Dr. G. Alan Marlatt is the founder and director of the Addictive Behaviors Research Center at the University of Washington, where he developed the Mindfulness-Based Relapse Prevention (MBRP) outpatient treatment program. He is also the author of Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Kevin Griffin interviewed Dr. Marlatt in October 2009 in Los Angeles.
Inquiring Mind: Can you tell us about Mindfulness-Based Relapse Prevention?
Alan Marlatt: Relapse prevention is a cognitive behavioral approach that mainly teaches people skills: how to cope with triggers and high-risk situations, how to manage urges and cravings. It also helps people get a better sense of their own personal journeys and the forks in the road that lead either to recovery or to falling off the wagon. In getting this bigger picture, mindfulness meditation enhances what many people call “meta-cognition”—the ability to stand back, observe what is happening and think about what you are doing rather than being on automatic pilot. We’re trying to promote approaches that will help people see their feelings and then develop more of a sense of choice. It’s when they’re in the habit-stimulus response that most people get into drug use and its consequences.
S.O.B.E.R. is one of the meditation breathing spaces we’ve developed. You can use it when you’re right on the verge of taking a drink. It enhances meta-cognition, giving you a chance to stand back and look at what’s going on. Say you’re walking by a bar you used to visit and the thought arises: “Maybe I’ll just pop in and see if anybody I know is inside.” S is for “stop” where you are. Stop walking. Then O, “observe” how you’re feeling—what are the physical sensations and cravings? B, focus on your “breath.” Take a deep breath, then another breath, and center your attention there. And E, “expand” your awareness so that you’ll have a larger sense of what would happen if you did go in the bar. How would you feel? In AA, they call this “thinking through the drink.” Finally, R, “respond” mindfully.
IM: Do you also teach people to meditate?
AM: We teach “regular” meditation practices like breathing meditation for 20 or 30 minutes and doing body scans. We’ve also developed mini-meditations, for instance, “urge surfing.” The Buddhist understanding of urges and cravings is that you can’t get rid of them. They are going to happen. So you have to learn some sort of acceptance, a recognition of what’s going on, and a more mindful perspective. Then you can ride them out. You can let go without giving in.
The idea for urge surfing came from a man who was trying to stop smoking. He described one attempt: “I made it forty-minutes, but that was all. These urges, they get stronger, and if I don’t give in to them, I think I’m going to go crazy.” I explained to him that an urge is like an ocean wave that grows bigger and bigger as it approaches the shore. As it grows, there’s the desire to just give in, but if you do, you’ll reinforce the power of the addiction. Instead, you can ride the “wave” by using the breath as a kind of surfboard.
It turns out this smoker was also a surfer, and the image of the wave really helped him. “Use your breath as a surfboard,” I told him. “You can at least ride the wave without getting wiped out and having a cigarette.” He wasn’t sure how this was going to work. He started out measuring his urges as he practiced with the “surfing” for about a month. He had a lot of slips, but he kept at it: “You know, I’ve managed not to smoke four out of five times. The fifth time, yeah, I had a cigarette, but my urges are getting a little further apart each time and they’re not as strong as they used to be. This seems to be working.” After about five weeks, he was off smoking altogether.
IM: The reinforcing effect of giving in to an urge sounds just like the law of karma—whatever you repeat gets stronger, and whatever you don’t repeat gets weaker. You’re also pointing people toward the impermanence of a craving. When I had the craving to drink, it felt like I had no choice, that if I didn’t drink I would die. Now I know that’s not true.
AM: A lot of people feel that way. One woman in our program had a problem with depression and drinking. She eventually went to a meditation retreat with Thich Nhat Hanh and took the precepts, including the vow not to drink. She said, “Okay, that’s it. Not only am I going to give up drinking for this retreat, I’m never going to drink again.” When she came back from the retreat, she said, “Well, when I am depressed I still have the thought that I need to drink, and the craving goes up. But now I can recognize it and watch it pass. My thoughts don’t need to dictate what I do. She reminded me that the word dictator has the same root as the word addiction; both are telling us to do something.
IM: How do people end up in MBRP?
AM: Most of our clients have already gone through some sort of intensive outpatient therapy or inpatient programs, detox, things like that. They come into our program already abstinent. So we pick them up in the aftercare phase, which has typically been social support, Twelve Step facilitation and meeting in groups once a week. We offer clients the option to take a mindfulness course. It’s an eight-session outpatient treatment program.
IM: How do they react to the meditation aspect of the program?
AM: People often ask if our program is religious. We explain that mindfulness came from Eastern traditions, including Buddhism and Hinduism, but that people have found it very helpful for dealing with pain and depression. And now we’re trying it with addiction. Clients can think of it as a cognitive coping practice that will help them get very relaxed and centered—and deal with urges and cravings a little more effectively. When people hear about it in that way, most agree to participate.
IM: So since your clients are already abstinent, your focus is on keeping them clean.
AM: Yes. We start by talking about relapse issues. For instance, if you have a strong craving, can you slow the whole process down? It will make a big difference to create some space before the mind goes to, “Where’s my next drink?” We talk about “automatic pilot” in the first session. A sense of choice is really what we’re trying to promote. As Viktor Frankl said, “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” With mindfulness, you realize you have a choice. It’s not inevitable that you go one way—down the tube.
We also teach the body scan meditation, which in terms of cravings and urges can be very helpful. People start to gain much more awareness of how they’re feeling and where in their bodies their cravings are “kicking” them. So their awareness and their mindfulness is enhanced. We give clients a CD with meditation instructions and ask them to do at least one 30-minute session a day.
In the second half of each session, we do more standard relapse prevention. We ask, What are your triggers? What are your high-risk situations? What kinds of things are going to instigate urges and cravings? Since most of the people in the program had chronic addiction problems with co-occurring mental health problems, we offer an integrated approach. How is your mental health problem, like your anxiety, a trigger for drinking? What can we do to help you manage your anxiety so it’s not so much of a problem? Meditation is perfect for that, because it’s both relaxing and it gives people more space.
The biggest trigger for relapse is negative emotional states. That’s very consistent with the Buddhist concept called “double dukkha.” Dukkha is suffering. You can’t prevent or avoid certain painful experiences, but when you add on the lament, “Oh, there I go again,” you feel even worse. You double the dukkha. With mindfulness you can appreciate, recognize and accept what is going on without doubling the dukkha. It’s the same with addictions. If you’re suffering and thinking, “Oh my god, I have to have a drink to get over it,” it’s a double-dukkha thing. Maybe the drink would give you temporary relief, but then the fact that you drank will bring you more suffering.
One strategy we teach to avoid double dukkha is to see through the “pig.” The pig is an animal with a huge appetite; it stands for the “problem of immediate gratification.” The pig shows up, grunting, “I’m hungry. I’m really having a craving. Come on, feed me.” If you respond, “Okay, if that’s what you need, I can give it to you,” then what happens? The pig gets bigger and gains more control. When your pig is saying, “Give me, give me, give me,” we suggest you talk to the pig. Have a moment of contact.
One young woman in our program had a cocaine problem. She tried talking to the pig. “You know,” she reported, “a strange thing happened. The pig came up and said, ‘Cocaine, cocaine.’ I imagined the pig was there, and I looked in the pig’s eyes and said, ‘Is that what you really want?’ The pig looked at me kind of sadly and said, ‘You know, I’d rather have a hug than a drug.’” It finally clicked with this woman that her desire to get loaded often came when she was feeling alone and upset. She told us, “Wow, that was a big turning point.”