How to treat addiction with mindfulness

One of the most effective treatments for addiction is a mindfulness-based treatment based on neuroscience and meditation research.

Mindfulness beats smoking addiction

In 2008, psychiatrist Dr. Judson Brewer proved that his mindfulness-based treatment for smoking addiction was five times as effective as the existing gold-standard treatment, as advocated by the American Lung Association.^[1] His approach did not include any medications, and did not even rely on willpower. The reason it worked was that it hacked a process called ‘reward-based learning’, otherwise known as ‘operant conditioning’.^[2] This is the process that makes people addicted, but it is also the process that can set them free.

Reward-based learning in Buddhist texts

Having been a dedicated meditator for many years, Judson Brewer began to see parallels between the psychological models of behaviour he was studying and the Buddhist models of the mind. He discovered that Buddhist philosophers had described a cycle of conditioning, called the ‘cycle of dependent origination’, which almost perfectly matched his scientific understanding of ‘reward-based learning’. This led him to shift his research into how mindfulness affects the brain and how that might help improve psychiatric conditions.^[3]

How reward-based learning works

Dr. Brewer discovered that not only could mindfulness be used to treat smoking addiction, but it could be used to intervene in various destructive habits, such as worrying, distraction, and emotional eating. The cycle of reward-based learning, which gets us hooked, works the same way, no matter what the habit is. These are the basic steps of the process:

1. Trigger.
2. Emotion.
3. Craving.
4. Rewarding behaviour.
5. Emotional reward (more positive emotion or less negative emotion).
6. Craving (for the trigger and/or emotional reward).
7. Repeat.^[4]

Even though this cycle can cause a lot of trouble, it also helped our ancestors survive in times of scarcity. By learning to associate certain triggers, such as ripe fruit, with a good feeling, their cravings would increase their chances of survival.^[5] However, this same habit loop can make people addicted to smoking, overeating, and other destructive behaviours.

What addiction really is

Unfortunately, our culture is saturated with unrealistic stories about addiction. People who are addicted often receive moral judgements from their environment, and are regarded as criminals instead of as patients. They are seen as ‘addicts’, instead of as human beings who are trying to relieve their suffering.^[6]

Addiction is clinically defined as “continued use, despite adverse consequences.”^[7] In other words, people keep engaging in a particular habit, even though it increases their long-term suffering. Dr. Brewer discovered that the vast majority of his patients engaged in their addictions to make something unpleasant go away, such as stress, rather than just to get pleasure.^[8] He therefore had to create a treatment protocol that helped them identify the underlying triggers of their addiction.

The RAIN protocol

The mindfulness-based treatment that Dr. Brewer designed consists of four basic steps:

1. Recognise.
2. Accept.
3. Investigate.
4. Note.^[9]

Recognise

In the first step, patients are encouraged to ‘recognise’ whenever they get caught up in a habitual behaviour, by mindfully observing the whole cycle, from the trigger to the emotional reward. For example, Dr. Brewer encouraged the smokers to pay close attention to (1) the triggers that made them want to smoke, (2) the craving to smoke, (3) the actual sensations of smoking (the behaviour), and (4) how good the smoking actually made them feel (the reward).^[10]

After just three days, most smokers were amazed by how often their urge to smoke was triggered by boredom or anxiety, and how disgusting the smoking itself actually was.^[11] Rather than telling them to use willpower to stop smoking, they were encouraged to ‘recognise’ when they got caught up in the habit, while paying attention.

Accept

In the second step, patients are encouraged to accept the cravings whenever they arise. Instead of seeing the cravings as a problem or a threat, patients are encouraged to see the cravings as a wave that naturally comes and goes. By not resisting those waves, they will pass of their own accord.^[12]

Investigate

In the third step, patients are encouraged to ‘investigate’, or get curious about the craving. How does the craving feel in the body? By triggering curiosity and interest, the brain’s reward centres are activated, which makes it more rewarding to observe the craving than to indulge in it, such as by smoking a cigarette. This enables the patient to observe the craving until the end, without letting it trigger the addictive behaviour.^[13]

Note

Finally, in the fourth step, patients can ‘note’ or ‘name’ the sensations they experience while observing the craving in their body. This helps to decrease the identification (or ‘cognitive fusion’) that normally occurs, and to simply observe the craving as an impersonal wave of sensation.^[14]

Disenchantment over willpower

The main reason that mindfulness works better than willpower is because mindfulness allows patients to become so disenchanted with their negative habit that they gradually lose interest in it. By observing how unrewarding it actually is, willpower becomes unnecessary.^[15]

Although the cravings keep coming for a while, even after the patient has quit the negative habit, they do decrease over time, until they finally disappear altogether.^[16] Dr. Brewer found a useful analogy to describe this in an ancient Buddhist text. Craving is like a fire that requires fuel (the addictive behaviour). When you quit the behaviour, the fire of craving will continue to burn for a while, until the fuel has been totally consumed. All one has to do is stop adding fuel to the fire by not engaging in the behaviour when the craving arises.^[17] By separating the craving from the behaviour, the chain of habituation has been cut.^[18]

Timo Pieters

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Sources

^[1] Dr. Judson Brewer, The Craving Mind: From Cigarettes to Smartphones to Love – Why We Get Hooked & How We Can Break Bad Habits (Yale University Press: 2017), p. 28.

^[2] Ibid, p. 5.

^[3] Ibid, Loc. 248.

^[4] Get Stressed. Eat. Repeat. How We Can Break Stress Eating Habits Simply By Paying Attention. | HuffPost Life.

^[5] Brewer, The Craving Mind, p. 2.

^[6] Dr. Carl Hart, Drug-Use for Grown-Ups: Chasing Liberty in the Land of Fear (Penguin Press: 2021).

^[7] Brewer, The Craving Mind, p. 18.

^[8] Ibid, p. 19.

^[9] Ibid, p. 30.

^[10] Ibid, p. 28.

^[11] Ibid.

^[12] Ibid, p. 31.

^[13] Ibid, p. 32.

^[14] Ibid.

^[15] Ibid, p. 33.

^[16] Ibid, p. 35.

^[17] Ibid.

^[18] Ibid, p. 36.