Addictive Behaviors 44 (2015) 65–70

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Addictive Behaviors

To suppress, or not to suppress? That is repression: Controlling intrusive thoughts in addictive behaviour Antony C. Moss a,⁎, James A.K. Erskine b, Ian P. Albery a, James Richard Allen b, George J. Georgiou c a b c

Department of Psychology, School of Applied Sciences, London South Bank University, 103 Borough Road, London SE1 0AA, United Kingdom Division of Population Health Sciences and Education, St George's, University of London, Cranmer Terrace, London SW17 0RE, United Kingdom Department of Psychology, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, United Kingdom

H I G H L I G H T S • We review evidence for the use of thought control strategies in addictive behaviour. • Thought suppression, mindfulness and repressive coping strategies are discussed. • We present a heuristic model suggesting a common mechanism for these strategies.

a r t i c l e

i n f o

Available online 22 January 2015 Keywords: Alcohol Mindfulness Repressive coping Smoking Thought suppression

a b s t r a c t Research to understand how individuals cope with intrusive negative or threatening thoughts suggests a variety of different cognitive strategies aimed at thought control. In this review, two of these strategies – thought suppression and repressive coping – are discussed in the context of addictive behaviour. Thought suppression involves conscious, volitional attempts to expel a thought from awareness, whereas repressive coping, which involves the avoidance of thoughts without the corresponding conscious intention, appears to be a far more automated process. Whilst there has been an emerging body of research exploring the role of thought suppression in addictive behaviour, there remains a dearth of research which has considered the role of repressive coping in the development of, and recovery from, addiction. Based on a review of the literature, and a discussion of the supposed mechanisms which underpin these strategies for exercising mental control, a conceptual model is proposed which posits a potential common mechanism. This model makes a number of predictions which require exploration in future research to fully understand the cognitive strategies utilised by individuals to control intrusive thoughts related to their addictive behaviour. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Several of the leading causes of early death worldwide are preventable, the result of a small number of habitual behaviours. For instance, tobacco use accounts for 9% of early deaths, and alcohol use for 5.9% (WHO, 2009, 2013). This paper will examine the effects of two cognitive strategies individuals use when attempting to control thoughts related to these behaviours (Bien & Burge, 1990; Burton & Tiffany, 1997; Meule, Heckel, & Kübler, 2012); thought suppression and repressive coping. In this special issue, Baumeister and Vonasch (2015) discuss addictive behaviour from the perspective of self-regulation theory, arguing persuasively that the operation and failure of self-regulatory control both play a key role in the development, maintenance and cessation of addictive behaviours. In this manuscript we will focus on a specific aspect of self-regulation, that is the act of controlling ones ⁎ Corresponding author. Tel.: +4420 7815 5777. E-mail address: [email protected] (A.C. Moss).

http://dx.doi.org/10.1016/j.addbeh.2015.01.029 0306-4603/© 2015 Elsevier Ltd. All rights reserved.

thoughts. One area of research which has developed in recent years in this field surrounds the use of thought suppression, and the impact that this has on the maintenance and cessation of smoking and alcohol use. We will begin by reviewing this emerging body of research, and then move towards a discussion of the links which have been proposed between thought suppression and repressive coping (e.g. Geraerts, Merckelbach, Jelicic, & Smeets, 2006). We will conclude by presenting a heuristic model which, based upon the research reviewed, proposes a common mechanism underlying thought suppression and repressive coping. 2. Thought suppression Thought suppression is a conscious process whereby an individual attempts not to think about something. There is evidence that thought suppression is a commonly used self-control strategy when attempting to reduce or stop smoking and drinking (Ingjaldsson, Laberg, & Thayer, 2003; Nosen & Woody, 2013; Salkovskis & Reynolds, 1994; Toll, Sobell,

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Wagner, & Sobell, 2001). In spite of its intended purpose – to reduce occurrences of thoughts about the target – previous studies have demonstrated that using thought suppression may cause individuals to think about the thought they are attempting to avoid more rather than less frequently (Wegner, Schneider, Carter, & White, 1987). The increased thinking, as a result of thought suppression, can occur during active suppression – the so-called immediate enhancement effect – or, more commonly, following suppression — the post-suppression rebound effect (Wenzlaff & Wegner, 2000). Since the original demonstration that suppressed thoughts can rebound, a meta-analysis suggests the effects are robust (Abramowitz, Tolin, & Street, 2001). Furthermore, studies have demonstrated that suppressed thoughts become hyperaccessible (Wegner & Erber, 1992). This is an important finding as hyperaccessibility of a construct in memory can have several critical downstream effects, chiefly greater subsequent thought, and greater subsequent awareness of content relating to the suppressed item (Bargh, 1989; Bargh & Chartrand, 1999; Klein, 2007). Beyond making a mental construct more accessible, and constructrelevant stimuli in one's environment more salient, suppression can also cause an increase in behaviour associated with the suppressed thought (Erskine & Georgiou, 2011). For example, suppressing thoughts of food or thirst can lead to a subsequent increase in food or drink consumption (Denzler, Förster, Liberman, & Rozenman, 2010; Erskine, 2008; Erskine & Georgiou, 2010). Furthermore, suppressing thoughts of smoking was shown to lead to increased smoking after a week of smoking related thought suppression, relative to groups actively thinking about smoking or thinking about anything they wished (Erskine, Georgiou, & Kvavilashvili, 2010). These effects are important because people do not only employ thought suppression to control their thoughts, but also as a way of controlling behaviour (Baumeister, Heatherton, & Tice, 1994; Wenzlaff & Wegner, 2000). However this strategy seems to be an ineffective approach to self-regulation. Wegner and Zanakos (1994) developed a measure of the extent to which individuals suppress thoughts in everyday life called the White Bear Suppression Inventory (WBSI). Their work demonstrated that individuals vary in the tendency to suppress thoughts and that these tendencies are stable over time. Since the creation of the WBSI, research has consistently demonstrated that the frequent suppression of thoughts is positively associated with a range of psychopathologies (Erskine, Kvavilashvili, & Kornbrot, 2007; Purdon, 1999; Wegner & Zanakos, 1994), although it is important to note that a recent review suggests that the use of thought suppression across a range of pathologies does not seem to lead to an increase in intrusive thoughts relative to control populations (Magee, Harden, & Teachman, 2012). As there is an emerging body of research in this area, we will now briefly review the literature on thought suppression in relation to smoking and alcohol consumption. 2.1. Smoking behaviour The great majority of daily smokers report wanting to quit (Jarvis, McIntyre, & Bates, 2002; Mullins & Borland, 1996). Furthermore, most smokers attempt to quit unaided (West, 1997; West & Zhou, 2007). Despite trying to quit the average unaided success rates (defined by continual abstinence over 12 months) is attained by between 2% and 4% of quitters (Hughes et al., 1992; Hughes, Keely, & Naud, 2004). In terms of cognitive strategies individuals use when they try to quit smoking, studies have indicated that whilst attempting to quit, individuals frequently experience smoking related intrusive thoughts. Furthermore almost all quitters report attempting to suppress thoughts of smoking (Salkovskis & Reynolds, 1994). Salkovskis and Reynolds (1994) demonstrated that participants attempting to suppress thoughts about smoking showed a subsequent increase in smoking thoughts compared to control groups. A further study investigated the extent to which individuals reported using thought suppression in everyday life (using the WBSI) and the success

of quitting smoking. The findings established that the WBSI score was significantly higher in smokers as opposed to ex-smokers (Toll et al., 2001). These studies suggest that intrusive smoking thoughts may serve as cues precipitating relapse (Marlatt & Gordon, 1985). With these studies in mind and the fact that thought suppression seems to elevate the accessibility of the formerly suppressed concept (Klein, 2007; Palfai, Colby, Monti, & Rohsenow, 1997a; Palfai, Monti, Colby, & Rohsenow, 1997b; Wegner & Erber, 1992) thought suppression should make individuals more likely to increase behaviour associated with the suppressed thought (Erskine & Georgiou, 2011; Wegner, 2009; Wenzlaff & Wegner, 2000). Erskine et al. (2010) demonstrated this effect (Erskine et al., 2010), showing that participants attempting to suppress smoking thoughts for a week increased their smoking the following week whereas participants merely monitoring their smoking thoughts or actively thinking of smoking for a week did not increase behaviour the following week. This demonstrates a phenomenon known as behavioural rebound, whereby formerly suppressed thoughts about a behaviour cause a subsequent increase in that behaviour. It is, however, important to note that not all studies have found an association between thought suppression and increased smoking (Haaga & Allison, 1994). Erskine and colleagues suggested that suppressing smoking thoughts may also elevate cravings. However a study examining the effects of suppressing smoking thoughts on subsequent cravings found that it did not result in a subsequently greater desire to smoke (Erskine et al., 2012). Nonetheless, the same study did show that a promising intervention for overcoming many of the effects of thought suppression – participant's degree of mindfulness (present moment awareness) – was negatively correlated with thought suppression (see also Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). Mindfulness has been defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994, p.4). In line with this, Wegner (2011) has suggested that mindfulness techniques may have some utility as a method of avoiding the effects of thought suppression. Studies have started to compare mindfulness and thought suppression based interventions for individuals attempting to quit smoking. For example, Rogojanski and colleagues assigned participants to use either mindfulness or thought suppression to deal with cravings whilst being exposed to cigarettes. The study tracked craving, negative affect, nicotine dependence, depression and self-efficacy before the interventions and over seven days. Contrary to previous work, both groups reported reduced smoking and being better able to cope with cravings at followup. However only the mindful group showed reduced negative affect, depression and nicotine dependence, indicating that mindfulness was more efficacious than thought suppression, which showed no effects (Rogojanski, Vettese, & Antony, 2011). One significant issue with the study of Rogojanski et al. (2011) is that there was no differentiation between suppressing thoughts of smoking specifically and other thoughts. As such, it is possible that participants were suppressing a variety of thoughts. In a related study Litvin, Kovacs, Hayes, and Brandon (2012) observed that both suppression and acceptance strategies were associated with less craving and smoking compared with a control group not using either strategy. One study took a different approach and investigated the extent to which individuals report suppressing smoking thoughts. Nosen and Woody (2013) revised the WBSI to include a new smoking specific scale (the WBSI smoking version, containing two subscales — thought intrusion and suppression). Results indicated that the intrusion subscale and overall scale were positively related to greater craving, smoking urges and negative affect. The suppression subscale was positively related to greater distraction, reappraisal, punishment and worry, but not to the urge to smoke or negative affect. Quitting smokers scored higher than continuing smokers. A review of early smoking lapse suggests that it may not be the severity of withdrawal symptoms that create difficulties in quitting but how individuals respond to these (Brown, Lejuez, Kahler, Strong,

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& Zvolensky, 2005). It has been suggested that thought avoidance or “experiential avoidance” will create problems, specifically increased intrusive thought and negative affect which have been linked to relapse (Kinnunen, Doherty, Militello, & Garvey, 1996). Whilst “experiential avoidance” is a broader construct it clearly has a lot in common with thought suppression; it is perhaps not surprising therefore that studies have demonstrated that both thought suppression and experiential avoidance can cause increased negative affect (Erskine et al., 2010; Kinnunen et al., 1996; Wegner & Zanakos, 1994). 2.2. Excessive alcohol use Studies have demonstrated that suppressing alcohol thoughts can result in subsequent hyperaccessibility of alcohol thoughts (Klein, 2007; Palfai, Colby et al., 1997; Palfai, Monti, et al., 1997). These findings are important as hyperaccessibility of substance related information is related to greater noticing of environmental cues relating to the addictive behaviour and greater motivation to engage in the behaviour (Franken, 2003; Moss & Albery, 2009, 2010). If thought suppression further elevates these it might maintain or worsen the addictive behaviour (Field & Cox, 2008). In the alcohol field, research related to thought suppression has focused more on interventions designed to control or regulate alcohol-related thoughts, rather than rebound effects associated with thought suppression. Specifically, a number of studies have examined the efficacy of mindfulness meditation techniques in contrast with thought suppression. The rationale for this comparison is that, as a cognitive strategy to deal with intrusive thoughts, mindfulness and thought suppression involve quite distinct responses (i.e. a passive vs. an active response). Bowen et al. (2006) examined the effects of a mindfulness intervention based on alcohol use and psychosocial variables in an incarcerated population. One group was given a ten day course of mindfulness, the second group received the usual chemical dependency treatment and education. After baseline measures participants were followed up at 3-months, and 6-months. Following release the mindfulness group demonstrated less alcohol and drug use compared to the treatment as usual group (Bowen et al., 2006). Bowen and colleagues also showed that reductions in the use of thought suppression partially mediated the effectiveness of mindfulness training. A follow-up study examined an eight week mindfulness based relapse prevention programme and compared its effectiveness to ‘treatment as usual’ for individuals in outpatient treatment for substance use disorders (including alcohol). Results indicated that those using the mindful interventions demonstrated less substance use and less cravings than those undergoing the usual treatments. Again the authors note that becoming mindful requires a reduction in the use of thought suppression (Bowen et al., 2009). A further study by Garland, Gaylord, Boettiger, and Howard (2010) compared a ten-week mindfulness intervention to a support group intervention in a therapeutic community treatment for alcohol dependence. Mindfulness participants significantly reduced their stress and use of thought suppression, and showed reduced attentional bias to alcohol cues. The decreased thought suppression in the mindful participants was significantly correlated with decreases in the impairment shown in alcohol response inhibition. A follow-up study (Garland, Carter, Ropes, & Howard, 2012) examined the effects of state and trait thought suppression and its impact on participants' responses to alcohol cues and urges as measured by an alcohol based Stroop task. The study found that greater use of thought suppression was linked to reduced heart rate variability and urge regulation. The authors therefore suggested that preventing thought suppression may be key in preventing relapses in dependent alcoholics. One study examined thought suppression and mindfulness in individuals with a posttraumatic stress disorder diagnosis that also had substance use issues. The results indicated that following traumatic

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experiences thought suppression increased which was associated with more severe posttraumatic stress and cravings. In contrast mindfulness was associated with less thought suppression, decreased cravings and reduced posttraumatic symptoms (Garland & Roberts-Lewis, 2013). Also Erskine and Georgiou (under review) replicated their smoking study from (2010) with alcohol and showed that participants attempting to suppress thoughts about alcohol for one week subsequently drank more alcohol the following week than participants in the nonsuppression control conditions. In one of the only studies to examine cross over effects from one behaviour to another (Palfai, Colby et al., 1997; Palfai, Monti, et al., 1997) investigated the effects of suppressing thoughts of alcohol on subsequent smoking behaviour, as smoking and alcohol use frequently co-occur (Faeh, Viswanathan, Chiolero, Warren, & Bovet, 2006). The results of Palfai, Colby et al. (1997); Palfai, Monti, et al. (1997) demonstrated that participants attempting to suppress thoughts of alcohol subsequently took significantly more puffs when allowed to smoke. As thought suppression has been shown to raise the activation level of the suppressed concept it is likely that this activation will spread to similar concepts such that suppressing alcohol-related thought results in greater smoking. Taken together, the literature which has developed in the fields of alcohol use and smoking, in relation to thought suppression, provide some interesting insights in to the ways in which attempts at thought control might help or hinder attempts at reducing or abstaining from these behaviours. However, it is clear that thought suppression is not a universal strategy employed by individuals to control unwanted thoughts. We will now turn to a parallel literature on repressive coping which provides further insights in to the nature of thought control. 2.3. Repressive coping The evidence reviewed thus far demonstrates that attempts to control thoughts surrounding smoking and alcohol consumption are not only common, but also quite counterproductive to their intended purpose. Acts of thought suppression are, by definition, conscious and volitional attempts to push a thought from one's mind. Repressive coping, on the other hand, involves the avoidance or ‘suppression’ of thoughts, but without the corresponding conscious intention which is present when an individual engages in thought suppression. It has been defined as a strategic coping mechanism, used when dealing with threatening information or negative intrusive thoughts (Myers, 2010). Unlike thought suppressors who actively intend (albeit, it would seem, unsuccessfully) to push thoughts out of consciousness, repressive copers have been described as ‘natural suppressors’ (e.g. Geraerts et al., 2006) due to their ability to apparently eliminate intrusive thoughts and avoid attending to threatening information. A significant literature has developed around repressive coping and its effects, and this work has been summarised in a review by Myers (2010). In general terms, repressive coping seems to be an effective short term strategy for exercising control over negative or threatening thoughts, though the longer term consequences of repressive coping do not seem to be adaptive, being associated with increased mortality and poorer health outcomes amongst various cohorts (e.g. heart attack and cancer patients, Denollet, Martens, Nyklicek, Conraads, & de Gelder, 2008; Frasure-Smith et al., 2002; Mund & Mitte, 2012; Giese‐Davis, & Spiegel, 2001). Despite evidence that repressive copers may be more proficient at exercising control over negative intrusive thoughts, repressive coping is also associated with a number of negative health outcomes. For instance, Frasure-Smith et al. (2002) found that, over a five year period, myocardial infarction patients with repressive coping styles had poorer health outcomes when placed in a novel treatment programme which involved more active contact between healthcare providers and patients. The authors of this research speculated that the negative treatment effect amongst repressive copers may have been because the

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treatment itself disrupted their usual coping strategy which is based on avoidance, compared with the treatment as usual group who received less intensive contact. The mechanisms which underlie repressive coping are not particularly well understood. In a study which examined the strategies used by repressive copers, Langens and Mörth (2003) demonstrated that, under conditions of low intensity threat, repressive copers seem to use simple attentional avoidance strategies. However, as threat levels increase, they switch to more active strategies — in their study this involved participants generating positive mental imagery related to success. Building on this work, Barnier, Levin, and Maher (2004) demonstrated that repressive copers were less likely than other participants to experience rebound effects after engaging in intentional acts of thought suppression — leading Geraerts et al. (2006) to argue that repressive copers may be skilled or ‘natural’ suppressors, who are more adept at controlling their thoughts. Indeed, supporting the view that repressive copers do engage in thought suppression, Szentagotai and Onea (2007) demonstrated a moderate correlation between a measure of repressive coping and the WBSI. A final piece of experimental evidence supporting this connection between suppression and repression comes from Geraerts, Merckelbach, Jelicic, and Habets (2007) who found evidence of stronger executive function and working memory amongst repressive copers. In their research Geraerts et al. demonstrated that repressive copers experienced fewer anxious intrusive thoughts after being asked to actively suppress these thoughts because of their superior EF and WM capacity. In the context of addictive behaviour, and compared with research in to addictive behaviour and thought suppression, there exists surprisingly little research which has examined the role of repressive coping in the development, maintenance, treatment of, and recovery from, addiction which is particularly surprising given the prima facie case that past research makes for a potential shared underlying mechanism. A search of PsycINFO for peer reviewed journal articles (all years) using combinations of the terms “repressive coping” and “smoking/alcohol/addiction/substance” returns a total of only 8 unique results. Of these, a review of the abstracts shows only one article which has directly investigated the relationship between substance use (alcohol) and repressive coping. This study, by Shirachi and Spirrison (2006), found that repressive copers drank and smoked significantly less than non-repressive participants. Repressive copers also reported a lower likelihood of experiencing negative consequences from drinking compared to other drinkers. Shirachi and Spirrison also cite an earlier study by Weinberger and Bartholomew (1996), which found a negative correlation between drinking and repressive coping. This seeming absence of attempts to integrate theory and evidence is not constrained to research into thought suppression and repressive coping. For instance, the broader construct of experiential avoidance (of which it has been argued, thought suppression is a specific manifestation, see Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, and Strosahl et al., 2004) also seems to lack a sufficiently well-integrated framework (Chawla & Ostafin, 2007), despite the prima facie conceptual utility of the construct for developing our understanding disorders such as addictive behaviour.1 2.4. Conceptual synthesis To draw parallels with repression and suppression implies a potential common mechanism underlying these mental acts. Curiously, the possibility that the processes may be connected has received little attention in the literature. It is tempting, on the evidence reviewed here, to hypothesise the existence of a common process underlying suppression and repression, and to further posit that individuals who engage in acts of repressive coping are those who have, in effect, automatized the act of 1 We are grateful to an anonymous reviewer for highlighting this important issue in relation to the experiential avoidance literature.

suppression — either due to ‘practice’ or because of a natural ability to do so. This has been argued by Geraerts et al. (2006), who suggest that repressive copers are natural suppressors. Interestingly, it seems that repressive copers may be more effective at avoiding the immediate rebound effects associated with thought suppression due better executive function and working memory capacity (Geraerts et al., 2007). Taken together, this review of research surrounding thought suppression and repressive coping provides a basis for a theoretical model which is presented in Fig. 1. This model presents a simple overview of the consequences of an individual experiencing a threatening intrusive thought of some kind. Dependent upon the level of threat, this model suggests different cognitive coping strategies — thought suppression or attentional avoidance. As demonstrated by Langens and Mörth (2003), repressive coping in response to threatening stimuli is characterised by lines (a) and (c) in this model (i.e. attentional avoidance for low threat intrusions, thought suppression for high threat intrusions). Thought suppressors, on the other hand, seem to be characterised by lines (b) and (c) (i.e. utilising thought suppression in response to any intrusions). Importantly, the consequences of any of these strategies seem to be mediated by executive function and working memory capacity (Geraerts et al., 2007). To take a concrete example, let us suppose that a recovering alcoholic finds themselves in a situation where alcohol is available, which triggers intrusive thoughts about drinking. It is reasonable to suppose that this intrusive thought might be judged more or less threatening as a function of context — such that being around supportive friends and family in this moment, who are aware of and support the individual's abstinence efforts, would ostensibly be less threatening than being around work colleagues who are unaware of the individual's problems with drink and efforts to maintain abstinence. In either of these circumstances, the coping response would be driven by the perceived severity of the threat, and executive function/working memory capacity. This model, which infers a possible common pathway underlying repressive coping and thought suppression, makes a number of testable predictions which would be worthy of future study. For instance, on the basis that repressive copers are thought to have stronger executive function/working memory, which underpins their apparent ability to successfully suppress thoughts, it would follow that under conditions of cognitive load, repressive copers should behave more like typical thought suppressors when dealing with intrusive thoughts — in that immediate enhancement effects from thought suppression should become more evident if the attentional capacity is diverted elsewhere. This may have important clinical implications, given the different impacts of thought suppression and repressive coping – in general terms – on health, and also in light of the consequences of acute and chronic drug use.

3. Conclusion In the context of addictive behaviours, attempts at regulating unwanted thoughts through active attempts at suppressing them are likely to be counterproductive, either in the short term (via thought suppression) or in the longer term (via repressive coping). More than this, given the range of working memory and executive function deficits which are known to be present – particularly amongst individuals who have developed drug dependence disorders – evidence surrounding the neural mechanisms of thought suppression and repressive coping suggests that individuals with such impairments will be inherently less successful in reducing unwanted and intrusive thoughts (Anderson & Levy, 2009). Future research in to these types of coping mechanism might usefully begin to examine both repressive coping and thought suppression as related constructs, rather than entirely distinct entities. The model presented in this review provides a conceptual framework within which repressive coping and thought suppression might be

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Threat Evaluation

Low Threat Stimulus

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Response Selection

a

Attentional Avoidance

b

Intrusive Thought High

c

Thought Suppression

Fig. 1. Conceptual model of intrusive thought coping responses.

meaningfully investigated as part of a more general model of threatrelated coping, rather than as necessarily distinct constructs. In conclusion, our model suggests that the distinction between repressive copers and thought suppressors is not that repressive copers fail to utilise thought suppression strategies. Rather, the distinction between a repressive coper and a thought suppressor is that, in situations of low threat, repressive copers utilise attentional avoidance strategies, whilst thought suppressors continue to utilise suppression strategies. Therefore, it is the more selective use of thought suppression which characterises repressive copers, in addition to greater apparent success in the use of this strategy (i.e. they experience fewer rebound effects). Author disclosure statement The authors of this manuscript have no conflicts of interest to declare. No funding was received for the conduct of this research. AM and JE produced the first drafts of this manuscript. JA and GG contributed to the review of the thought suppression literature. AM and IA developed the model presented in the final section. All authors have approved the final version of this manuscript. References Abramowitz, J.S., Tolin, D.F., & Street, G.P. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21, 683–703. Anderson, M.C., & Levy, B.J. (2009). Suppressing unwanted memories. Current directions in psychological science, 18, 189–194. Baer, R.A., Smith, G.T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27–45. Bargh, J.A. (1989). Conditional automaticity: Varieties of automatic influence in social perception and cognition. Unintended thought, 3, 51–69. Bargh, J.A., & Chartrand, T.L. (1999). The unbearable automaticity of being. American psychologist, 54, 462. Barnier, A., Levin, K., & Maher, A. (2004). Suppressing thoughts of past events: Are repressive copers good suppressors? Cognition and emotion, 18(4), 513–531. Baumeister, R.F., Heatherton, T.F., & Tice, D.M. (1994). Losing control: How and why people fail at self-regulation. San Diego, CA: Academic Press. Baumeister, R.F., & Vonasch, A.J. (2015). Uses of self-regulation to facilitate and restrain addictive behavior. Addictive behaviors, 44, 3–8. Bien, T.H., & Burge, R. (1990). Smoking and drinking: A review of the literature. Substance use & misuse, 25, 1429–1454. Bowen, S., Chawla, N., Collins, S.E., Witkiewitz, K., Hsu, S., Grow, J., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance abuse, 30, 295–305. Bowen, S., Witkiewitz, K., Dillworth, T.M., Chawla, N., Simpson, T.L., Ostafin, B.D., et al. (2006). Mindfulness meditation and substance use in an incarcerated population. Psychology of addictive behaviors, 20, 343. Brown, R.A., Lejuez, C.W., Kahler, C.W., Strong, D.R., & Zvolensky, M.J. (2005). Distress tolerance and early smoking lapse. Clinical Psychology Review, 25, 713–733. Burton, S.M., & Tiffany, S.T. (1997). The effect of alcohol consumption on craving to smoke. Addiction, 92, 15–26. Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology, 63, 871–890. Denollet, J., Martens, E.J., Nyklicek, I., Conraads, V., & de Gelder, B. (2008). Clinical events in coronary patients who report low distress: Adverse effect of repressive coping. Health psychology, 27, 302–308.

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