My colleagues and I recently had a new paper accepted for publication in the highly esteemed, international journal Neuroscience and Biobehavioral Reviews. This paper draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to opioid misuse and addiction among chronic pain patients taking prescription opioids for pain relief. In brief, we theorize that addictive use of opioids is the outcome of a cycle initiated by chronic pain and negative emotions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. We conclude the paper by introducing Mindfulness-Oriented Recovery Enhancement (MORE) as a potentially effective approach to disrupting the downward spiral. This is a particularly exciting publication for our research team, because it lays the theoretical groundwork for developing new and innovative efforts to help people recover from chronic pain and opioid addiction.
Recently, my research on mindfulness, thought suppression, stress-primed cue-reactivity, and trauma in people struggling with drug and alcohol addiction was featured in an article in Scientific American Mind. This is a nice article in the popular press that discusses the role of negative emotions in psychological health.
Inevitably, we encounter hardship in our lives. We become ill, fall into debt, are subject to criticism, harried by rumor and jealousy, and assailed by the many challenges and unrelenting demands of the world. Yet, individuals differ to the extent to which they remain resilient in the face of such stressors. One key to resilience is positive reappraisal – the capacity to reframe or re-interpret difficult life experiences such that they become imbued with personal meaning. For instance, after facing a stressor, one might come to believe, “Dealing with this experience has made me a stronger person,” or, “I have grown and learned from adapting to this situation,” or even, “I would not be who I am today without this experience, no matter how difficult it has been.” Through positive reappraisal, we come to find meaning in the face of adversity.
Such positive reappraisals may be essential means of adapting to the rigors of life. People often believe that they have personally grown or learned from dealing with the stressful events of their lives. For example, over half of 2000 survivors of the devastating 2008 earthquake in Sichuan province, China, which reached 8.0 on the Richter scale, reported having experienced a form of meaningful growth in its wake, such as developing personal strength, a sense of appreciation of life, or an opening to new possibilities (Xiu & Liao, 2011). Similarly, after a deadly tornado struck Madison, Florida in 1998 and obliterated over 100 homes and business, 9 out of 10 survivors reported experiencing psychological benefits from the event, such as greater appreciation for others and a deepened sense of personal growth (McMillen, Smith, & Fisher, 1997). Innumerable examples may be found in the annals of history. Every time another tragedy is announced on the news, from devastating floods to acts of savage terrorism, positive reappraisals emerge during the interviews of survivors. The common theme echoed such tragic incidents is “This experience brought our community closer” and “This experience is a reminder of what is really important in life.”
At the same time, finding positive meaning in adversity does not only occur in the aftermath of large scale disasters; it is also commonly occurs in the face of daily stressors. For example, after being snubbed and disrespected by a work supervisor, one might reappraise the mistreatment into an opportunity to realize the importance of being sensitive to the opinions and viewpoints of others. And after a long, exhausting day at the office, being treated rudely by the clerk at the grocery checkout line might be seen as an opportunity to feel empathy for the fact that she was probably standing on aching feet for more than eight hours. Similarly, a person stricken with a non-fatal heart attack might positively reappraise the event as a chance to change their diet and start exercising more. A person who has recovered from a vicious rape might view their survival of the assault as evidence of their strength and resilience, and they might decide to dedicate their life to helping others make similar recoveries. A person entangled in a fight with her spouse might initially villanize him and recoil from his attempts to resolve the conflict, and then, after recognizing his unwavering devotion to their relationship, redouble her efforts to understand his point of view.
Though reappraisal is well-known to enhance resilience and help individuals cope with stress, less is known about how this strategy works and how it can be strengthened. It is my contention that mindfulness promotes reappraisal. Mindfulness is a state of mind in which one observes his or her mental experiences without becoming “stuck in” or “trapped by” them. In the state of mindfulness, you become aware of thoughts, feelings, sensations, and perceptions without trying to hold on to them, and without trying to push them away. As the state mindfulness deepens, you not only become aware of where your mind is in the moment (i.e., on what content is it focused), you also become aware of the quality of that observing mind itself. At the deepest levels of mindfulness practice, this metacognitive observation can be a bit like a mirror mirroring mirrors – being aware of being aware (and maybe, if you are really good, being aware of being aware of being aware!). Some neuroscientists suppose that the folds of the prefrontal cortex have evolved over millennia to allow for this metacognitive reflection.
So what do these abstract ideas have to do with reappraisal? Well, to make a positive reappraisal, one must first be aware of the initial negative or stressful appraisal (e.g., “This situation is horrible!”). Next, one must “step back” or disengage from that reappraisal. My colleagues and I (Garland, 2007; Garland, Gaylord, & Park, 2009) have argued that mindfulness affords that mental shifting function – allowing one to decenter from a given thought about one’s life, into the openly observing, metacognitive mode of awareness. Once the mind has stepped back from the stress appraisal into this state of mindfulness, attention broadens to encompass previously unattended details about one’s life circumstance – you begin to notice things about yourself and your situation that you had overlooked or ignored because you were so stressed and upset. For example, bad feedback from a boss might lead you to think, “I always screw up and my boss hates me.” However, if you were to engage mindfulness, you might be able to step back from this thought and then begin to notice the ways in which you have been successful at work and the recent times when your boss has given you praise. After which you might think, “Well, that’s not really true. Usually I do a good job at work and that’s why my boss is giving me this critical feedback – she believes that I can take my career to the next level!” This positive reappraisal might then motivate you to take constructive action at work. Thus, the metacognitive aspect of mindfulness allows us to see that our thoughts are not necessarily facts. By becoming aware of awareness, we come to realize that who we are is much bigger than any one thought, feeling, or stressful life event, and that ultimately, we are free to choose the meaning of our lives.
In these ways, mindfulness helps us to disrupt habits of negative thinking, allowing the mind to naturally expand to consider new possibilities and novel ways of seeing the world. When, through mindfulness, we suspend our preconceived notions and assumptions about the difficult aspects of our lives, we are able to bring increased awareness to the richly woven tapestry of life that unfolds all around us, allowing us to draw out innumerable golden threads. The smiling face of a passerby, the song of a bird perched in a nearby tree, the trill of insects on a warm summer evening, a tiny flower blossoming from a crack in a sidewalk, the laughter of children, or even the ever-constant companion of one’s own breath can become sources of wonder and delight to savor, in spite of and perhaps because of the stressors and challenges we face. Facing bitter hardship and adversity can help us to truly taste and appreciate the moments of sweetness that surround us. Through mindfulness and reappraisal we can learn to widen the scope of our awareness to encompass more of the meaningful and beautiful experiences in life, making the painful and dissatisfying ones smaller by comparison.