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Beginning with the Symptom: Incorporating Mindfulness in the Treatment of Substance Misuse

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Part of the Essential Clinical Social Work Series book series (ECSWS)


Integrating mindfulness-based practices with a harm reduction approach can be particularly useful in the treatment of substance misuse and co-occurring disorders. This chapter focuses on the theory and application of mindfulness practices to address substance use and other risky behaviors from a harm reduction perspective (Bowen et al. 2010). Conceptualizing substance misuse as stemming from the complex interaction of biopsychosocial factors that leads one to self-medicate requires that we adopt a highly individualized approach that is attuned to the goals and needs of each person (Murphy and Khantzian in Psychotherapy and substance abuse. Guilford, New York, 1995; Tatarsky in Harm reduction psychotherapy. Rowman & Littlefield Publishers, Inc, Lanham, 2007). Mindfulness practices are uniquely suited to helping people across the spectrum of substance use issues as it provides a framework observing one’s experiences with curiosity and kindness and enhances the development of self-regulation capacities. Working from a harm reduction approach, with its emphasis on collaboration and empowerment helps clients explore the types of changes they wish to make and supports them in attaining their goals. Clinical examples and a case discussion are provided to illustrate this integrative approach.


  • Childhood Sexual Abuse
  • Criminal Justice System
  • Risky Behavior
  • Harm Reduction
  • Relapse Prevention

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    See Kabat-Zinn’s (1990) work on MBSR for more extensive discussion on this topic as well as other chapters in this text.


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Appendix 1: SOBER Breathing Space (Bowen et al. 2010)

This is a practice you can do almost anywhere and at anytime. This is an especially useful practice to try during times of increased stress or in high-risk situations. When things in ourselves or in our environment trigger us, we tend to go into automatic pilot mode, which can result in reactions and behaviors that are not in our best interest. This is a technique that can be used to help us step out of that automatic mode and become more aware and mindful of our actions.

  • STOP: Stop, slow down, and check in with what is happening, this is the first step in shifting out of automatic pilot.

  • OBSERVE: Observe the sensations in the body. Observe any emotions, moods, thoughts, or judgments you are having. Just notice as much as you can about your experience.

  • BREATH: Gather your attention and bring it to your breath.

  • EXPAND: Expand your awareness to include the rest of your body, your experience, and the situation, seeing if you can gently hold it all in awareness.

  • RESPOND: Respond (vs. react) mindfully, with awareness of what is truly needed in the situation and how you can best take care of yourself. Whatever is happening in your mind and body, you still have a choice in how your respond.

Appendix 2: Harm Reduction and Mindfulness Resources

Harm Reduction Resources

Mindfulness Resources

Appendix 3: Checking-in Practice

This practice can be done as part of a formal sitting practice and can also be used throughout the day as a way to gather your awareness and observe your experiences. The intention of this practice is to help you slow down and note what is happening in the mind, body, heart, and breath. As you notice your experiences and sensations in the body, try to greet them with openness, curiosity, and compassion. Try to welcome your experiences without judgment.

Let us pause for a few moments and acknowledge what is here now:

  • What is the quality of your breath? Where do you notice your breath?

  • How does your body feel in this moment? Try a brief body scan starting with the crown of the head and observe sensations in your body. What posture is your body in right now? Can you feel the weight of your body in the chair, on the floor? Can you observe where your body is making contact with the fabric of your clothes, with the seat that you are on or the ground beneath you? Do you notice the temperature of the air on your skin?

  • What types of thoughts do you notice? How are you narrating this moment? Are there critical thoughts? Worry thoughts? See if you can observe your thoughts without attaching judgment to them.

  • How is your heart feeling? What emotions are here now?

  • Allow your awareness to rest on your breath again and observe the sensations of your breath. If you get distracted, simply begin again with the next breath. If you find it difficult to focus on breath, try to experiment with counting your breath each time you exhale and when you reach 5, start over. You can also practice counting how long it takes to inhale and exhale without manipulating it—just notice how long each of your breaths are.

What was it like for you to slow down and check in with yourself?

Appendix 4: Urge Surfing Practice (Adapted from Bowen et al. 2010)

For this practice, you will imagine a situation where you find yourself struggling to manage an intense urge or craving to use a substance or engage in a behavior that might be problematic for you. Select a scenario that is not too overwhelming and that is of moderate intensity to start with.

This practice will guide you through the process and will help you stay with your experience without reacting in habitual ways. Please remember that you are doing your best and that the intention is to greet all your experiences with kindness, curiosity, openness, and compassion. If the practice feels too intense, you can always open your eyes, notice your surroundings, and observe the position of your body and the connection to your seat and/or chair.

Once you have selected the scenario you wish to practice with, take a few moments to really imagine yourself there. Perhaps close your eyes and allow yourself to feel the experience more fully. How you are feeling? What thoughts are here? Note sensations in your body, the emotions you are observing, and how your breath is.

Try to imagine the scenario up until the point where you might have previously responded to with reactivity and without full awareness. See if you can pause and stay here for a moment without reacting. How does it feel to stay with and notice the experience without reacting? What do you observe? Can you stay with the experience and be gentle with yourself? What about this feels intolerable? What sensations do you notice in the body? What emotions are you feeling? How are you thinking about this experience?

Remember that you can always pause and open your eyes if this is feeling too overwhelming. You may shift to just observing the sensations of your breath before deciding to return to the practice.

Observe how it feels to be with this urge or craving—can you feel it without resisting it or judging it? How does it feel to not engage in the behavior and continue to observe the experience? Can you explore what else is here? What you might truly need or want in this moment? Is there a longing for something? What are you seeking? See if you can gently observe this with curiosity and kindness.

If the craving feels intense, you may begin to image that it is like a wave in the ocean. Imagine the size of the wave, its color, its size. Imagine that you are now riding that wave using your breath as a surfboard that allows you to stay steady. Try to keep your balance by focusing on your breath as you ride out the intensity of the wave. See if you can be with these feelings and intensity using your breath to help you.

Perhaps you are noticing that you can be with this craving and this intensity without reacting to it or wishing it would go away. You are watching how the craving rises and falls, how it shifts with time and as you move your focus to your breath.

Take your time to gently let go of this scenario and return your attention to your breath and to your surroundings. Perhaps observe the sounds in the room, the shapes and colors you see and observe the position of your body. You may take a few deep breaths and make gentle movements with the body, if you would like.

Appendix 5: Grounding and Focusing on Five Senses (Adapted from Najavits 2002; Linehan 1993; Marra 2004)

At times, it is useful to practice grounding and orienting to the present moment. You can try this practice when you are feeling overwhelmed, have difficulty shifting your focus away from a disturbing memory, intense emotions, or a strong craving to engage in a behavior you feel is problematic for you. During times of increased distress, we might struggle to soothe ourselves in adaptive ways and you may try some of these practices to see if they help you navigate difficult situations with more ease. Some people find it helpful to focus on their surroundings and notice the five senses during times of increased distress and reactivity. This practice is focused on moving your awareness to what is external rather than focusing inward.

Suggestions for Practice

  • You should begin to experiment with these practices when you are not feeling overly distressed or overwhelmed. It takes time to learn these practices and identify which ones feel most useful to you.

  • You can practice this anytime and anywhere. It is recommended that you keep your eyes open and be aware of your surroundings.

  • Try to rate how you are feeling before and after the practice using a scale of 1–10.

  • Remember to maintain your focus on the present moment and if you mind wanders to the past or future, gently try to bring your attention back to the present.

  • Avoid judging yourself as you practice. You may feel distracted and you may struggle to engage with this practice. Try to be patient and adopt an attitude of kindness toward yourself and your experiences.

  • The intention of this practice is to help you accept the moment and engage in safer ways of coping with discomfort and distress.

Focusing on the Five Senses

Gently and with a playful attitude, see if you can move your awareness to your senses and what you are observing around you.

  • Vision: What can I look at that will make me feel good things?

  • Hearing: What is pleasing to the ear? What can I listen to that soothes me?

  • Smell: What aromas make me feel at ease?

  • Taste: What can I eat and savor that is pleasing to me?

  • Touch: What can I touch that will invoke feelings that are different from what I am experiencing right now?

Grounding Practices

  • Observe and describe your present environment in detail—what colors, shapes, and textures do you see? Where are you in right now? What position or posture is your body in?

  • Carry a special object with you that you can focus on such as a small stone, lotion, mints, a picture, or a certain song you can listen to.

  • Count to a certain number such as 10 or 20 and then start again.

  • Notice how your feet are making contact with the floor—perhaps press your feet downward so you can feel the connection to the ground beneath you.

  • Stretch your arms, legs, move your head from side to side, do a gentle twist in your seat.

  • Practice mindfully walking and observing the movement of each leg/foot as you walk along with the sights, sounds, smells around you.

  • Observe your breath and count each time you inhale and exhale. Perhaps pair a certain word with each in-breath and out-breath such as “soften,” “soothe,” “release” or any other word that you would like to use. Notice how the body gently moves with each breath.

  • Imagine a safe place—it can be a place you have been to before or a place that you create for yourself in your mind. Using your senses, try to imagine yourself in that safe space and observe how it feels to be there. How is your breath?

  • Say a self-soothing statement to yourself like, “this will pass,” “may I be at ease,” “I will be okay,” “this is feeling won’t last forever.”

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Talley, J. (2017). Beginning with the Symptom: Incorporating Mindfulness in the Treatment of Substance Misuse. In: Northcut, T. (eds) Cultivating Mindfulness in Clinical Social Work. Essential Clinical Social Work Series. Springer, Cham.

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