Buddhism in Addiction Recovery

Deﬁnition: Buddhism was established by Guatama Buddha as a practice to liberate sentient beings from suffering. Mindfulness-Based interventions (MBIs) are Western psychologists’ adaptation of mindfulness/Vipassana to treat mental illnesses. In addition to mindfulness, Buddhist recovery peer-support programs also adopt the Four Noble Truths, the Noble Eightfold Path, and the Five Precepts, which are the Buddha’s prescription to cease suffering and to discipline one’s ethical conduct.


Introduction
Buddhism has its roots in addressing suffering and cravings [1].Individuals have also found documentation of the Buddha explaining the dangers of cravings and how cravings contribute to one's cyclical suffering [1,2].Moreover, one of the earliest teachings taught by the Buddha, the Dhammacakkappavattana Sutta, addressed the human tendency of addiction to sense-pleasures or self-mortification [3].The Buddha then instructed ways to alleviate suffering and the practices to which one should adhere.These teachings are the Four Noble Truths (Skt.catvāri āryasatyāni), the Noble Eightfold Path (Skt.āryās .t . ā ṅgamārga), and the Five Precepts (Skt.pañcaśīla) [3,4].
In recent decades, mindfulness has garnered increasing interest in health care [5] and significant attention in relation to mental health [6].Additionally, Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR) built the foundation for Mindfulness-Based Interventions (MBIs) [6].Furthermore, the model of MBIs has influenced the treatment of addiction and substance use disorders, including the establishment of Mindfulness-Based Relapse Prevention (MBRP) [7], Mindfulness-Oriented Recovery Enhancement (MORE) [8], and other MBIs [9].In addition to Mindfulness-Based Interventions, researchers also conducted studies to examine Acceptance and Commitment Therapy (ACT) and its efficacy for addiction treatment [10][11][12][13][14].However, critics of MBIs posited that Western psychology's adaptation of mindfulness is inadequate, as it neglects necessary teachings of morality, the broader philosophical context of Buddhism, and the original significance of mindfulness in Buddhism [4,6,15,16].Therefore, future research needs to integrate essential Buddhist teachings, besides mindfulness techniques, into clinical application [16][17][18].In contrast to clinical research in Western psychology, Buddhist recovery peer-support programs incorporated the essential teachings of the Four Noble Truths, the Noble Eightfold Path, and the Five Precepts [19][20][21].However, despite the growing population in Buddhist recovery [22], clinical research has largely overlooked Buddhist recovery peer-support groups.
This paper conceptualized Buddhism in addiction recovery as three major categories: traditional Buddhist teachings, mindfulness in Western psychology, and Buddhist recovery peer-support programs.Specifically, Buddhist theories are examined and compared in the discussion of Western psychology and Buddhist recovery peer support groups.Finally, we drew comparisons between Western interventions and Buddhist recovery peer-support programs, highlighting the implication and current limitation of both approaches.

Addiction and Cravings in Buddhism
Prince Siddhartha founded Buddhism in the Himalayas, currently referred to as Nepal.He was born in 463 BCE and died in 383 BCE.After attaining enlightenment, his disciples referred to him as the Buddha or Guatama Buddha.His teachings were referred to by himself as the Dharma-Vinaya.Moreover, the Western term Buddhism originated in the early 19th century [23], although it already had its equivalent in Indian and Chinese literature before the 19th century.Additionally, the Western construction of Buddhism also occurred before the 19th century, as early as the second century [4].Therefore, the Western interpretation of Buddhism has a long imprint in history.
Prince Siddhartha lived a privileged life filled with sense-pleasures and free from sufferings.After witnessing suffering on a journey outside of his palace, he decided to embark on a path of spiritual cultivation and left his palace [24].The prince practiced asceticism for six years and, eventually, found his path of practice.According to tradition, he sat under the pipal tree one night and meditated, eventually entering a profound state of mental absorption [25].The Buddha awakened to one of the most important teachings in Buddhism, the Twelve Dependent Originations (Skt.dvādaśā ṅga-pratītyasamutpāda).The Twelve Dependent Originations are the following: (1) ignorance (Skt.avidyā), (2) volitional activities (Skt.sa ṁskāra), (3) consciousness (Skt.vijñāna), (4) name and form (Skt. nāmar ūpa), (5) six senses (Skt.s .ad .āyatana), (6) contact (Skt.sparśa), (7) feelings (Skt.vedanā), (8) cravings (Skt.tr .s .n .ā), (9) attachment (Skt.upādāna), (10) becoming (Skt.bhava), (11) birth or rebirth (i.e., reincarnation; Skt.jāti), and (12) old age and death (Skt.jarā-maran .a).The Buddha taught that these twelve factors account for the mental and physical suffering that are interdependent with birth and rebirth [26].The Twelve Dependent Origination explained that sentient beings develop consciousness, physical forms, and feelings through delusion and ignorance.Consequently, cravings arise, and sentient beings would pursue them, further growing attachments, not knowing that this is the reason for rebirth and suffering.What an individual is pursuing brings them back to their cyclical existence of suffering.Living life in this way is the aggregate of all suffering, such as sadness, grief, and mental afflictions [2].This teaching demonstrates the role cravings play in one's endless suffering.
In addition to the Twelve Dependent Originations, there have been voluminous descriptions of addiction or the danger of cravings in the Buddha's teachings.For instance, some documentation suggests that the Buddha once helped a king who was addicted to food to recover [27].Additionally, Buddhism teaches that there is a realm called the hungry ghost realm.Along with the hell and animal realms, the hungry ghost realm is one of the three undesirable realms.Hungry ghosts are beings with mouths as tiny as needles and endless desires.However, their thirst and cravings for food can never be satisfied [28].For instance, there has been a description that when hungry ghosts consume food, it would cause great pain in their stomach.Some interpret the hungry ghosts as a state of addiction, since the mental state of the hungry ghosts is one of continuous craving and perpetual dissatisfaction [21,27,29].Moreover, similar to addiction, the hungry ghosts resemble the mental state of appeasing one's inner emptiness with substances [27].Sutras have also described the importance of observing desires as fire pits or sharp knives that hurt, noticing and understanding our desires, and not residing in the state of cravings.Finally, the sutra also described cravings or desires as one of the impediments of enlightenment [2].
Moreover, the Buddha potentially talked about current addictions in the Dhammacakkappavattana Sutta [21].In the Dhammacakkappavattana Sutta, the Buddha explained addiction as sense-pleasures or self-mortification.Therefore, the practice of Buddhism is to cultivate the Middle Path (Skt.Madhyama-pratipadā), which is the Noble Eightfold Path.Furthermore, the Noble Eightfold Path includes right understanding, right thought, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration [3].Dhammacakkappavattana Sutta explained that the mental state of indulging in sense-pleasures is the cause of suffering.This teaching is the second truth of the Four Noble Truths [21], which is one of the first teachings taught by the Buddha [4].The First Noble Truths suggest that suffering is a shared experience of all beings, as we all have to experience birth, sickness, old age, and death, with which sorrow, grief, or despair may arise [3].The second noble truth suggests that craving is the leading cause of suffering, as craving is the reason for future rebirth [4].Some understand this craving as sense-pleasures and the desire for existence or non-existence [1].The third noble truth suggests that there is an end to suffering, and the fourth noble truth suggests that there is a path to the end of suffering [3].The path that leads to the cessation of suffering is, as the Dhammacakkappavattana Sutta indicated, the Noble Eightfold Path, balancing between the two extremes of having and not having.Practitioners have integrated the four noble truths and the Noble Eightfold Path as the backbone of most Buddhist recovery programs in the West (e.g., Refuge Recovery, Recovery Dharma, Eight Step Recovery, Noble Steps; [19][20][21]. Finally, the Buddha taught about the Five Precepts for laypeople, instructing that those who adhere to the Five Precepts can eradicate undesirable behaviors that would lead to bad karma and be born into the realm of the heavens where there is no suffering.The Five Precepts are: (1) not harming life, ( 2) not taking what is not given, (3) no sexual misconduct, (4) no false speech, and ( 5) not taking intoxicants [2].Some Buddhist recovery programs in the West have also adopted the Five Precepts, as these are considered appropriate ethical guidelines for addiction recovery (e.g., Recovery Dharma and Eight Step Recovery).

Mindfulness and Addiction Treatment in Western Psychology
Asian immigrants in the early 19th century introduced Buddhism and Buddhist meditations to the West.Unfortunately, due to the social-political climate, they faced many challenges to propagate Buddhism [30,31].In 1976, Joseph Goldstein, Sharon Salzberg, and Jack Kornfield founded the Insight Meditation Society (IMS), a mindfulness Meditation Center in Massachusetts [32].Moreover, the founders of IMS played a crucial part in popularizing Western mindfulness in the US.Subsequently, starting from 1970, the mindfulness/Vipassana movement in the US rose [6].Jon Kabat-Zinn studied at IMS, and, in 1991, he was inspired to create mindfulness-based stress reduction (MBSR) [32].MBSR then built the foundation for Mindfulness-Based Interventions (MBIs).Additionally, some scholars attribute the popularization of mindfulness in Western psychology to Jon Kabat-Zinn [6].In the late 1970s, Dialectical Behavior Therapy (DBT) incorporated aspects of mindfulness [33].In 1999, Steven Hayes introduced Acceptance and Commitment Therapy (ACT).Moreover, ACT has emphasized mindfulness and present-moment-awareness [34].In 2002, Segal, Williams, and Teasdale established Mindfulness-Based Cognitive Therapy (MBCT) as an MBI, modeling after MBSR to treat depression [35].In 2010, Bowen, Chawla, and Marlatt established Mindfulness-Based Relapse Prevention (MBRP), which modeled after MBCT [7].In 2013, Kristen Neff and Christopher Germer founded Mindfulness Self-Compassion (MSC).Moreover, they suggested that MSC can complement MBSR and MBCT [36,37].As a result, these interventions have used mindfulness to assist those experiencing mental illnesses and addiction.
Recent research has advanced in third-wave cognitive behavioral therapy and its efficacy in addiction recovery, including MBIs and ACT [12].ACT is a behavioral treatment that focuses on acceptance, values, and mindfulness.Moreover, as an evidence-based intervention, ACT targets psychological flexibility due to its positive impact on mental health [14].Psychological flexibility is the ability to be presently aware and modify or maintain behaviors according to one's values [38].Moreover, some have conceptualized addiction as having significant experiential avoidance [11].Therefore, those who have addictions could use substances to avoid or suppress unwanted internal or external experiences [14].Currently, research has shown that psychological flexibility-based interventions, such as DBT [39] and Mindfulness-Oriented Recovery Enhancement (MORE) [8], have a higher rate of substance cessation when compared to traditional interventions, such as 12-step groups [40] or brief motivational interventions [13,41].Further, Azkhosh and colleagues (2016) found that ACT could improve psychological flexibility, while 12-steps Narcotics Anonymous was less successful [10].Finally, research has shown the efficacy of ACT in treating alcohol and marijuana use disorders, tobacco cessation, polysubstance use, and methamphetamine use [14].Therefore, previous and current research suggests that ACT could be a beneficial treatment for addiction recovery.
Other research has shown that MBIs have promising results in reducing substance dependence [42].Mindfulness-Based Relapse Prevention (MBRP) is one of the most wellresearched MBI for substance use [9].MBRP arose due to the efficacy of cognitive-behavior therapy (CBT) and relapse prevention (RP).Based on the foundation of MBCT, MBRP is a cognitive, behavioral, and client-centered program that combines Vipassana practices and RP techniques to prevent relapse for addiction, such as substance use or binge eating [7].MBRP is composed of eight sessions, each lasting for 120 min.For each session, clinicians ask participants to start with meditation practices, inquires, and discussion of personal practices, emphasizing cultivating awareness to recognize external triggers and internal reactions to the triggers [9].Moreover, MBRP teaches clients to nonjudgmentally observe their emotional and physical discomfort without reacting or acting upon the cravings.The therapy highlights the practice of mindfulness and shifting the relationship with oneself to a gentler, more patient, forgiving, and accepting relationship.Further, several studies have shown that MBRP demonstrates promising results in substance use reduction.Finally, research has suggested that MBRP is more efficacious than treatment-as-usual (TAU) [7].The results of these research indicate the significance of mindfulness in addiction recovery.
Mindfulness-Oriented Recovery Enhancement (MORE) is an MBI that addresses the dysregulated hedonic reward-learning process and the automatic substance use action schemas [8].MORE consists of 10 sessions, with each session lasting 120 min.Participants are taught the three foundations of MORE with the addition of the Buddhist teaching of impermanence [9].The three foundations of MORE are mindfulness, third-wave Cognitive-Behavioral Therapy, and positive psychology.MORE aims to target attentional biases, cognitive appraisal processes, negative emotions and maladaptive cognitions, natural reward processing, bottom-up substance use action schemas, and the ability to regulate craving [8].Although MORE was first developed by researchers to treat alcohol dependence, further research suggested that MORE is efficacious for substance addiction and behavioral addictions, such as opioid use and internet gaming [43][44][45].These results demonstrate the efficacy of mindfulness when used in conjunction with positive psychology.
Despite the efficacy of MBIs in treating mental illnesses, scholars have criticized the Western application of Buddhism in psychology.Some have suggested that clinical interests in Buddhism have predominantly emphasized mindfulness [16].Others have criticized Western psychology's application of mindfulness as a reductionistic approach, as research of MBIs mostly exercises aspects of mindfulness without the fundamental principles or context of Buddhism [15].For example, Krägeloh suggested that omitting culturally embedded aspects of Buddhist practices from MBIs resulted from the secularization of mindfulness.Consequently, this misapplication of mindfulness could be unbeneficial since the clinicians may not fully understand the context of mindfulness, especially the morality aspect essential in Buddhism [46].Some researchers argued that when Jon Kabat-Zinn transformed mindfulness into MBSR, he neglected the moral values ingrained in Buddhism [6].Additionally, by re-focusing Buddhism's emphasis of suffering solely on stress and highlighting mindfulness as the treatment, MBSR was criticized by Giraldi to be emulating the wisdom of Buddhism without the complete teachings of Buddhism [6].Finally, others have assessed Thai Theravada Buddhist monks with Western mindfulness measures and found that although the Theravada Buddhist monks scored higher on two aspects of mindfulness than American college students, the Theravada Buddhist monks scored lower on three other aspects of mindfulness [47].They suggested that the discrepancy could be because the Theravada Buddhist monks did not practice mindfulness to reduce stress but to cultivate a broader Buddhist practice.As a result, when researchers develop measures to assess Western psychology's implementation of mindfulness, the results could be more accurate for those practicing in MBSR or other MBIs.
As a solution to address this issue, scholars have suggested that to ameliorate Western psychology's misapplication of mindfulness, researchers should incorporate other fundamental Buddhist principles.For example, some have suggested that researchers apply Buddhism's understanding of the self, emptiness, and the Middle Way into clinical research [18].Others have suggested that researchers broaden current mindfulness research by including the concept of Buddha Nature [17].Additionally, some recommended that other Buddhist principles, such as compassion, loving-kindness, or no-self should also be integrated into clinical research [16].Moreover, others have argued a need to strengthen and expand evidence-based practices for including Buddhist principles more comprehensively.Furthermore, Buddhist teachers and clinicians should work together to ensure the integrity of evidence-based practices derived from Buddhism [16].In conclusion, although mindfulness in Western psychology has promising results in treating mental illnesses, future research should incorporate essential teachings of Buddhism into clinical research to be more culturally accurate and to benefit from Buddhism's complete philosophy.

Buddhist Recovery Peer Support Programs in the West
Typically, in addiction, treatment can be divided into professionally directed addiction treatment and recovery mutual aid societies, such as Alcoholics Anonymous [48].Buddhist recovery programs are recovery mutual aid societies and primarily include addictions of all kinds, including behavioral addiction (e.g., Refuge Recovery, Recovery Dharma, and Eight Step Recovery, Noble steps; [20][21][22]).Unlike most of the professionally directed addiction treatment in Western psychology, Buddhist recovery mutual aid programs adopt mindfulness practices and embody Buddhism's essential views of ethics.Similarly, according to Dr. Silkworth in the Big Book of Alcoholics Anonymous, moral psychology is also essential in traditional Twelve Step programs [49].Considering the omission of morality in MBI's approach to mindfulness and the importance of moral psychology in addiction recovery, these Buddhist Recovery programs fill in the gaps of how researchers currently apply Buddhism in clinical research.
In a pamphlet, the Spiritual Milestones in Alcoholics Anonymous, the co-founder of Alcoholics Anonymous (i.e., AA) suggested that the Noble Eightfold Path and Buddhist philosophies could be an alternative for Twelve Steps [50].Additionally, some researchers have suggested alternative approaches to 12-step programs due to their religious nature or spiritual biases [51,52].As a result, starting from 2005, there has been a rise of Buddhist recovery efforts in the US, starting with the Buddhist Recovery Network (BRN).According to BRN's website [53], Kevin Griffin, Paul Saintilan, and others co-founded BRN as an online resource network for Buddhist addiction recovery.BRN is a non-profit foundation that aims to raise funds and support online resources regarding Buddhist recovery.Currently, the online organization offers virtual meetings, Buddhist Academy, podcasts, and bi-annual summit [54].Therefore, BRN is a pioneer of Buddhist recovery in the West, being one of the first to organize resources regarding Buddhism and addiction.
In 2013, George Johns founded Noble Steps.Noble Steps uses the twelve steps in their meetings and combines the practice of the Four Noble Truths, Noble Eightfold Path, compassion, non-harming, and interdependence [55].In addition, Valarie Mason-John and Dr. Paramabandhu co-founded the Eight Step Recovery program as an alternative to Twelve Step or an addition to the 11th step.The program incorporates the Four Noble Truths and the Noble Eightfold path.Moreover, Eight Step Recovery emphasizes the five precepts by which its members abide.Finally, Valarie Mason-John and Dr. Paramabandhu defined addiction as a mental and physical compulsive quality that creates sufferings [21].In 2014, Noah Levine established Refuge Recovery as an alternative to Twelve Step programs [20].As of 2019, Refuge Recovery had 500 meetings worldwide [22].Refuge Recovery uses the Four Noble Truths and the Noble Eightfold Path as the program's foundation [20].In 2019, Recovery Dharma separated from Refuge Recovery and became a new Buddhist recovery mutual-help organization.As of 2020, Recovery Dharma has an estimate of 16,000 members [22].Recovery Dharma also uses the Four Noble Truths and the Noble Eightfold Path as the program's backbone, clearly explaining the Five Precepts [19].Additionally, Recovery Dharma is currently the most extensive Buddhist Recovery peer-support program in the US [22].The rise of Buddhist recovery programs and the growing popularity denotes the need for clinical research to examine this population and the efficacy of the Buddhist teachings for addiction recovery.
Perhaps due to how Buddhism and mindfulness were introduced and interpreted among Westerners [4], these Buddhist Recovery programs primarily emphasized the Four Noble Truths, the Noble Eightfold Path, and the Five Precepts, neglecting other aspects and paths of practices in different Buddhist traditions [19][20][21].Therefore, there is a need for these programs to incorporate other Buddhist traditions more comprehensively.Moreover, besides a study in 2021 examining the similarities and differences of Recovery Dharma and other mutual-help organizations [22], no researchers have conducted qualitative or quantitative studies to investigate these Buddhist recovery programs and their efficacy of addiction recovery.Future research could benefit from these programs, as they adopt Buddhist principles that clinicians have neglected in current MBIs.Furthermore, except for a current scale examining Right Speech [56], no researcher has established scales to measure the Four Noble Truths and the Noble Eightfold Path.Therefore, Buddhist recovery programs can serve as a foundation for creating more measures and broader evidence-based practices for addiction recovery.

Conclusions
Buddhism has a long history of addressing suffering and cravings.In the Buddha's earliest teachings, he instructed his disciples on the truth of suffering and the way leading to the cessation of suffering.The path to the end of suffering is the Noble Eightfold Path, in which mindfulness is a necessary component of practice.Western psychology has taken a tremendous interest in Buddhism in recent decades, focusing on mindfulness.Moreover, mindfulness has demonstrated promising empirical evidence in treating mental illnesses when used in mindfulness-based interventions or other third-wave cognitive-behavioral therapy, such as Acceptance and Commitment Therapy or Dialectical Behavioral Therapy.However, researchers have also criticized that mindfulness in Western psychology neglects the larger context of Buddhism or the teachings from which mindfulness originated.
On the other hand, Buddhist recovery peer support groups in the West have used essential Buddhist teachings, such as the Four Noble Truths, the Noble Eightfold Path, and the Five Precepts in addiction recovery.Unfortunately, despite their growing population, clinical research has largely overlooked these peer support groups.Therefore, this paper suggests that to ameliorate the shortcomings of how clinicians apply mindfulness in Western psychology, there is a need for future research to include fundamental Buddhist constructs and establish more measures to assess these constructs.Moreover, future research should conduct broader qualitative and quantitative studies to investigate the efficacy of Buddhist recovery peer support groups.Consequently, Buddhist recovery peer support groups could serve as a foundation for future research to advance.