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Mindfulness-Based Relapse Prevention


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By Stephen Keeley, MS, CADC III, CGAC II, at May 2011 Oregon Problem Gambling Services Spring Training.

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Published in: Health & Medicine
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Mindfulness-Based Relapse Prevention

  1. 1. How Does Relapse Happen? The Cognitive Behavioral Model Marlatt & Gordon, 1985 High-Risk Situation Effective Coping Response Increased Self-Efficacy Decreased Probability of Relapse Ineffective Coping Response Decreased Self-Efficacy + Positive Outcome Expectancies (for initial effects of the substance ) LAPSE (Initial Use of Substance ) Increased Probability of Relapse “ Abstinence Violation Effect” Slides: Bowen et al. 2011
  2. 2. Relapse Prevention Therapy Marlatt & Gordon, 1985 High-Risk Situation Ineffective Coping Response Decreased Self-Efficacy + Positive Outcome Expectancies (for initial effects of the substance ) LAPSE (Initial Use of Substance ) “ Abstinence Violation Effect” Self Monitoring, Inventory of Situations Coping Skills Training Stress Management, Relaxation Education about Immediate vs Delayed Effects Contract to limit use, Reminder Card (what to do if you lapse) Cognitive Restructuring: Lapse is a mistake vs a failure Slides: Bowen et al. 2011
  3. 3. Research on Relapse Prevention <ul><li>Meta-analyses and reviews (Irvin, et al., 1999; Carroll, 1996) support RP as an effective treatment across disorders </li></ul><ul><ul><li>Alcohol (Dimeff & Marlatt, 1998; Kadden et al., 1992; Larimer & Marlatt, 1990; Monti et al., 2002) </li></ul></ul><ul><ul><li>Cocaine (Schmitz, et al., 2001) </li></ul></ul><ul><ul><li>Marijuana (Roffman, et al., 1990) </li></ul></ul><ul><ul><li>Smoking (Killen, et al., 1984) </li></ul></ul><ul><ul><li>Eating disorders (Mitchell & Carr, 2000) </li></ul></ul><ul><ul><li>Gambling (Echeburua, et al., 2000) </li></ul></ul><ul><ul><li>Sexual Offenses (Laws, 1995) </li></ul></ul>Slides: Bowen et al. 2011
  4. 4. Review of 24 Randomized Trials (Carroll, 1996) <ul><li>Does not prevent a lapse better than other treatments, but is more effective at delaying and reducing duration and intensity of lapses </li></ul><ul><li>Effective at maintaining treatment effects over long term follow-up (1-2 years or more) </li></ul><ul><li>“ Delayed emergence effects” - greater improvement in coping over time </li></ul><ul><li>May be most effective for more severe substance abuse, greater levels of negative affect, and greater deficits in coping skills </li></ul>Slides: Bowen et al. 2011
  5. 5. Enhancing Relapse Prevention with Mindfulness Slides: Bowen et al. 2011
  6. 6. What is Mindfulness? <ul><li>“ Awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment” </li></ul><ul><li>(Kabat-Zinn, 2003) </li></ul>Slides: Bowen et al. 2011
  7. 7. Paying attention: In the present moment … Nonjudgmentally: Mindfulness and Substance Use Greater awareness of triggers and responses, interrupting previously automatic behavior ( Breslin et al. , 2002) <ul><ul><li>Accepting present experience, rather than using substances to avoid it </li></ul></ul><ul><ul><li>Detach from attributions and “automatic” thoughts that often lead to relapse </li></ul></ul>Slides: Bowen et al. 2011
  8. 8. <ul><li>Mindfulness-Based Relapse Prevention (MBRP) </li></ul>NIDA Grant # R21 DA010562; PI Marlatt Slides: Bowen et al. 2011
  9. 9. MBRP Structure <ul><li>Integrates mindfulness with Relapse Prevention </li></ul><ul><li>Patterned after Mindfulness-Based Stress Reduction (Kabat-Zinn) and Mindfulness-Based Cognitive Therapy for depression (Segal et al.) </li></ul><ul><li>Outpatient Aftercare Treatment </li></ul><ul><ul><li>8 weekly 2 hour sessions; daily home practice </li></ul></ul><ul><li>Therapists have ongoing meditation practice </li></ul><ul><li>Components of MBRP </li></ul><ul><ul><li>Formal mindfulness practice </li></ul></ul><ul><ul><li>Informal practice </li></ul></ul><ul><ul><li>Coping strategies </li></ul></ul>(Bowen, Chawla & Marlatt, 2010; Witkiewitz et al., 2005) Slides: Bowen et al. 2011
  10. 10. Awareness: From “automatic pilot” to awareness and choice Triggers: Awareness of triggers, interrupting habitual reactions Acceptance: Change relationship to discomfort, decrease need to “fix” the present moment Intentions of MBRP Balance and Lifestyle: Supporting recovery and maintaining a mindfulness Slides: Bowen et al. 2011
  11. 11. Session 1: Automatic Pilot and Relapse Session 2: Awareness of Triggers and Craving Session 3: Mindfulness in Daily Life Session 4: Mindfulness in High-Risk Situations Session 5: Acceptance and Skillful Action Session 6: Seeing Thoughts as Thoughts Session 7: Self-Care and Lifestyle Balance Session 8: Social Support and Continuing Practice Awareness, Presence MBRP Session Themes Mindfulness and Relapse Bigger Picture: A Balanced Life Slides: Bowen et al. 2011
  12. 12. “ Formal” Practices Body Scan <ul><ul><li>Sitting Meditation </li></ul></ul>Walking Meditation Mindful Movement Mountain Meditation <ul><ul><li>“ Lovingkindness” or “metta” </li></ul></ul>Slides: Bowen et al. 2011
  13. 13. <ul><li>Direct </li></ul><ul><li>Experience </li></ul><ul><li>( pain ) </li></ul>Reactions, Stories, Judgment ( suffering ) Adapted from Segal et al., 2002 Inquiry Pain in left knee, Restlessness “ I can’t do this” Emotionaldiscomfort (depression, anxiety) “ I can’t handle this. I need an escape. I need a drink.” - Relationship to Craving, Relapse, Recovery - Not personal Slides: Bowen et al. 2011
  14. 14. <ul><li>“ Informal” Practices </li></ul>Mindfulness of daily activities “ SOBER” breathing space Urge surfing Slides: Bowen et al. 2011
  15. 15. Stop Observe Breath “ SOBER” Breathing Space Expand Respond Slides: Bowen et al. 2011
  16. 16. Urge Surfing Riding the wave, rather than giving into the urge and being wiped out by it. Staying with the urge as it grows in intensity, riding it to its peak. using the breath to stay steady as it rises and crests, knowing it will subside. Trusting that without any action on your part, all the waves of desire, like waves on the ocean, arise and eventually fade away.
  17. 17. urge time Slides: Bowen et al. 2011
  18. 18. Awareness of Triggers Situation/ Trigger An argument with my girlfriend . What moods, feelings or emotions did you notice? Anxiety, hurt, anger What sensations did you experience? Tightness in chest, sweaty palms, heart beating fast, shaky all over What thoughts arose? “ I can’t do this.” “ I need a drink.” “ Forget it. I don’t care anymore” Slides: Bowen et al. 2011
  19. 19. Mindfulness and Substance Use Disorders: The Research Slides: Bowen et al. 2011
  20. 20. <ul><li>N = 168 </li></ul>Funded by National Institute on Drug Abuse Grant R21 DAO 10562-01A1; PI: G. Alan Marlatt MBRP Study Design Completed Inpatient or Intensive Outpatient 8 weeks MBRP TAU Slides: Bowen et al. 2011 Post Course (61%) 2months (57%) 4months (73%) Baseline
  21. 21. Participants <ul><li>72% completed high-school </li></ul><ul><li>41% unemployed </li></ul><ul><li>33% public assistance </li></ul><ul><li>62% less than $4,999 / year </li></ul><ul><li>Homeless/unstably housed </li></ul><ul><li>50% Caucasian </li></ul><ul><li>28% African American </li></ul><ul><li>15% Multiracial </li></ul><ul><li>7% Native American </li></ul><ul><li>Age 40.5 (10.3); 64% male </li></ul>Slides: Bowen et al. 2011
  22. 22. Results: Feasibility <ul><li>Attendance </li></ul><ul><ul><li>65% of sessions </li></ul></ul><ul><li>(M = 5.18, SD = 2.41) </li></ul><ul><li>Formal Practice </li></ul><ul><li>4.74 days/week ( SD = 4.0) </li></ul><ul><li>29.94 minutes/day ( SD =19.5 ) </li></ul>(Bowen et al., 2009)
  23. 23. Results: Mindfulness & Acceptance <ul><li>Across 4-month follow-up, significant differences between groups: </li></ul><ul><ul><li>Mindfulness (awareness) </li></ul></ul><ul><ul><ul><li>(p =.01) </li></ul></ul></ul><ul><ul><li>Acceptance </li></ul></ul><ul><ul><ul><li>(p =.045) </li></ul></ul></ul>Slides: Bowen et al. 2011
  24. 24. <ul><ul><li>Time x treatment: p =.02 </li></ul></ul><ul><ul><li>Time 2 x treatment: p =.02 </li></ul></ul>PACS, Flannery et al., 1999 Results: Craving Slides: Bowen et al. 2011
  25. 25. Time x group interaction: p= .02 Time 2 x group interaction: p= .01 Percentage Any AOD Use Results: Substance Use MBRP = 2.1 days of use TAU = 5.4 days of use Slides: Bowen et al. 2011
  26. 26. Comorbidity Worse substance use treatment outcomes (e.g., Hodgins, el Guebaly, & Armstrong, 1995; Witkiewitz & Villarroel, in press) Depression has particularly strong relationship with craving and relapse (Gordon et al., 2006; Zilberman et al., 2007; Curran et al., 2000 ; Levy, 2008) 40% (in the U.S.) with depressive/anxiety disorders have co-occurring substance use disorders (NCS; Kessler, Nelson, McGonagle, Liu, et al., 1996) Slides: Bowen et al. 2011
  27. 27. Results: Depression and Craving Substance Use Craving Depression MBRP (Witkiewitz & Bowen, 2010) Slides: Bowen et al. 2011
  28. 28. Results: Depression and Craving TAU MBRP Substance Use Slides: Bowen et al. 2011
  29. 29. Summary of Results <ul><ul><li>Increased awareness and acceptance </li></ul></ul><ul><ul><li>Reduction in craving </li></ul></ul><ul><ul><li>Decreased rates of substance use </li></ul></ul><ul><ul><li>Weaker relationship between depressive symptoms and substance </li></ul></ul><ul><ul><ul><li>Thereby weakened relationship between depression and substance use </li></ul></ul></ul>Slides: Bowen et al. 2011
  30. 30. Implications <ul><li>Findings consistent with intention and hypothesized mechanisms </li></ul><ul><ul><li>Experience discomfort without “automatically” reacting </li></ul></ul><ul><ul><li>Decrease craving in the presence of internal (e.g., depression) and external (e.g., environment) cues. </li></ul></ul><ul><li>Consistent with findings from other mindfulness-based interventions </li></ul><ul><li>(Dahl et al., 2004; Bowen & Marlatt, 2009; Gifford et al., 2004; Hayes et al., 1999; Levitt, et al., 2004) </li></ul><ul><li>Relationship between depression and craving: Negative affect doesn’t have to lead to relapse (Gifford et al, 2004; Bowen & Marlatt, 2009) </li></ul><ul><li>May be helpful in treating dual-diagnosis clients </li></ul><ul><li>May enhance Relapse Prevention by offering additional skills </li></ul>Slides: Bowen et al. 2011
  31. 31. <ul><ul><li>Is this for everyone? </li></ul></ul><ul><ul><ul><li>Gender </li></ul></ul></ul><ul><ul><ul><li>Dependence severity </li></ul></ul></ul><ul><ul><ul><li>Dual diagnosis (depression, anxiety, trauma) </li></ul></ul></ul><ul><ul><li>Long term effects </li></ul></ul><ul><ul><ul><li>Latency to first lapse </li></ul></ul></ul><ul><ul><ul><li>Pattern of use following the first lapse </li></ul></ul></ul><ul><ul><li>Physiological and Neurological effects </li></ul></ul><ul><ul><ul><li>Stress reactivity to triggers </li></ul></ul></ul><ul><ul><ul><li>Brain activation </li></ul></ul></ul><ul><ul><ul><li>Neuroplasticity </li></ul></ul></ul><ul><ul><li>Underlying “Automatic” Cognitive Processes </li></ul></ul><ul><ul><ul><li>Cognitive Inhibition (ability to disengage attention from triggers) </li></ul></ul></ul><ul><ul><ul><li>Metacognition </li></ul></ul></ul>Future Directions Slides: Bowen et al. 2011
  32. 32. Thank you! Slides: Bowen et al. 2011
  33. 33. <ul><li>Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician’s Guide </li></ul><ul><li>Guilford Press, November 2010 </li></ul><ul><li> </li></ul>Slides: Bowen et al. 2011