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ACCEPTANCE AND HAZARDOUS DRINKINGOSTAFIN AND MARLATT
SURFING THE URGE: EXPERIENTIAL
ACCEPTANCE MODERATES THE RELATION
BETWEEN AUTOMATIC ALCOHOL MOTIVATION
AND HAZARDOUS DRINKING
BRIAN D. OSTAFIN
North Dakota State University
G. ALAN MARLATT
University of Washington
There is growing evidence for the role of automatic mental processes in substance
use. Recent research suggests that mindfulness training may be a useful treatment
for substance use disorders and theoretical analyses suggest mindfulness works by
decoupling the relation between automatic appetitive responses and actual behav-
ior. The current study was designed to examine whether mindfulness moderates
the relation between automatic processes and alcohol behavior. A sample of un-
dergraduate drinkers (
N
= 50) completed measures of hazardous drinking, mindful-
ness and automatic alcohol motivation (using the Implicit Association Test;
Greenwald, McGhee, & Schwartz, 1998). Regression analyses indicate that greater
mindful acceptance of current experience weakens the positive relation between
automatic alcohol–approach associations and hazardous drinking found in other
research (Palfai & Ostafin, 2003). The results contribute to basic science by indicat
-
ing that the relation between automatic mental processes and behavior may be
moderated by mindfulness and to clinical science by suggesting how mindfulness
might work in changing substance use behavior.
A defining element of addiction is the difficulty in refraining from
substance use even when one has conscious intentions to do so
404
Journal of Social and Clinical Psychology, Vol. 27, No. 4, 2008, pp. 404–418
This research was supported by Grant F32 AA15228–01 provided by the National Insti
-
tute on Alcohol Abuse and Alcoholism of the National Institutes of Health, awarded to
Brian D. Ostafin.Wewould like to thank Jonah Bergman, Joel Grow, Beth Jones and Joshua
Stabbert for their help with data collection.
Address correspondence to Brian D. Ostafin at brian.ostafin@ndsu.edu.
(Widiger& Smith, 1994). This accounts for the high relapse rates found
after treatment (see McKay, Franklin, Patapis, & Lynch, 2006) and sub
-
stance users’ self–reported difficulty in controlling their urges
(Gudgeon, Connor, Young, & Saunders, 2005). Why is it so hard to re
-
frain from using? Addiction researchers have increasingly used the
cognitive psychology construct of automatic mental processes (Posner &
Snyder, 1975; Shiffrin & Schneider, 1977) to model the nonvolitional
nature of addiction (see Tiffany, 1990; Wiers & Stacy, 2006).
Automatic processes are differentiated from controlled processes
in that automatic processes are usually defined as being: (a) uninten
-
tional, (b) efficient (i.e., effortless), (c) difficult to control, or(d) not in
-
volving awareness whereas controlled processes are defined as be
-
ing: (a) intentional, (b) relying upon limited attentional resources, (c)
controllable, and (d) occurring within awareness (Bargh, 1994). Sub
-
stance use, like other behaviors, may start out as a function of con-
trolled processes (e.g., consciously deciding whether to go out for a
drink). However, with repeated use and reinforcing consequences,
substance use decisions may shift from a deliberative “mental alge-
bra” (Goldman, Brown, Christiansen, & Smith, 1991) to automatic
appetitive processes that promote use (see Tiffany, 1990). These au-
tomatic processes have begun to be studied with a variety of implicit
tasks borrowed from cognitive and social cognition researchers (see
Wiers & Stacy, 2006).
Of the variety of measures used to assess automatic stimulus–af-
fect associations (see Fazio & Olson, 2003), the one that has become
most widely used is the Implicit Association Test (IAT; Greenwald,
McGhee, & Schwartz, 1998). The IAT provides an indirect measure of
the strength of associations among concepts by having participants
categorize stimuli from four categories using one of two response
keys. The IAT is based on the idea that stronger associations between
concepts will result in faster response times when they share the
same response key than when they do not share the same response
key. Several studies have used the IAT to assess automatic alco
-
hol–affect associations. This research has found that automatic alco
-
hol–approach associations predict heavy drinking episodes and
urge responses to alcohol cues, even when covarying an explicit
measure of alcohol–affect associations (Ostafin & Palfai, 2006; Palfai
& Ostafin, 2003). Other research with the IAT has found that auto
-
matic alcohol–valence and alcohol–arousal associations similarly
ACCEPTANCE AND HAZARDOUS DRINKING 405
predict alcohol behavior (Jajodia & Earleywine, 2003; Wiers, van
Woerden, Smulders, & de Jong, 2002).
Automatic and controlled processes can come into conflict, such as
when a hazardous drinker attempting to abstain experiences a
strong automatic (i.e., unintentional and difficult to control)
appetitive response when offered a beer. In such situations, the
drinker may attempt to self–regulate by effortfully controlling the
automatic appetitive response. However, because controlled pro
-
cess resources are limited (Muraven, Tice, & Baumeister, 1998) and
because inhibiting automatic responses may lead to a rebound effect
in which the responses become more accessible and likely to influ
-
ence mood and behavior (Palfai, Colby, Monti, & Rohsenow, 1997;
Wegner, 1994), attempts to inhibit automatic responses may be inef
-
fective. That is, the drinker may end up acting on a behavioral im
-
pulse to use despite conscious intentions to do otherwise. Recent re-
search with the alcohol–approach IAT using cross–sectional (Palfai
& Ostafin, 2003) and experimental (Ostafin, Marlatt, & Greenwald,
2007) designs suggests that automatic processes do play a role in
dyscontrolled alcohol use.
New approaches to psychological treatment hold promise in modu-
lating the influence of automatic appetitive responses on behavior.
One category of such treatments emphasizes the utility of changing
the relationship to one’s internal experience rather than changing the
content of the experience (Hayes, 2004). Mindfulness falls into this cate-
gory of treatments and can be defined as consisting of the following:
(a) awareness of immediate experience, and (b) a nonjudgmental and
accepting attitude toward that experience which involves “a con
-
scious decision to abandon one’s agenda to have a different experi
-
ence” (Bishop et al., 2004, p. 233). Behavioral impulses to approach re
-
inforcing stimuli and avoid aversive stimuli (i.e., impulses to change
the nature of one’s current experience) are to be allowed and experi
-
enced for their duration (i.e., accepted) rather than acted upon. That is,
with an accepting attitude, impulses (and thoughts and emotions) are
simply to be observed as mental content that comes and goes.
These components of mindfulness may be illustrated in the every
-
day experience of having an itch. An itch may enter awareness as a
mildly aversive experience that elicits an automatic response of
scratching behavior. Because an accepting attitude involves aban
-
doning an agenda to have a different experience (i.e., more pleasant
406 OSTAFIN AND MARLATT
or less aversive), motivational dispositions should be less likely to be
acted upon. Thus, one may be less likely to scratch an itch, or, in a
more clinically relevant situation, a hazardous drinker may be less
likely to order a drink when experiencing automatic motivational
dispositions to drink. Instead, the drinker may accept the disposition
to drink, allowing it to grow and recede without taking action to ac
-
tually drink (to reduce negative affect or increase positive affect).
Marlatt has described this type of accepting attitude toward auto
-
matic appetitive responses in addiction as “urge surfing” (Marlatt,
1994). Recent work suggests that mindfulness may indeed be a use
-
ful treatment for substance use behaviors including alcohol, cocaine,
marijuana and cigarette use (Bowen et al., 2006; Davis, Fleming,
Bonus, & Baker, 2007).
The above analysis suggests that mindfulness may influence sub
-
stance use by modulating the effect of automatic appetitive pro-
cesses on behavior. The current study was designed to examine this
question. We expected that an accepting attitude toward one’s expe-
rience would moderate the relation between automatic alcohol moti-
vation and hazardous drinking. Specifically, we predicted that the
positive relation between automatic alcohol–approach associations
and hazardous drinking found in other research (Palfai & Ostafin,
2003) would be reduced in individuals who are more accepting of
their present experience. We did not have ahypothesis for theaware-
ness component of mindfulness to similarly reduce the relation be-
tween automatic alcohol motivation andhazardous drinking.In fact,
awareness of internal state might actually increase the association
between affective associations and alcohol behavior, as alcohol ex
-
pectancies have been shown to more strongly predict alcohol use in
participants who are more aware of their internal experience
(Bartholow, Sher, & Strathman, 2000). To examine our hypothesis,
participants completed a measure of automatic alcohol motivation
and self–report measures of drinking behavior and mindfulness.
METHOD
PARTICIPANTS
Fifty college students (28 females) who reported consuming alcohol
at least once in the previous month participated as partial fulfillment
of a class requirement. Mean participant age was 19.97 years old (SD
ACCEPTANCE AND HAZARDOUS DRINKING 407
= 2.47). Self–reported ethnicity was White (n = 31), Asian/Pacific Is
-
lander (n = 11), Multi–racial (n= 3), American Indian/Alaskan native
(n= 2), Hispanic (n = 2), and Black (n =1). Participants reportedan av
-
erage of 4.37 (SD = 4.70) heavy drinking episodes and 5.24 (SD = 7.0)
alcohol–related problems over the past month.
MEASURES
Hazardous Drinking. Heavy drinking episodesover thepast month
were measured as the number of times that participants consumed
four or more (for females) or five or more (for males) drinks on one
occasion (Wechsler, Davenport, Dowdall, Moeykens, & Castillo,
1994). Alcohol–related problems over the past month were assessed
with a 12–item Likert measure (e.g., “Got hurt or injured”) with op
-
tions ranging from 0 (No, not in the past 30 days)to17(21–30 times in
the past 30 days; Wechsler et al., 1994). The problems measure demon-
strated adequate internal consistency (Coefficient alpha = .67). Stan-
dardized values of the heavy drinking and alcohol problem vari-
ables were aggregated into a single hazardous drinking variable
(Coefficient alpha = .71).
Automatic Alcohol Motivation. Each participant completed an IAT
that assessed alcohol–motivation associations and was presented on a
personal computer with Inquisit software (Draine, 2004). The IAT is as-
sessed by having participants categorize stimuli from four catego-
ries—two target categories (e.g., pictures of beer and water) and two at
-
tribute categories (e.g., approach and avoidance–related words)—by
pressingone of two response keys. During thecombination blocks, each
response key is paired with one target and one attribute category. For
example, the left key would be pressed whenever beer or approach
stimuli are presented and the right key would be pressed wheneverwa
-
ter or avoid stimuli are presented. The IAT is based on the idea that
stronger stimulus–affect associations will lead to faster response times
for both the target (e.g., beer pictures) and attribute (e.g., approach
words) stimuli when they are paired on the same key. Over two combi
-
nation blocks, each target category is matched with both attribute cate
-
gories (e.g., with both approach and avoidance words). The IAT score is
calculated as a difference score between congruent (for those with
appetitive motivation towards alcohol, the beer–approach/wa
-
ter–avoid block) and incongruent (e.g., water–approach/beer–avoid
408 OSTAFIN AND MARLATT
block) response times, with larger scores indicating stronger automatic
approach motivation towards alcohol.
Mindfulness. The Kentucky Inventory of Mindfulness Skills (Baer,
Smith, & Allen, 2004) consists of 39 itemsthat use a Likert–scalerang
-
ing from 1 (Never or very rarely true)to5(Almost always or always true)
to assess four scales. The measure includes two scales that reflect the
acceptance and awareness components of mindfulness (internal con
-
sistencies are in parentheses): the Accepting without judgment scale
(Coefficient alpha = .84) assesses an attitude that consists of letting go
of an agenda to maintain or change one’s experience (e.g., “I tell my
-
self that I shouldn’t be feeling the way I’m feeling”) and the Observ
-
ing scale (Coefficient alpha = .83) assesses awareness of internal and
external phenomena (e.g., “I pay attention to sensations, such as the
wind in my hair or sun on my face”). The measure also includes two
other mindfulness–related scales: the Describing scale (Coefficient al-
pha = .86) assesses the tendency to apply words to experience and the
Acting with awareness scale (Coefficient alpha = .79) assesses the
ability to engage undivided attention on a current task.
PROCEDURE
Participants were run individually and began by completing the al-
cohol motivation IAT. Participants then completed the hazardous
drinking and mindfulness measures.
The stimuli for the IAT consisted of five alcohol–related pictures,
five water–related pictures, five approach–related words, and five
avoidance–related words (see Appendix A). The IAT was presented
in seven blocks: (a) a 14–trial target discrimination block (for the con
-
gruent block first IAT order, left = beer and right = water); (b) a 14–trial
attribute discrimination block (left = approach and right = avoid); (c) a
20-trial combination block (left = beer + approach and right = water +
avoid); (d) a 40-trial combination blockof the same combination in (c);
(e) a 14-trial target discrimination block in which the target catego
-
ries were reversed (left= water and right = beer); (f) a 20-trial combina
-
tion block (left = water + approach and right = beer + avoid); and (g) a
40-trial combination block of the same combination in (f). Each block
had one additional lead–in trial. The stimuli for the target and attrib
-
ute discrimination blocks were presented randomly. The stimuli for
the combination blocks were presented randomly with the restric
-
ACCEPTANCE AND HAZARDOUS DRINKING 409
tion that the trials alternated between target and attribute stimuli. A
250 ms interval separated each trial after a response was made. Par
-
ticipants were instructed to respond as quickly and accurately as
possible. If participants made an error, they saw an error message
and were required to make the correct response before the next trial
was presented. Two IAT orders were utilized: one with the beer and
approach (and water and avoid) combination (the congruent block)
first and one with the water and approach (and beer and avoid)
combination (the incongruent block) first. The two IAT orders were
counterbalanced across participants.
RESULTS
The IAT score was calculated with the revised IAT scoring algorithm
(Greenwald, Nosek, & Banaji, 2003). In order to examine whether the
alcohol motivation IAT was related to drinking behavior, a regres-
sion analysis on hazardous drinking was performed with IAT order
and gender entered as Step 1 and IAT score entered as Step 2. The re-
sults indicated a relation between the IAT and hazardous drinking (β
= .26, p = .08) comparable in magnitude to that found in previous re-
search (Ostafin & Palfai, 2006; Palfai & Ostafin, 2003).
The main hypothesis was that the acceptance component of mind-
fulness would moderate the relation between automatic alcohol moti-
vation and hazardous drinking. The moderator–interaction effect was
examined with a regression analysis on hazardous drinking with IAT
order and gender entered as Step 1, IAT score and Acceptance entered
as Step 2 and a product of the standardized values of the IAT score and
Acceptance variables entered as Step 3. The results indicated that Ac
-
ceptance acted as a moderator of the relation between automatic alco
-
hol motivation and hazardous drinking (β = –.37, p = .02; see Table 1).
Regression analyses indicated that the other scales did not moderate
the relation between the IAT and hazardous drinking at alpha = .05,
including the Observe (β = .26, p = .08), Describe (β = .10, p = .47), and
Act with awareness (β = –.21, p = .22) scales.
We conducted several analyses to assist the interpretation ofthe in
-
teraction effect with the Acceptance scale. In one set of analyses, we
created a median split on the Acceptance scale and conducted a re
-
gression analysis on hazardous drinking for both the Low Accep
-
tance (n = 23) and High Acceptance (n = 27) groups. IAT order and
410 OSTAFIN AND MARLATT
gender were entered as Step 1 and IAT score was entered as Step 2.
The results indicated astrong positive relation between the IAT score
and hazardous drinking in the Low Acceptance group (β = .43, p =
.06) and a null relation in the High Acceptance group (β = –.10, p =
.62), suggesting that greater acceptance of current experience weak-
ens the relation between automatic alcohol motivation and hazard-
ous drinking. In a second set of analyses, we examined whether the
Acceptance variable was related to either hazardous drinking or the
IAT, as a moderator–interaction effect can be most clearly inter
-
preted when the moderator is not related to either the predictor or
criterion variable (Baron & Kenny, 1986). A partial correlation analy
-
sis in which gender was covaried indicated that Acceptance was not
significantly related to hazardous drinking (pr = –.15, p = .30). A re
-
gression analysis on the IAT score with IAT order and gender en
-
tered as Step 1 and Acceptance entered as Step 2 indicated that Ac
-
ceptance was not related to the IAT score (β = –.02, p = .92). These
latter results contribute to the confidence of interpreting the
Acceptance variable as a moderator of the relation between
automatic alcohol motivation and hazardous drinking.
DISCUSSION
The present study examined whether the relation between automatic
alcohol motivation and hazardous drinking would be lower in indi
-
ACCEPTANCE AND HAZARDOUS DRINKING 411
TABLE 1. Experiential Acceptance as a Moderator of the Relation Between Automatic
Alcohol Motivation and Hazardous Drinking
Variable
R
–squared change
F
–change
Hazardous drink
-
ing
Step 1
IAT order .01
F
(2, 47) = .25
Gender .06
Step 2
IAT score .08
F
(2, 45) = 2.05 .25
Acceptance –.14
Step 3
IAT × Acceptance .10
F
(1, 44) = 5.55 –.37*
Note.
Hazardous drinking = aggregate of heavy drinking frequency + alcohol problems; IAT order (1 =
congruent block first, 2 = incongruent block first); Gender (1 = male, 2 = female); IAT score (larger scores
= stronger approach associations); Acceptance = nonjudgmental acceptance of experience; IAT × Accep
-
tance = product of the IAT and Acceptance variables. *
p
< .05.
viduals with high levels of acceptance of their present experience
and, conversely, that it would be higher in individuals with lower
levels of acceptance. The results indicate that an accepting attitude
toward one’s experience is indeed associated with a reduced positive
relation between automatic alcohol–approach associations and haz
-
ardous drinking. Recent research has indicated that heavy alcohol
use (as well as other substance use behavior) may be reduced after a
mindfulness intervention (Bowen et al., 2006; Davis et al., 2007). The
current study suggests that one way in which mindfulness training
may influence alcohol use is by decoupling the relation between au
-
tomatic appetitive responses and actual alcohol behavior. That is, ac
-
ceptance may “increase the gap between impulse and action” (Paul
Ekman, cited in Boyce, 2005, p. 40), allowing for more adaptive
responding.
Mindfulness is often defined as including both greater accep-
tance and awareness of internal experience (Bishop et al., 2004;
Kabat–Zinn, 2003). We did not have a hypothesis regarding the po-
tential role of awareness as a moderator in this study. The results in-
dicated that awareness marginally served as a moderator in the di-
rection of increasing the relation between the IAT and hazardous
drinking. This is not surprising, given past research in which
greater awareness of internal experience increased the relation be-
tween alcohol expectancies and alcohol use (Bartholow et al., 2000).
Similarly, a recent study has found that the awareness subscale of a
mindfulness questionnaire (different from the one in this study)
was correlated with more heavy drinking episodes and smoking
behavior (Leigh, Bowen, & Marlatt, 2005). The current study and
past research indicate that simply being aware of one’s motiva
-
tional responses may make one more likely to act on them. It may be
that in addition to awareness, developing acceptance of one’s inter
-
nal state is necessary for the beneficial effects of mindfulness train
-
ing on substance usebehavior. The idea that acceptance is central to
modulating the impact of behavioral dispositions on actual behav
-
ior is supported by a recent study with a sample of obsessive com
-
pulsive disorder participants (Twohig, Hayes, & Masuda, 2006).
The results indicated that an acceptance-based intervention led to a
reduction in symptoms as well as a greater acceptance of and,
importantly, a decreased need to act on compulsive behavioral
dispositions.
412 OSTAFIN AND MARLATT
The results of the study have implications for both basic and clini
-
cal science. Basic research has established a rolefor automatic mental
processes in cognition, affect, and behavioral dispositions (Chen &
Bargh, 1999; Fazio, Jackson, Dunton, & Williams, 1995). As evidence
accumulates for the existence of automatic mental processes, work
has turned toward examining the conditions inwhich their influence
is more or less likely to occur (e.g., Perugini, 2005). One model pro
-
poses that behavior may be more likely to be influenced by con
-
trolled processes when there is motivation and opportunity to
self–regulate and by automatic processes when either motivation or
opportunity are lacking (Fazio & Towles–Schwen, 1999). The current
study makes a novel contribution by indicating that the influence of
automatic processes on behavior may also be moderated by
dispositional acceptance of current internal experience. Future re
-
search should examine whether the current findings extend to other
domains, such as whether acceptance moderates the influence of au-
tomatic motivational responses on self–regulation (Fishbach &Shah,
2006) or intergroup bias (Fazio et el., 1995).
The results also have clinical implications. Although a growing
number of studies indicate that the mindfulness training may have
beneficial effects on psychological well–being (Baer, 2003), little is
known about the paths by which mindfulness leads to clinical im-
provements. One suggestion is that mindfulness shifts the relation-
ship with mental content from one of identification (e.g., believing
negative self–thoughts as reflecting reality) to a decentered perspec
-
tive in which content is experienced more as “passing thoughts and
feelings that may or may not have some truth in them” (Teasdale et
al., 2002, p. 276). The current study supports this idea in that the
strength of automatic alcohol–approach associations did not differ
as a function of level of acceptance. That is, participants high in
dispositional acceptance were as likely to experience strong auto
-
matic appetitive responses to alcohol as were those low in accep
-
tance. What did differ is the link between automatic alcohol motiva
-
tion and behavior. It may be that greater levels of acceptance allow
one to decenter from automatic motivational responses—to have the
response but not act on it. Given the increasing evidence for a role of
automatic mental processes in psychopathology such as substance
abuse (Palfai & Ostafin, 2003), depression (Gemar, Segal, Sagrati, &
Kennedy, 2001) and anxiety (Teachman & Woody, 2003), altering the
ACCEPTANCE AND HAZARDOUS DRINKING 413
influence of these automatic processes would have important clini
-
cal potential. However, such interpretations of the current results are
limited by the use of a non–clinical sample and a cross sectional
study design. Future research should examine whether acceptance
decreases the harmful influence of automatic processes in clinical
samples.
Future research should also use an experimental design to examine
whether mindfulness training leads to a decoupling of automatic
processes and alcohol behavior. At this early stage, it is difficult to
tell whether mindfulness training may be best utilized in substance
use disorders as a primary intervention (Bowen et al., 2006; Davis et
al., 2007) or for relapse prevention (Witkiewitz, Marlatt, & Walker,
2005), as is done in Mindfulness–Based Cognitive Therapy for de
-
pression (Teasdale et al., 2000). However, the current findings sug
-
gest that any mindfulness intervention for problematic alcohol use
may benefit from having participants deliberately practice relating
differently toward their automatic appetitive responses toward alco-
hol—to cultivate an attitude toward the automatic processes that
might be described as ‘accepting,’ ‘allowing,’ or ‘letting be’ (Segal,
Williams, & Teasdale, 2002).
In sum, the current study suggests that an accepting attitude to-
wards one’s experience may interrupt the relation between auto-
matic mental processes and overt alcohol behavior. The results sup-
port models of treatment in which the target of change is the relation
toward one’s internal experience. The nature of this relation toward
one’s experience can be illustrated with two contrasting pictures of
emotion regulation, both of which depict emotion as animal like. In
the first perspective, a wild horse representing emotion is to be con
-
trolled by the charioteer’s whip and spur of reason (Plato, 2002).
Given the limitations involved in effortful self–control, this strategy
may be of modest use. Alternatively, the approach proposed in the
second perspective is to create a spacious meadow for the animal.
That is, the best strategy for regulating the animals of the mind is to
“. . . watch them, just to watch them, without trying to control them”
(Suzuki, 1974, p. 32). Perhaps best way to tame “wild” emotions and
their harmful influence is not by force, but with a nonjudgmental
attitude that creates space between impulse and action.
414 OSTAFIN AND MARLATT
APPENDIX A
IAT stimuli
Beer stimuli Water stimuli
Approach stimuli Avoid stimuli
Advance Avoid
Approach Away
Closer Escape
Forward Leave
Toward Withdraw
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