Spirituality, mindfulness and substance abuse

Addictive Behaviors 30 (2005) 1335 1341 Spirituality, mindfulness and substance abuse Janis LeighT, Sarah Bowen, G. Alan Marlatt Department of Psychology, University of Washington, Box 351525, Seattle WA 98195-1525, United States Abstract A growing body of research suggests that mindfulness-based therapies may be effective in treating a variety of disorders including stress, chronic pain, depression and anxiety. However, there are few valid and reliable measures of mindfulness. Furthermore, mindfulness is often thought to be related to spirituality, given its roots in Buddhist tradition, but empirical studies on this relationship are difficult to find. The present study: (1) tested the reliability and validity of a new mindfulness measure, the Freiburg Mindfulness Inventory (FMI), (2) explored the relationship between mindfulness and spirituality, and (3) investigated the relationship between mindfulness and/or spirituality and alcohol and tobacco use in an undergraduate college population (N=196). Results support the reliability of the FMI and suggest that spirituality and mindfulness may be separate constructs. In addition, smoking and frequent binge-drinking were negatively correlated with spirituality scores; as spirituality scores increased the use of alcohol and tobacco decreased. Thus, spirituality may be related to decreased substance use. In contrast, a positive relationship between mindfulness and smoking/frequent bingedrinking behavior was uncovered, and warrants further investigation. D 2005 Elsevier Ltd. All rights reserved. Keywords: Spirituality; Mindfulness; Substance abuse; Smoking; Binge-drinking; Freiburg Mindfulness Inventory 1. Introduction Mindfulness is receiving increased attention in the scientific community, and has been described as an awareness of moment by moment experience arising from purposeful T Corresponding author. Present address: Department of Psychiatry and Behavioral Sciences, 1959 NE Pacific Street, Box 356560, Seattle WA 98195-6560, United States. E-mail address: janis2@u.washington.edu (J. Leigh). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.01.010

1336 J. Leigh et al. / Addictive Behaviors 30 (2005) 1335 1341 attention (i.e., meditation), along with a non-judgmental acceptance of these present-moment experiences (Kabat-Zinn, 2003). A growing body of research suggests that mindfulness-based therapies may be effective in the reduction of chronic pain (Kabat-Zinn, 1990), anxiety (Kabat-Zinn et al., 1992), and in the prevention of depressive relapse (Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000). Mindfulness-based interventions are now being considered for the treatment of substance abuse disorders (Marlatt et al., 2004), and Generalized Anxiety Disorder (Roemer & Orsillo, 2002, 2003). Although mindfulness meditation is associated with positive outcomes, there are few valid and reliable methods for assessing the construct of mindfulness. Therefore, the first aim of this study was to test the reliability and validity of a new mindfulness measure, the Frieburg Mindfulness Inventory (FMI) (Buchheld, Grossman, & Walach, 2002). As mindfulness is rooted in Buddhist philosophy, it is often thought to be related to spirituality; however, to our knowledge this relationship has not been studied empirically. Spirituality is a fairly new construct in empirical science, when viewed as separate from religiousness or religiosity. While religiosity may include spirituality within a framework of specific beliefs, customs, and practices, spirituality is a much more individualized approach to a practice of worship. A spiritual practitioner may not adhere to a formal religious practice or associate with an established religion (Longo & Peterson, 2002). In a recent study of spirituality and substance use in college students, subjects were asked how important their spiritual or religious beliefs were in their decision to use drugs and/or alcohol, and in other life decisions (Stewart, 2001). Those students who rated spiritual beliefs important drank less than those who did not, but this buffering effect diminished as the students got older. Differences in use between high and low spirituality students did not diminish over time when examining marijuana use; 41% of students who reported low importance of spirituality used marijuana, as compared to approximately 15% of students who reported high importance of spiritual beliefs, across all age groups in the study. Researchers have also examined the relationship between spirituality (as measured by the Spiritual Transcendence Index [STI]) (Seidlitz et al., 2002) and the effect of stress on both emotional and physical adjustment in college students. Findings suggest that spirituality buffered the adverse effects of stress on negative affect and physical adjustment/symptoms, but had no significant effect on positive affect (Kim & Seidlitz, 2002). In order to clarify the relationship between mindfulness and spirituality, the current study included the STI for comparison with the FMI. In addition, the authors chose to investigate the relationship between mindfulness and/or spirituality and substance abuse, specifically alcohol and tobacco use, in a college population. It has been widely reported that alcohol consumption is a problem on college campuses throughout America, and the resulting negative consequences are experienced by the drinker and the non-drinker alike. It is estimated that annually approximately 1400 college students (between the ages of 18 and 24) die from alcohol-related injuries, 500,000 students are unintentionally injured while under the influence of alcohol, 600,000 students are assaulted by another student who has been drinking, and over 70,000 students are the victims of alcohol-related sexual assault or rape (National Institute on Alcohol Abuse and Alcoholism

J. Leigh et al. / Addictive Behaviors 30 (2005) 1335 1341 1337 (NIAAA), 2002). Furthermore, full-time college students are more likely to drink than their non-fulltime peers. Over 63% of college students reported drinking in 2001, as compared to 53.3% of non-college students (US DHHS, 2001). Results of The Harvard University School of Public Health 1999 College Alcohol Study (as reported by Wechsler, Lee, Kuo, & Lee, 2000) found that the overall rate of bbingeq drinking (5 drinks in a row for men, or 4 drinks in a row for women) did not change significantly between 1993 and 1999. However, the number of frequent binge-drinkers (those engaging in binge-drinking an average of 2 or more times per week) did change significantly, increasing by 14.5% between 1993 and 1999. Although the health hazards of smoking have been widely reported, cigarette use is increasing on campuses nationwide. A recent review of the Harvard School of Public Health College Alcohol Study (Wechsler, Rigotti, Gledhill-Hoyt, & Lee, 1998), found that the prevalence of current smoking rose by 27.8% from 1993 to 1997 to 28.5% of college students. 2. Methods Undergraduate students (N=196) 18 and older completed questionnaires administered during mass/pre-testing in their Introductory Psychology class. The sample consisted of 123 females (63%), 70 males (36%), and 3 (1%) unidentified. Mindfulness was measured using the newly developed FMI. The FMI includes 30 items (e.g., bi am open to the experience of the present moment.q) rated on a 4-point scale ranging from Rarely to Almost Always. Spirituality was assessed with two measures: the Spirituality Assessment Scale (SAS) (Howden, 1992), and the Spiritual Transcendence Index (STI). The SAS has been reported to be a reliable and valid measure of spirituality, while having no significant relationship to one s attendance at weekly religious meetings (Howden, 1992). The 28-item SAS is rated on a 6-point scale ranging from Strongly Disagree to Strongly Agree (e.g., bmy inner strength is related to a belief in a Higher Power or Supreme Being.Q). The STI has been reported to be a reliable and valid measure assessing a more inclusive concept of spirituality, as distinct from religiousness or religious affiliation (Seidlitz et al., 2002). The 8-item STI is rated on a 6-point scale ranging from Strongly Disagree to Strongly Agree (e.g., bmy spirituality gives me a feeling of fulfillment.q). Alcohol use was assessed with two measures: the Daily Drinking Inventory (DDQ; Dimeff, Baer, Kivlahan, & Marlatt, 1999), and the Alcohol Use Disorders Identification Test (AUDIT; NIAAA, 2000). Subjects also identified themselves as either a smoker or a non-smoker. 3. Results A reliability analysis of the FMI scale yielded a reliability coefficient of 0.80. A principal components factor analysis (with Varimax rotation) extracted three factors: (1) Acceptance

1338 J. Leigh et al. / Addictive Behaviors 30 (2005) 1335 1341 Table 1 Smoking, hazardous drinking, peak weekend drinking, mindfulness and spirituality Non-smokers (n=146 151) Smokers (n=38 42) Audit a, TTT 3.81 (5.14) 10.42 (5.08) Drinks Pk. WE nightttt 1.40 (2.50) 6.37 (5.00) FMI score (1 to 4)T 2.66 (.33) 2.79 (.31) STI score (1 to 6)TT 3.84 (1.56) 3.04 (1.41) SAS score(1 to 6) 4.62 (.57) 4.43 (.48) Smokers had significantly higher AUDIT scores than non-smokers (t(191)= 7.38, pb0.001), and drank significantly more drinks per night on a peak week-end (t(187)= 8.71, pb0.001). The significant positive relationship between smoking and FMI scores (t(190)= 2.20, pb0.05), is contrasted with a significant negative relationship between smoking and STI scores t(185)=2.89, pb0.01). The negative relationship between smoking and SAS scores approached significance (t(182)=1.95, p=0.052). a A score of 8 or higher is considered hazardous drinking. T Significant at 0.05 value. TT Significant at 0.01 value. TTT Significant at 0.001 value. and Openness to Self and Experiences (e.g., bi accept myself as I am.q) alpha=0.76, (2) Mind/ Body Awareness (e.g., bi notice how my emotions express themselves through my body.q) alpha=0.73, and (3) Non-Attachment to Thoughts (e.g., bi watch my thoughts without identifying with themq) alpha=0.62. To assess the relationship between the constructs of mindfulness and spirituality, a correlational analysis was performed on the FMI, SAS, and STI mean scores. SAS scores were positively correlated with FMI scores (r=0.45, pb0.01), and with STI scores (r=0.52, pb0.01). No significant correlation was found between FMI and STI scores. This might suggest that the SAS contains features of both mindfulness and spirituality, while the FMI and STI may be measuring these constructs separately. A t-test comparing smokers and non-smokers with FMI, SAS and STI mean scores revealed that non-smokers scored significantly higher than smokers on the STI, while the reverse was true on the FMI (Table 1). A t-test of drinking behavior was limited to Table 2 Drinking, mindfulness and spirituality Non-drinker (n=79 81) Frequent binge (n=39 41) FMI score (1 to 4)TT 2.65 (.34) 2.83 (.31) STI score (1 to 6)T 4.06 (1.61) 3.30 (1.32) SAS score (1 to 6) 4.63 (.62) 4.54 (.50) The significant positive relationship between frequent binge-drinking and FMI scores t(120)= 2.78, pb0.01) is contrasted with a significant negative relationship between frequent binge-drinking and STI scores (t(116)=2.54, pb0.05). SAS score differences were not significant. T Significant at 0.05 value. TT Significant at 0.01 value.

J. Leigh et al. / Addictive Behaviors 30 (2005) 1335 1341 1339 frequent binge-drinkers and non-drinkers only, with non-drinkers scoring significantly higher than frequent binge-drinkers on the STI, while the reverse was true on FMI scores (Table 2). To clarify the relationship between smoking/frequent binge-drinking and mindfulness, a t- test was performed on subscales of the FMI. Smokers scored significantly higher on the Mind/Body Awareness Subscale (t(190)= 2.03, pb0.05). Similarly, frequent binge-drinkers also scored significantly higher on this subscale (t(120)= 3.06, pb0.01). 4. Discussion Analysis of the FMI scale provided support for its reliability, and the principle components analysis supported a three-factor solution, with good reliability ratings for the three subscales extracted. Although the present study demonstrated reliability of the FMI in a college sample, continued use of this measure by the scientific community is suggested in order to determine if it is a valid and reliable measure of mindfulness. FMI scores were not significantly correlated with STI scores, which raises the question of the differentiation of the two constructs. From a Buddhist perspective, mindfulness is seen as a necessary technique in the pursuit of spiritual goals. However, mindfulness may also be viewed as a way of being present and open to one s life experiences; unrelated to a spiritual path per se. Spirituality, however, can be conceptualized as an acceptance of specific spiritual beliefs that do not necessarily include a mindful approach to experience. In this sense, spirituality can be understood as an adoption of a set of philosophical beliefs, whereas mindfulness may be a way of approaching experiences. Either perspective could theoretically include the other, but does not necessarily do so. The positive relationship between FMI scores and smoking/frequent binge-drinking was unexpected, and may be the result of increased sensitivity to body sensations in those who smoke and/or frequent binge-drink. This relationship may be viewed from both a negative and a positive reinforcement perspective. According to Self-Medication Hypothesis (Khantzian, 1985), individuals use substances as a negative reinforcer to avoid or alleviate uncomfortable physical or affective states. As suggested by Marx and Sloan (2003), alcohol may be used as a tool to reduce psychological distress. Perhaps those in our sample were attempting to desensitize their heightened physical sensitivity, or avoid negative emotions, with alcohol and/or tobacco. From a positive reinforcement perspective, the smoker and frequent binge-drinker may be more attuned to the bhighq they feel when using these substances. Thus, they smoke and/or frequent binge-drink in order to achieve and maintain pleasurable physical and emotional sensations. A planned future study will examine the sensitivity phenomenon using the Eysenck Short Questionnaire for Extraversion and Neuroticism (Eysenck & Eysenck, 1964). If smoking and frequent binge-drinking are related to introversion, we would expect to see a positive relationship between introversion scores and substance use. We will also include measures of experiential avoidance and thought suppression to explore substance use as an avoidance behavior.

1340 J. Leigh et al. / Addictive Behaviors 30 (2005) 1335 1341 In contrast to the positive relationship between mindfulness and substance use, we found a negative relationship between spirituality and substance use. This finding suggests that those with high spirituality engage in fewer harmful behaviors and is consistent with the 12-step philosophy. Perhaps those with high spirituality scores have a higher internal locus of control, a relationship that will be explored in our follow-up study. Given the rise in both frequent binge-drinking and smoking on college campuses, there is a growing need for new interventions. Further research may clarify the role of mindfulness and spirituality in substance use, and assist in prevention efforts by identifying important mediators of these addictive, and potentially harmful, behaviors. To our knowledge this is the first study to test the reliability and validity of the FMI in the United States. This study may also be the first to examine empirically the relationship between mindfulness and spirituality. While the results are preliminary, they suggest that these constructs can be measured reliably through self-report and may assist in identifying an important relationship between substance use and mindfulness. Can heightened sensitivity be a risk-factor in the use of substances? Our next study may help to answer that question. References Buchheld, N., Grossman, P., & Walach, H. (2002). Measuring Mindfulness in Insight Meditation (Vipassana) and Meditation-Based Psychotherapy: The Development of the Freiburg Mindfulness Inventory (FMI). Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief alcohol screening and intervention for college students (BASICS): A harm reduction approach. New York7 The Guilford Press. Eysenck, S. B. G., & Eysenck, H. J. (1964). An improved short questionnaire for the measurement of extraversion and neuroticism. Life Sciences, 3, 1103 1109. Howden, J. W. (1992). Development and psychometric characteristics of the spirituality assessment scale (Doctoral dissertation, Texas Woman s University, 1992). Dissertation Abstracts International, 54 (1-B), 166B. (UMI No. 9312917). Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York7 Dell Publishing. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present and future. Clinical Psychology: Science and Practice, 10(2), 144 156. Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. The American Journal of Psychiatry, 149(7), 936 943. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142(11), 1259 1264. Kim, Y., & Seidlitz, L. (2002). Spirituality moderates the effect of stress on emotional and physical adjustment. Personality and Individual Differences, 32(8), 1377 1390. Longo, D. A., & Peterson, S. M. (2002). The role of spirituality in psychosocial rehabilitation. Psychiatric Rehabilitation Journal, 25(4), 333 340. Marlatt, G. A., Witkiewitz, K., Dillworth, T. M., Bowen, S. W., Parks, G. A., MacPherson, L. M., et al. (2004). Vipassana meditation as a treatment for alcohol and drug use disorders. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and Acceptance: Expanding the Cognitive behavioral Tradition (pp. 267 287). New York7 Guildford Press. Marx, B. P., & Sloan, D. M. (2003). The effects of trauma history, gender, and race on alcohol use and posttraumatic stress symptoms in a college student sample. Addictive Behaviors, 28, 1631 1647.

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