India, Hinduism, and yoga, but his speech triggered national interest in spiritual and physical practices from Tibet, China, and Japan. In the decades that followed, the secular aspects of Hinduism, Taoism, and Buddhism – yoga, taiji/qigong, and meditation, respectively – slowly worked their way into American culture. The 1960s saw an explosion of interest in yoga with the publication of a popular series of books by Richard Hittleman, and in 1970 yoga made it to television: the show Yoga for Health proved yoga, and by extension, mindfulness practices in general, were here to stay.

Dr. Jon Kabat-Zinn, a researcher at the University of Massachusetts, conducted the first scientific studies on the mental health benefits of mindfulness. He began by examining the effect of mindfulness on chronic pain management, then widened the scope of his research to include stress, anxiety, and depression. He synthesized his work into a system known as Mindfulness Based Stress Reduction (MBSR). MBSR is now a default therapeutic technique in use by therapists, treatment centers, and addiction experts worldwide. It’s been combined successfully with a variety of traditional psychotherapeutic modes, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Relapse Prevention (RP). Evidence for the complete integration of MBSR with these techniques – and its acceptance by the scientific community – is reflected in a new family of acronyms: MBCBT (Mindfulness-Based Cognitive Behavioral Therapy), MBDBT (Mindfulness-Based Dialectical Behavioral Therapy), MBACT (Mindfulness-Based Acceptance and Commitment Therapy), and MBRP (Mindfulness-Based Relapse Prevention). Thankfully, a simpler way of labeling mindfulness-related therapies has supplanted the acronym avalanche: they’re now collectively known as Mindfulness Training, or MT.

Mindfulness Training: Neurochemical Mechanisms

For generations, both the neuroscience community and the general public lived with the belief that after a certain point early in life, neurogenesis, or the formation of new brain cells, stopped. This misconception was debunked in the late 1990s, first by identifying the formation of new brain cells in songbirds and finally by identifying the formation of new brain cells in adult humans in the early 2000s. A growing body of research proves definitively that mature humans can not only produce new brain cells, but the new brain cells can be produced in a relatively short amount of time – as little as eight weeks – by the practice of mindfulness techniques.

Mindfulness training results in an increase in brain matter density (neurogenesis) in the following brain regions:

Hippocampus: The hippocampus is an essential structure in the limbic network, the part of the brain primarily responsible for emotional regulation. The hippocampus also contributes to the formation of memory and cognitive functions like self-awareness, compassion, and reflection.

Amygdala: Part of the limbic network, the amygdala is known to be associated with sensations of stress and anxiety.

Posterior Cingulate Cortex (PCC): The PCC is involved in the process of assessing the relevance of external stimuli to oneself, and contributes to placing these self-referential stimuli in an individual’s emotional and autobiographical context.

Cerebellum: The cerebellum is primarily known for its function with regards to sensory perception and motor control, but it also contributes significantly to the regulation of cognitive and emotional processes.

Temp-parietal Junction (TPJ): The TPJ facilitates the integration of internal and external sensory information, social cognition, and the ability to interpret the desires, intentions, and goals of others. Activation of the TPJ is linked to feelings of empathy and compassion.

The brain structures stimulated and strengthened by mindfulness training combine to form a functional group uniquely relevant to the treatment substance abuse and addiction. Substance abuse disorders compromise and lead to deficits in emotional regulation, stress response, anxiety, self-awareness, social intelligence, and empathy. While these deficits manifest in different ways for different people, their cumulative effect leads to dysfunctional behavior in the form of counter-productive coping skills. Self-medication suppresses powerful emotions, disproportionate stress-response and exaggerated anxiety increase desire for self-medication, distorted perception of the self-in-context normalizes the denial of the self-destructive consequences of substance abuse, and diminished social intelligence and empathy contribute to the tendency of addicts to lose sight of the consequences of their actions on the people around them. Mindfulness training reinforces the neural mechanisms necessary to bolster the perceptive skills required to bring these deficits back into balance, enabling individuals to see and understand their behavior, which in turn allows them to build the healthy and life-affirming coping skills that lead to sustainable recovery.

A Mindful Model of Addiction

A deep dive into the scientific literature available on the effects of mindfulness training on mental health disorders, including addiction treatment and recovery, leads the diligent reader to mountains of data describing positive benefits related to well-being, mood, self-efficacy, stress tolerance, the ability to gain non-judgmental perspective on behavior. However, only one study elucidates the connection between Buddhist philosophy – the theoretical basis of most practical mindfulness techniques – and contemporary theories of addiction. In “Craving to Quit: psychological models and neurobiological mechanisms of mindfulness as treatment for addictions”, a 2012 paper published in Psychology of Addictive Behaviors, researchers apply the Buddhist theory of human suffering to substance abuse disorders, calling it “an early model of addiction.”

The Buddhist Model

The Buddhist theory of suffering is relatively simple. It states that desire causes all human suffering, and therefore, the path to enlightenment – or in the case of regular people living 21st century lives, the path to health and wellness – lies in releasing attachment to objects of desire. Buddhist philosophy also asserts that personal identity is formed, in part, by associations created by habitual behavior. An individual desires an object or subjective sensation and connects fulfillment of that desire to a concept of identity, which reinforces both the habitual fulfillment-seeking behavior and concept of self to the sensations and attendant emotional states achieved by fulfilling the desire. In the case of an individual struggling with substance abuse, pleasurable sensations that follow substance use are the objects of desire. Those sensations become an aspect of identity. When those sensations fade, so fades the habituated sense of identity. The fulfillment of desire, therefore, becomes the search to maintain identity, and identity becomes inextricably intertwined with substance use. 

Mindfulness Training: Interrupting the Craving Cycle

The way to break this cycle is to separate the habituated sense of identity from the cycle of desire. Substitute the idea of craving for the phrase cycle of desire, and addictive behavior can be understood by recognizing that what addicts do is logical: they crave reinforcement of their sense of identity. More simply put, they crave being themselves. In the case of an individual struggling with addiction, the created self is counter-productive and damaging to long term health, function, and survival. When the cycle continues in unchecked, iterative repetition, the self of addiction undermines the true self by distorting emotion, perception, memory, and cognitive function. It supplants and ultimately destroys the original self and becomes the default state of identity.

Buddhist scholars call this cycle “the chain of dependent origination.” Craving is what connects identity to the chain; therefore, breaking the cycle of craving may enable an individual to escape the cycles of addiction. Mindfulness training teaches the skills required to see the cycle as it is – a self-destructive one – and replace it with constructive patterns of behavior. Dr. Lawrence Peltz, author of “The Mindful Path to Addiction Recovery: A Practical Guide to Regaining Control over Your Life”, describes mindfulness training as

“… a powerful accompaniment to the recovery, psychotherapy, and medicine an alcoholic or addict needs. In essence, mindfulness is the quality of awareness that sees without judgment, shining a light on each moment just as it is. This includes physical sensations, feelings, thoughts, and the nature of our experience continually shifting and changing. With practice, it is a skill that can be developed by anyone.”

The first step in developing this important recovery skill is learning to slow the mind down, relax, focus, and “shine a light on each moment just as it is.” There are many paths to this mind-state, such as seated meditation, walking meditation, breathing exercises, and the practice of yoga postures. What all these techniques have in common is their ability to grant the practitioner the ability to clearly see what drives their actions, and the perspective to decide whether those actions help them or hurt them.

Mindfulness allows an individual to observe, for instance, that stress triggers a cascade of emotion that leads to a particular behavior, i.e. substance use. Mindfulness further allows the individual to understand that though substance use temporarily alleviates the symptoms of stress, that same stress, anxiety, and tangle of uncomfortable emotions returns when the substance of abuse clears their system. The clarity of mindful perception can lead to the insight that substance use does nothing whatsoever to mitigate the underlying cause of the stress. This insight may lead to greater and greater levels of understanding. The authors of “Craving to Quit” summarize the benefits of mindful perception in this way:

“By decoupling pleasant and unpleasant experience from habitual reactions of craving and aversion, careful attention to the present moment can function to bring a broadening or spaciousness of awareness that allows new appraisals of life situation. A possible result of this…is the ability of mindfulness to facilitate positive reappraisal.”

Mindfulness in Action

In the context of treatment and recovery, the power of mindfulness lies in its ability to support, complement, and functionalize more traditional modes of therapy. While methods such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Relapse Prevention (RP) help individuals identify patterns of behavior which undermine health and well-being, they do not offer specific techniques with the strength to arrest craving cycles during the critical moments in which cravings occur. When craving hits, habituated patterns of addiction drive behavior towards that which reaffirms the distorted sense of self and identity caused by addiction. Traditional therapies based on talking and thinking often fail to interrupt these patterns, whereas mindfulness training – through breathing exercises, somatic practices, and the cultivation of non-judgmental detachment – teaches skills to stop the cycle of craving in its tracks, allow the moment of craving to pass without acting upon it, and create the internal space to replace the negative patterns of addiction with the positive patterns of recovery.

For decades, mindfulness training has helped individuals struggling with substance abuse and addiction disorders achieve balance and harmony in their lives. In the early days of the mindfulness movement, these techniques were regularly devalued, ignored, or ridiculed by the scientific establishment. Those days, thankfully, are over. Advances in neuroimaging have allowed researchers to identify discrete changes in brain structure following mindfulness training, offering clear data on the mechanisms by which mindfulness supports recovery. Coupled with a compelling, logical theory to elucidate the role of mindfulness vis a vis identity, choice, action, and behavior, mindfulness training has shed the baggage of unverified novelty and assumed its proper place in the mental health community as an effective, practical, and evidence-based mode of treatment for substance abuse and addiction disorders.