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founded by S. N. Goenka in the tradition of Sayagyi U Ba Khin






Problems with Current Therapeutic Approaches for Alcohol

-By Dr. Raman Khosla

Substance abuse is a very complex disorder, being neither a medical disorder alone, nor a psychological problem, nor a social disturbance, but a biopsychosocial disorder. Complex in its causation, effects and treatment, the addict demonstrates the "revolving door phenomenon" characterised by initiation, continuation, abuse, cessation and relapse.

In recent psychiatric diagnosis and understanding, tremendous importance has been given to the concept of "craving," understood in substance abuse language as "one drink, another drink." In the World Health Organisation (WHO) International Classification of Diseases ICD-10 draft (1988), as many as four out of seven concepts in the diagnosis of substance abuse are related to the phenomenon of "craving."

The available treatment modalities in substance (alcohol and drug) abuse are divided into 3 major groups: chemical treatment, psychotherapeutic approaches and behavioural therapies. Chemical treatment includes acute detoxification usually with benzodiazepines or clonidine, and chronic maintenance treatment with disulfiram, naltrexone or methadone. Psychotherapies include self-help groups like Alcoholics Anonymous or Narcotics Anonymous (A.A / N.A.), family therapies, and individual psychotherapies; supportive, cognitive or analytic reconstructive. Behaviour therapies comprise a wide variety of procedures, such as the relaxation procedures like Jacobson's progressive muscle relaxation or biofeedback procedures, aversion therapies, systemic desensitisation, covert sensitisation and social skills and assertiveness training.

There are many disadvantages with these treatment modalities:

  • None of them alone helps. One to two year studies show not more than one-third of all substance abusers to be totally free of drugs, even with optimal treatment combination.
  • The problem of matching an addict to treatment, i.e. which addict would benefit from which treatment, has not been solved, despite many attempts to do so.
  • The creation of an iatrogenic (i.e., health professional created) substitute dependence, of the abuser on lesser evils; either substitute chemicals, external instruments or other humans (therapists).
  • None of them tackles craving, the most powerful cause of relapse. It is a psychological drive or desire, having all the three important components of cognition, conation and mood. Most therapies tackle only the secondary biopsychosocial consequences only of the drug.
  • Finally, the most significant element is that the personality is dominated by its unconscious aspects. We attempt to change it analytically or cognitively through the conscious mind, thereby tackling only the tip of the iceberg. Intellectual insight alone does not help drug abusers. Drives, mood states, motivation, and other personality components are very difficult to handle with psychotherapeutic procedures. The hallmarks of a drug addict's personality, i.e. emotional immaturity, emptiness, need for immediate gratification, escapist, manipulative and irrational attitudes, seem extremely resistant to change by intellectual means.

Meditation is defined as a family of techniques which have in common a conscious attempt to focus attention or awareness in a non-analytical way, and an attempt not to dwell on the discursive, ruminative content of thought. All forms of meditation help drug addicts, who show short-term improvement. However, with most forms of meditation this is due to a non-specific physiological relaxation response. Unfortunately, the important relative demerit of all other meditations is their total lack of relationship with the mental defilements and impurities of craving and aversion at the deepest roots of the mind.

Vipassana meditation is not a treatment modality for drug abuse or any other mental or physical illness, but a way of living. However, like the by-product of molasses obtained in the production of sugar, many psychosomatic diseases show improvement due to the purification of the mind.

As opposed to most meditations, which aim at concentration or relaxation of the mind, the aim of Vipassana is one step beyond that. The goal is purification of the mind by removing all its negativities and hence uncovering all its positivities, which are the basic inherent nature of every human mind. The ultimate goal is a totally pure or deconditioned mind. A creative mind (self aware, with positive emotions, represented symbolically by the spiral) replaces the routine reactive mind, (obeying the stimulus-response principle, with no self-awareness, represented symbolically by the wheel). As a consequence, mental equanimity or balance of mind increases in every life situation.

The basis of mental purification in Vipassana is that it tackles mental impurities at their roots, that is, at the level of physical bodily sensations, awareness of which is the only proven basic function of the unconscious mind. The importance of the mind has been repeatedly emphasised by Gotama the Buddha, the master psychologist beyond compare, who rediscovered Vipassana. The Buddha said: "Mind precedes all phenomena. Mind matters most, because everything is mind-made. Mind can become one's worst enemy or one's best friend."

Psychoanalysts, behaviourists and cognitive psychologists all accept emotion, but only its psychological component, totally ignoring its physical component of sensation. Every sensation is a truth, the product of an underlying biochemical reaction. And every emotion is accompanied by a sensation. In this way, the emotions can be explored through the concrete medium of body sensations. Therefore the emphasis in Vipassana is on vedana, the feeling of bodily sensations. Vedana is the third of the four parts of the mind described by the Buddha. In the modern information-processing paradigm, these four parts of the mind are best described as consciousness, perception, sensation and reaction. Although simultaneous observation of body (kaya), sensations (vedana), mind (citta) and mental contents (dhamma) is going on in every Vipassana meditator, the focus for the meditator is very clearly on (vedananupassana) the observation of sensations. Hence the advantage of Vipassana is that it works at the level of both mind and matter. The exploration of matter is done using the instrument of mind and the exploration of mind is done using the unique and wonderful instrument of matter. Here lies the basic difference with other psychologies, which tackle mind at the level of mind alone.

In Vipassana, there is no dependence on any instrument, chemical or human being (therapist, teacher or guru) or group of beings. In the words of the Buddha: "You are your own master and you make your own future."

The basic practical difference between Vipassana and all other meditation techniques is that it deals with truth at an experiential level within. There is no trace of falseness, no verbalisation or visualisation as seen in other meditations. Insight or wisdom in Vipassana is not received or intellectual but experiential insight at the level of the feeling of body sensations. Walking on the path of truth (Dhamma), personal realisation of truth automatically changes the habit pattern of the mind, which subsequently lives according to the truth only. The truth is the natural law of the mind and body-all laws of physics are observed by any Vipassana meditator to be the same, both inside and outside the individual. Hence Vipassana is not just a scientific art of living, but the true science of the mind, the true psychology.

As regards drug abuse, the basis of all addiction has been found to be craving (tanha). Literally meaning thirst, craving is the mental habit of insatiable longing for what is not, which implies an equal and irremediable dissatisfaction with what is.

The root of all craving is vedana. All human behaviour is the result of reactions to inner body sensations, be they mental, vocal or physical reactions. All reactions are either in the group of "I want/ like" (craving) or "I don't want/ like" (aversion), which are two sides of the same coin. This leads to clinging (upadana), which can lead only to unhappiness. In the words of the Buddha: "All suffering which arises has reaction as its cause. If all reactions cease to be, there is no more suffering."

The Buddha has done yeoman service to human psychology by describing and analysing in detail 108 ways of behaviour or manifestations of craving which can be basically grouped into three categories-craving for:

  • sense objects,
  • becoming (I, mine, my views) and
  • non-existence or non-becoming.

In craving, there is a marked attachment to the habit of seeking sensual gratification. Addicts take a drug because they wish to experience the pleasurable sensation that it produces in them, even though they know that by taking it, they reinforce their addiction. Deeper than this is the addiction to the condition of craving. The object of craving is secondary, best seen in those persons who abuse multiple drugs; more importantly, they seek to maintain continually the state of craving itself, because it produces a pleasurable sensation within them, which they wish to prolong. Hence, the basis of all addictions is an " addiction to one's own inner bodily sensations"-liking and craving for the pleasant sensations and disliking and aversion to the unpleasant ones. Craving then becomes a habit which they cannot break. Just as an addict gradually develops tolerance towards the drug of abuse and requires larger doses to achieve the desired effect, this addiction to craving becomes steadily stronger, the more people seek to fulfill it. The greater the craving, the more it leads to unhappiness; as it prevents people from seeing the reality of every moment, seeing instead only the distorted truth, the truth as if through a dark glass.

Vipassana has and will continue to help alcohol and drug addicts because it tackles the root of all addiction, which is craving. There is a need for scientific studies demonstrating the tremendous efficacy of Vipassana in helping alcohol and drug abusers.

To conclude with the ever inspiring words of the Buddha: "If the roots remain untouched and firm in the ground, a felled tree still puts forth new shoots. If the underlying habit of craving and aversion is not uprooted, suffering arises anew over and over again."