Motivation and emotion/Book/2018/Mindfulness and addiction

Overview
When addiction is thought of, it is often thought of in regards to the maladaptive effects that an addiction can have on an individual and those surrounding that individual. Traditionally, addiction has been thought of in the context of substance-related abuse, however, in more recent times there has been an increase in the recognition of additional addictions such as internet addictions (Du, Jiang, Lin, Vance, & Zhang, 2013), gambling addictions (George, Jaisoorya, & Kallivayalil, 2014) and gaming addictions (Griffiths, Konijn, Roelofsma, & Spekman, 2013). When a behaviour is affected by the strength of the reinforcement, causing self-regulation to be negatively affected, and the behaviour is maladaptive, it is considered an addiction (Webb, Sniehotta, & Michie, 2010).

The Australian Medical Society categorises addiction into two distinct categories:

Substance dependence “A chronic brain disease that involves the compulsive or uncontrolled use of one or more substances, and that has the potential for relapse as well as recovery” (Australian Medical Association, 2017)

Behavioural addiction “A similar condition that involves compulsive or uncontrolled behaviours or activities such as pathological gambling, compulsive buying, exercise and internet addictions.” (Australian Medical Association, 2017)

These categories highlight that addictions centre on “compulsive or uncontrolled” engagement with a behaviour or substances. It may then be asked, what is it that unconsciously drives addictions?

This book chapter aims to help you to understand the underlying motivations of addiction and how mindfulness can be used as a therapeutic approach. This chapter will discuss the characteristics of addiction, the motivational theories of addiction and the effect of mindfulness on addiction.


 * What is an addiction?
 * What are the underlying motivations of addiction?
 * How can mindfulness affect addiction?

Characteristics of addiction
1. Reinforcement Initially, an individual will engage in a behaviour which leads to the positive reinforcement of this behaviour. Positive reinforcement occurs when a substance is first introduced, as it elicits a strong positive response that increases the likelihood for the behaviour to occur again. For example, in nicotine addictions, individuals experience a significant ‘euphoria’ (Pomerleau & Pomerleau, 1992). When the reinforced behaviour or substance begins to decrease, it causes an aversive withdrawal for the individual (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). Therefore, the individual becomes motivated by negative reinforcement, as they engage in the behaviour in order to avoid the aversive reaction.

2. Craving A specific drive for individuals to re-engage in an addictive behaviour is the persistence of cravings. Cravings of an addiction are intense and specific, as these cravings are linked to a sensory memory and cues of the addictive stimulus (Pelchat, Johnson, Chan, Valdez, & Ragland, 2004). For example, in drug addictions, cravings may elicit feelings of arousal, physiological reactions and taste sensations that are experienced during the consumption of a substance (Childress, et al., 1999).

3. Loss of control Addiction is characterised by the inability to control the intake of a behaviour or substance (Marlatt, Demming, & Reid, 1973). Bechara (2005) suggests that addictions, specifically drug addictions, can be compared with patients with ventromedial prefrontal cortex damage (VMPC). This research displays two significant factors; Firstly, both VMPC patients and addicts display an inability to recognise future consequences as they are driven by a present time perspective. Secondly, both groups prioritise the anticipation of a reward, despite the consequences that may result from this. Due to the changes in the neurocognitive bases of motivation, individuals with addictions lose the ability to consciously control their own behaviour. Therefore, addictions instigate a loss of control over the motivation for general well-being and reduction in future consequences.

4. Tolerance Tolerance is when the prolonged exposure to a behaviour or substance leads to the reduction of response over time, to a consistent dosage (Greenblatt & Shader, 1978). Therefore, an individual increases a dosage in order to attain a substantial positive response.

5. Negative consequences The prioritisation of a substance or behaviour is often at the detriment of functioning in other aspects of an individual’s life. Consequences of an addiction relate to biological, cognitive, psychological and social factors. Biological consequences of addiction can occur in neural functioning, displayed in neuroadaptations (Shaffer & Kidman, 2003). Cognitive functioning sees a reduction in reasoning, attention and decision making (Morgan, Muetzelfeldt, & Curran, 2010). Individual’s with addiction are also more vulnerable to additional mental illnesses, such as depression (Kim, et al., 2006). Furthermore, individuals experience social consequences such as the negative effect on work or school and significant relationships (Kim, LaRose, & Peng, 2009). The consequences of an addiction are also significantly related to the maintenance of it, for example, the loss of social support network and significant relationships can drive an individual to re-engage in the addictive behaviour as a compensatory behaviour.

Theories of addiction
On reflection of the implications of addiction, individual's may become curious as to the motivations that drive another individual to engage in a behaviour that is maladaptive to their own lives. Two theories of addiction will be examined to answer this.

Opponent-process theory of motivation
Solomon and Corbit (1974) propose the opponent-process theory of motivation. This theory suggests that addiction occurs in two processes and it is these processes that instigate a motivational change for an individual. The motivational changes that occur are varied over time and are related to three states, hedonic, affective or emotional (Solomon & Corbit, 1974). They suggest that the three stages are opposed by mechanisms within the central nervous system which leads to a reduction in the intensity of hedonic sensations. This occurs through two processes:



1. A-process Firstly, is the a-process which focuses on the initial engagement of an addictive substance or behaviour and the tolerance that is exerted during this time. Shortly following the presentation of this stimulus, an individual experiences a positive sensation that is associated with the “intensity, quality and duration of the reinforcer” (Koob & Moal, 2008).

2. B-process Following this process is the b-process which increases following repeated exposure to a stimulus. The b-process is the negative withdrawal reaction that builds up (Solomon & Corbit, 1974), it is characterised by a slow onset and resistance to decay. This theory proposes that an individual experiences the initial affective state which leads to their central nervous system creating an opposing reaction (Solomon & Corbit, 1974). The duration of this opposing reaction continues despite the initial affective state ceasing. Thus, the continuation of addictive behaviour is driven by the desire to reduce cravings and experience relief from maladaptive withdrawal symptoms.

Addiction cycle
Koob and Volkow (2010) propose the addiction cycle, this model focuses on the role of neurobiological functions in addiction. This theory suggests that addiction is initially characterised by a dominate impulsivity followed by compulsivity which leads to a change in reinforcement (Koob & Volkow, 2010).

1. Binge/intoxication This stage is the introduction of a stimulus or behaviour which is then positively reinforced (Koob & Moal, 2005). The engagement with a substance leads to the release of opioid peptides and dopamine into the ventral striatum which causes a sense of euphoria. The substance reinforces behaviour through an association with a primary reinforcer, thus, transitioning from a neutral stimulus to its own reinforcer (Koob & Volkow, 2016). The role of dopamine in this process is significant as midbrain dopamine cells have been shown to fire at the cues of a reward delivery prior to the introduction of the direct stimuli. Therefore, a new reward triggers phasic dopamine cells to fire and an increases the activity of dopamine D1 receptors (Koob & Volkow, 2016). This strengthens the conditioned response and solidifies the associations between reinforcers and cues.



2. Withdrawal/negative affect This stage relates to the abstinence from a substance which leads to the experience of withdrawal and a change from positive to negative reinforcement (Watkins, Koob, & Markou, 2000). There are two systems that are significant in this stage; the within-system neuroadaptations and the between-system neuroadaptations (Koob & Volkow, 2016). The within-system neuroadaptation occurs as exposure to a substance increases thus, creating a neurochemical change. The primary cellular response to a substance attempts to adapt to the initial effect of the substance, by implementing an opposing reaction. This reaction continues, despite the removal of the substance and its effects, which creates the negative withdrawal experience (Koob & Bloom, 1988). The between-system neuroadaptation occurs as neurochemical systems, outside of those involved with reward, are dysregulated by the constant reward activation. An ‘anti-reward system’ (Koob & Volkow, 2016) occurs, as the withdrawal is further driven by brain stress systems that develop further negative emotional states. Thus, during this stage, the reward function decreases as the stress function increases (Koob & Volkow, 2016).

3. Preoccupation/anticipation This stage is involved with an individual’s experience of cravings and re-engagement with drug-seeking behaviours. During this time the prefrontal activation of the craving system sees a reduction in executive functions, specifically a reduction in decision making, self-regulation, inhibitory control and working memory (Koob & Volkow, 2016).

Whilst the addiction cycle predominately focuses on drug and alcohol addiction, this framework can be considered in general addictions. The introduction of an addictive behaviour, as well as a substance, can lead to a withdrawal and preoccupation of the behaviour. There is a reduction of control and continuation of the behaviour, which is persistent despite the negative consequences associated with addiction.

What is mindfulness?
Mindfulness has been in practice for thousands of years, with origins of this practice being traced back to Eastern cultures. The techniques of mindfulness displayed in Eastern cultures aim to achieve enlightenment, a disengagement from material goods and the reduction of negative emotions such as greed (Bodhi, 2011).

Mindfulness in Western societies has become increasingly popular with the increase of apps that assist with mindfulness techniques. The aim of mindfulness across Western cultures is to reduce stress, enhance personal growth and increase individual happiness. Whilst an engagement with mindfulness can offer many personal benefits, the use of mindfulness in therapeutic settings has also been assessed. Popularity surrounding this technique grew in the 1970’s (Melbourne Academic Mindfulness Interest Group, 2006) and since then applications of mindfulness have been noted in areas such as in managing depression (Hofmann, Sawyer, Witt, & Oh, 2010), binge eating disorder (Kristeller, Wolever, & Sheets, 2014) and chronic pain (Hilton, et al., 2017).

One of the proposed techniques of mindfulness in Western society was by Herbert Benson and the “relaxation response” (Foret, et al., 2012). The relaxation response (RR) is considered the opposite of our innate ‘flight or fight’ response. Benson and Klipper (1975) suggest that the acute stress in an individuals life creates a heightened state of physiological responses and through the use of mindfulness techniques these responses can be reduced, in order to achieve the RR. There are two elements to be considered in order to achieve the RR; Firstly, there should be the repetition of a thought or simple muscular activity and secondly, when an individual experiences distractions or intrusive thoughts, they should consciously return to the previous repeated thought or activity (Foret, et al., 2012). Building upon this theoretical framework, a two-component model of mindfulness was proposed (Bishop, et al., 2004).

Two-component model of mindfulness
First component: The self-regulation of attention

This component centres on the self-regulation of attention, it is recognising ‘thoughts’, ‘feelings’ and ‘sensations’ that an individual is presently experiencing (Bishop, et al., 2004). When an individual is engaged in an activity, their focus should remain on the ‘now’ (Carlson & Garland, 2005). This means that despite the constant stream of thought, the individual should choose to attend to their current activity as opposed to this thought stream. As in Benson’s relaxation response (1975), there is an emphasis on time perspective and uninterrupted engagement with an activity or thought.

Second component: The orientation to experience

The second component of this model focuses on the attitude of an individual when engaging with a mindful activity. A willing attitude and sense of openness allow for the necessary engagement in attention (Carlson & Garland, 2005). Two approaches of mindfulness-based techniques in the treatment of addictions are mindfulness-based stress reduction and mindfulness-based relapse prevention.

 Thomas is a 24-year-old male and is currently in withdrawal for a heroin addiction. Thomas has completed an initial introduction to psychological treatment, his psychologist has suggested that Thomas engage in mindfulness-based techniques in addition to his treatment. Throughout this section, Thomas will be used as an example.

Mindfulness-based stress reduction
Mindfulness-based stress reduction (MBSR) was proposed by Jon Kabat-Zinn (Kabat-Zinn, 1990) and utilises mindfulness-based activities such as meditation and hatha yoga (Kabat-Zinn, 2003). The therapy runs in addition to the individual’s medical or psychological treatment and is presented over 8-weeks, with 2.5-hour classes daily and an all-day workshop once a week. Classes consist of physical movements accompanied by an educational explanation.

There are four key exercises that run within this model.

Figure 5. Mindfulness-based stress reduction exercises (Kabat-Zinn, 1990; Vallejo & Amaro, 2009).

Applications in addiction therapy

MSBR can offer as an effective complementary therapy technique however, Vallejo and Amaro (2009) identify several key factors that suggest the need for adaptations when applying MSBR to addiction therapy. To accommodate for these differences, the following adaptations have been suggested;
 * 1) During early withdrawal, individuals experience physiological reactions which can challenge the ability to remain still
 * 2) The prescribed pharmacological treatments in addiction rehabilitation can cause drowsiness thus, challenging their ability to remain attentive
 * 3) Complete awareness of the body may be traumatic for individual’s in early withdrawal and furthermore, the silence experienced during these exercises may be overwhelming
 * 4) Further awareness of the body may draw attention to present cravings
 * 1) Having an outlet for participants’ agitation, such as through fast-paced exercise (Vallejo & Amaro, 2009)
 * 2) Reducing the length of time that participants’ engage in still meditative practices (Vallejo & Amaro, 2009)
 * 3) Increasing psychological services, to address anything that may have surfaced during a session (Vallejo & Amaro, 2009)
 * 4) Providing assistive materials outside of the classroom (Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007)
 * 5) Initiating group discussion (Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007)

 Considering the case study, MBSR assists Thomas in recognising his own time perspective, which was previously associated with how he would access heroin in the future, and assists in alleviating the pressure he felt to constantly engage in his thought process. When Thomas is engaging in these techniques, he finds himself agitated and overwhelmed. To manage this, Thomas could reduce the duration of still meditative processes and engage in a physical outlet.

Mindfulness-based relapse prevention
Mindfulness-based relapse prevention (MBRP) is specifically designed for the application of addiction therapy. This approach incorporates mindfulness techniques and cognitive-behavioural practices by focusing on an awareness of the cognitive processes, behavioural processes and triggers that occur during an addiction and withdrawal (Witkiewitz & Bowen, 2010). Participants engage in an 8-week program, completing still and seated meditative practices for up to an hour every day (Bowen, et al., 2014). Bowen et al,. (2009) propose four goals of MBRP:

A significant aspect of this approach is understanding the experience of cravings, in order to minimise the likelihood of a relapse. As displayed in the opponent-process theory of motivation, individuals continue addictive behaviours in order to minimise the negative withdrawal symptoms. Mindfulness addresses this by assisting an individual to recognise that both states are not enduring and it is their engagement with the stimulus that continues their own suffering (Witkiewitz, Bowen, Douglas, & Hsu, 2013).

 Following Thomas’ progression through MBRP, he begins to reflect on the four key goals and the interactions that these factors have on his life. Thomas recognises his risk factors, withdrawing from his support network and work stressors; his situational cues, such as the environments that promote heroin use; his personal challenges, being aware that the negative state he experiences following the absence of heroin can be overcome.

Quiz
Test your understanding with some quiz questions! Choose the correct answers and click "Submit": {Which of the following is NOT a listed characteristic of addiction? - Reinforcement - Reduced control - Craving + Genetic Predisposition - Tolerance
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{Quiz Question 2: What is the b-process?} - Positive sensation following a stimulus + The build-up of a negative withdrawal - An emotional baseline - The process of craving

Conclusion
This chapter has aimed to highlight the underlying motivations of addiction and analyse the role that mindfulness can have in this field. Mindfulness techniques can provide individuals with the opportunity to become aware of the underlying processes that an addictive substance or behaviour elicits within themselves. When an individual becomes aware of their addiction cycle, mental and physical processes, and risk factors, they are more likely to ‘weaken the habitual response’ (Groves & Farmer, 2009). Whilst further research is needed to ensure mindfulness techniques accommodate addiction treatment, frameworks such as Mindfulness-Based Stress Reduction and Mindfulness-Based Relapse Prevention offer a positive step in the inclusion of mindfulness in addiction therapy.

Take home points
 * Addiction is driven by underlying motivations, as proposed by the opponent-process theory of motivation and the addiction cycle
 * Mindfulness is based on the regulation of attention and attitude of engagement
 * Mindfulness is beneficial in addiction therapy as it allows individuals to be aware of the addiction experience