OVERVIEW OVERVIEW MINDFULNESS APPROACHES IN ADDICTION TREATMENT AND! LONG-TERM RECOVERY MANAGEMENT THERISSA LIBBY! METROPOLITAN STATE UNIVERSITY

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1 MINDFULNESS APPROACHES IN ADDICTION TREATMENT AND! LONG-TERM RECOVERY MANAGEMENT THERISSA LIBBY! METROPOLITAN STATE UNIVERSITY RUTGERS SUMMER SCHOOL OF ADDICTION STUDIES OVERVIEW OVERVIEW Tuesday! Introduction To Mindfulness and Mindfulness Practices! Mindfulness-Based Stress Reduction! Wednesday! Mindfulness-Based Interventions (MBIs) in the Treatment of Psychiatric Disorders! MBIs in the Treatment of Substance Use Disorders Thursday! Mindfulness-Based Relapse Prevention: Literature Review! Mindfulness-Based Relapse Prevention: A Promising Practice! Friday! Mindfulness-Based Relapse Prevention: Overview of Curriculum 3 4

2 OVERVIEW TUESDAY Saturday! Mindful Practice of Counseling! Course Completion Introduction To Mindfulness and Mindfulness Practices! Mindfulness-Based Stress Reduction 5 6 INTRODUCTION Contemplative Practices! Buddhism! Zen Buddhism in America The Center for Contemplative Mind in Society Concept & design by Maia Duerr; illustration by Carrie Bergman 7 8

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4 Jon Kabat-Zinn Alan Marlatt MINDFULNESS MINDFULNESS-BASED STRESS REDUCTION What do we mean?! v=wpnemxwsnxg&list=plslgf43b7in- F0xCgmBEa1TT0NF0R91hf&index=2 Jon Kabat-Zinn, U Mass Medical Center! Chronic pain patients in Stress Reduction and Relaxation Program! Kabat-Zinn (1982), Gen Hosp Psychiatry 4(1):33-47! Kabat-Zinn et al. (1985), J Behav Med 8(2):

5 MINDFULNESS-BASED STRESS REDUCTION Investigations expanded to other conditions! Improvements in physical health! Improvements in stress management! Improvements in mental health (tomorrow) MINDFULNESS-BASED STRESS REDUCTION Eight weeks, nine sessions! Information, discussion and exercises! Practice (in and between sessions)! sitting and walking meditations! body scan! gentle yoga 19 20

6 BODY SCAN WEDNESDAY What did you notice?! Tonight: bodyscan.html Mindfulness-Based Interventions (MBIs) in the Treatment of Psychiatric Disorders! MBIs in the Treatment of Substance Use Disorders BODY SCAN If you did it, what did you notice?! If you did not do it, what did you notice? 23 24

7 MBI FOR PSYCHIATRIC DISORDERS MBCT MBSR: addresses physical illness and/or life stress, may result in improvements in psychiatric symptoms! Mindfulness-Based Cognitive Therapy: addresses risk of relapse to depressive symptoms! NREPP lists both, with research quality ratings of (on a scale). Targets prevention of relapse to depressive symptoms! Formalized by Zindel Segal and colleagues! Teasdale et al. (2000) J Consult Clin Psychol 68(4): ! Crane et al. (2014) Behav Res Ther 63: MBCT Kuyken et al. (2010) Behav Res Ther 48: ! Mediators of treatment effects (vs medication)! Mindfulness (as measured by Baer s Kentucky Mindfulness Scale)! Self compassion (as measured by Neff s Self Compassion Scale) Crane et al. (2014) Behav Res Ther 63:

8 MBCT MBI FOR ANXIETY DISORDERS Reasonable evidence base! Many books published for use with other disorders, but without the research to back them up Stress reduction in healthy individuals and those with general medical conditions! Symptom reduction in those diagnosed with anxiety disorders (or anxiety associated with other psychiatric disorders) MBI FOR ANXIETY DISORDERS MBI FOR PTSD/TRAUMA Studies too limited to draw many conclusions! MBCT: little research to draw from! MBSR! GAD, Panic Disorder! PTSD Outcomes (studies with n>100)! nonjudgment of experience correlates with reduced avoidance symptoms (Thompson and Waltz, 2010)! mindful awareness and attention correlates with fewer PTSD, depressive and physical symptoms and fewer alcohol problems in firefighters (Smith et al., 2011) 31 32

9 MBI FOR PTSD/TRAUMA Sample outcomes from smaller studies (more investigation needed) showed positive outcomes among! low-income women of color survivors of intimate partner violence (Dutton et al., 2013, MBSR)! survivors of child abuse (Earley et al., 2014)! combat veterans (King et al., 2013; MBCT)! MBI: OVERVIEW OF EFFECTIVENESS VA Evidence-based Synthesis Program Reports! Hempel et al., Evidence Map of Mindfulness [Internet]. Washington (DC): Department of Veterans Affairs (US); 2014 Oct.! victims of warfare (Marzabadi and Zadeh, 2015)

10 MBI FOR SUBSTANCE USE DISORDERS Systematic reviews! Effectiveness of MBIs for substance use: Chiesa and Serretti (2014) Subst Use Misuse 49(5): ! Mechanisms of MBIs: Chiesa et al. (2014) Holist Nurs Pract. 28(2): MBI STUDIED FOR SUBSTANCE USE DISORDERS MBSR AND SUDS Vipassana meditation! MBSR! MBCT! Mindfulness-Based Relapse Prevention! Spiritual Self-Schema Therapy! Dialectical Behavior Therapy! Acceptance and Commitment Therapy Limited benefit in reducing substance use or psychological stress! Benefit in smoking cessation 39 40

11 MBCT AND SUDS ACCEPTANCE AND COMMITMENT THERAPY Limited benefit in alcohol abstinence! Benefit in smoking cessation A mindfulness-based, values-driven behavioral therapy developed by Steven Hayes and colleagues! Six core processes! Goal: to increase psychological flexibility (Harris, 2007) ACT AND SUDS Benefit in opioid abstinence using MAT + ACT vs MAT alone! Benefit in smoking cessation, more sustained remission 43 44

12 DIALECTICAL BEHAVIOR THERAPY Developed by Marsha Linehan to address Borderline Personality Disorder! Teaches four skill sets! mindfulness! distress tolerance! emotion regulation! interpersonal effectiveness DBT AND MINDFULNESS Be aware of/present to all thoughts, feelings and actions! Become responsive rather than reactive! Practice nonjudgment! Differentiate self from thoughts, feelings and actions! Practice acceptance rather than avoidance DBT AND SUDS NEXT: MBRP BPD and substance use! 1999 Linehan study (n=12): greater retention in treatment, reduced substance use, sustained improvement at follow-up! Sober Breathing Space 2002 Linehan study (n=23): sustained reductions in substance use and psychopathology 47 48

13 SOBER BREATHING SPACE What did you notice?! SOBER: Stop, Observe, focus on Breath, Expand awareness, Respond mindfully! Tonight: use this when the opportunity arises THURSDAY Mindfulness-Based Relapse Prevention: Literature Review! Mindfulness-Based Relapse Prevention: A Promising Practice 51 52

14 SOBER BREATHING SPACE MBRP If you did it, what did you notice?! If you did not do it, what did you notice? Mindfulness-Based Relapse Prevention was developed by G. Alan Marlatt, bringing together two of his passions:! mindfulness and meditation as tools in clinical psychotherapy, and! relapse to addictive behaviors and how to prevent it or lessen its severity PRE-MBRP STUDIES Leigh et al. (2005) Addict Behav 30: ! Bowen et al. (2006) Psychol Addict Behav 20: 343-7! Bowen et al. (2007) Addict Behav 32: Bowen et al.,

15 MBRP: 2009 STUDY Bowen et al. (2009): Mindfulness-based relapse prevention for substance use disorders: a pilot efficacy trial. Substance Abuse, 30: ! This paper was followed by several others that evaluated various aspects of the same study mindfulrp.com PARTICIPANTS DESIGN n = 168! 63.7% male, 36.3% female! average age 40.5 years! 51.8% White, 28.6% African-American, 15.3% multiracial, 7.7% Native American! 71.6% had at least a high school diploma! Participants had completed residential or intensive outpatient treatment and were starting aftercare! Randomized to eight weeks of either MBRP group or treatment as usual (TAU) aftercare group! Multiple measures taken at baseline, end of MBRP group, and two and four months later 62.3% earned < $5K per year, 41.3% unemployed 59 60

16 OUTCOMES TABLE 1 Means (Standard Deviations) for Alcohol and Other Drug Use and Process Variables During the Study 2 months 4 months Baseline Posttest post-intervention post-intervention Variables MBRP TAU MBRP TAU MBRP TAU MBRP TAU Compared to TAU participants, MBRP participants showed! greater decreases in substance use! greater decreases in craving! greater increases in acceptance! Significant differences at end of intervention and two months after, but not at four months after 61 AOD days (24.0) (24.8) (.3) (9.1) (7.2) (14.7) (14.9) (15.3) (n = 93) (n = 70) (n = 77) (n = 56) (n = 74) (n = 56) (n = 69) (n = 49) SIP (5.4) (4.7) (4.5) (5.6) (5.3) (5.8) (5.4) (5.8) (n = 93) (n = 75) (n = 62) (n = 42) (n = 53) (n = 42) (n = 71) (n = 52) PACS (1.1) (1.4) (1.1) (1.4) (1.0) (1.5) (1.3) (1.5) (n = 91) (n = 75) (n = 62) (n = 41) (n = 53) (n = 42) (n = 70) (n = 52) AAQ (7.5) (9.6) (7.8) (10.0) (9.1) (9.6) (7.5) (10.3) (n = 76) (n = 72) (n = 56) (n = 40) (n = 51) (n = 39) (n = 63) (n = 50) FFMQ-ACT (6.2) (6.9) (7.0) (7.2) (6.3) (7.2) (5.8) (7.9) (n = 84) (n = 72) (n = 55) (n = 40) (n = 52) (n = 37) (n = 61) (n = 48) Note. MBRP = Mindfulness-Based Relapse Prevention; TAU = treatment as usual; AOD = alcohol and other drug use; SIP = Short Inventory of Problems; PACS = Penn Alcohol Craving Scale; AAQ = Acceptance and Action Questionnaire; FFMQ-ACT = Five-Factor Mindfulness Questionnaire Act With Awareness Scale. 62 MBRP 2009 STUDY: FURTHER ANALYSIS MBRP 2009 STUDY: FURTHER ANALYSIS Witkiewitz et al. (2010) J Consult Clin Psychol 78: ! Bowen and Kurz (2011) J Clin Psychol 68: ! Witkiewitz et al. (2013a) Addict Behav 38(2): Beck Depression Inventory! Penn Alcohol Craving Scale (modified to include other drugs)! MBRP Adherence and Competence Scale (Chawla et al., 2010)! Working Alliance Inventory, Short Form! Five Facet Mindfulness Questionnaire! Acceptance and Action Questionnaire 63 64

17 WITKIEWITZ ET AL., 2010 BOWEN AND KURZ, 2011 In 2009 study participants, craving mediated the relationship between depression and relapse! This effect was attenuated by MBRP, suggesting that MBRP participants were better able to manage negative affect and thus reduce likelihood of relapse Studied between-session practice and therapeutic alliance as predictors of mindfulness! Greater between-session practice predicted higher mindfulness scores at end of course, but not at follow-up! Greater therapeutic alliance predicted higher mindfulness scores at two-month, but not fourmonth, follow-up WITKIEWITZ ET AL., 2013A RACIAL/ETHNIC MINORITY WOMEN Craving reduction was mediated by acceptance, attention and nonjudgment! No one of these factors was sufficient to mediate the reduction in craving; it required all three! Thus, these appear to be skills enhanced by MBRP that support abstinence/reduction in use! Witkiewitz et al. (2013) Addict Behav 38: , women offenders in residential treatment (n=54 at follow-up)! Nonwhite women who participated in MBRP, at 15- week follow-up, had fewer drug use days and lower ASI scores than women in RP group 67 68

18 RACIAL/ETHNIC MINORITY WOMEN Amaro et al. (2014) Subst Use Misuse, 49: ! MB relapse prevention curriculum adapted from MBSR for low-income racial/ethnic minority women! In treatment sample (n=318), 36% completed (although satisfaction ratings were high)! Greater participation (>4 of 9 sessions) correlated with reduced alcohol severity, drug severity and perceived stress at 12-month follow-up MBRP: 2014 STUDY Results from multiple analyses of data from pilot study sufficiently encouraging to merit further research! Bowen et al. (2014): Relative Efficacy of Mindfulness- Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders: A Randomized Clinical Trial. JAMA Psychiatry, 71, SUBJECTS DESIGN n = 286! 71.5% male, 28.5% female! 42.1% from racial/ethnic minority groups! age range years Participants recruited from those completing residential or IOP treatment at two private non-profit treatment centers! Randomized to eight weeks of either MBRP, Relapse Prevention (Marlatt model, cognitive) and TAU! Evaluated on multiple use-related measures (TLFB, urine screens) at baseline and three, six and twelve months 71 72

19 OUTCOMES OUTCOMES Three months: no between-groups differences! Six months: MBRP and RP (vs TAU)! reduced risk of relapse to drug use! reduced risk of heavy drinking! in those who did drink, fewer days of heavy drinking! Six months: MBRP (vs RP)! longer time to first use Twelve months: MBRP (vs RP)! fewer drug use days! reduced risk of heavy drinking! Perhaps explained by the participants improved ability to recognize and tolerate discomfort associated with craving or negative affect. (p 554)

20 MBRP Fully manualized (Bowen, Chawla and Marlatt, 2011)! All instructions, exercises and handouts are included! Intended to be used in aftercare, with participants who have a counselor/therapist outside of group! The originators, authors and trainers emphasize what one factor as absolutely vital to the proper delivery of MBRP? THOUGHTS FRIDAY What did you notice?! Tonight: Practice mindful sitting with the image from this practice Mindfulness-Based Relapse Prevention: Overview of Curriculum 79 80

21 THOUGHTS MEDITATION If you did it, what did you notice?! If you did not do it, what did you notice? CHARACTERISTICS OF MBRP NOTICING Awareness! Curiosity! Openness! Gentleness! Nonjudgment Direct Experience! Physical sensations! Thoughts! Feelings! What s familiar! What s common 83 84

22 IN CONTRAST TO... PART I Story! Explanation! Interpretation! Judgment Facilitating! Inquiry! Home Practice! Co-Facilitation PART I Facilitators! Training! Personal Practice! MBRP and 12-Step Approaches p

23 PART I Logistics! Home Practice! Attendance! Gender and Group Size! Precourse Meetings! Issues to Consider! Working with Trauma PART II PART II Automatic Pilot and Relapse! Awareness of Triggers and Craving! Mindfulness in Daily Life! Mindfulness in High- Risk Situations! Acceptance and Skillful Action! Seeing Thoughts as Thoughts! Self-Care and Lifestyle Balance! Social Support and Continuing Practice Sessions 1-3! our tendency toward automatic pilot! stepping out of it by attending to present-moment experience 91 92

24 PART II Session 1: Automatic Pilot and Relapse! Session 2: Awareness of Triggers and Craving! Session 3: Mindfulness in Daily Life p PART II PART II Sessions 4-6! application of mindfulness practices to risky situations! individual risk and individual integration of practices Session 4: Mindfulness in High-Risk Situations! Session 5: Acceptance and Skillful Action! Session 6: Seeing Thoughts as Thoughts 95 96

25 PART II Sessions 7-8! widen the lens! making choices that support recovery and mindfulness practice over time p PART II Session 7: Self-Care and Lifestyle Balance! Session 8: Social Support and Continuing Practice p

26 MOUNTAIN MEDITATION What did you notice?! Tonight: Watch walking meditation video! at least through 2:20! Tomorrow: meet outdoors for walking meditation SATURDAY MINDFULNESS AT WORK Mindful Practice of Counseling! Course Completion What would it mean to bring mindfulness to your counseling or other professional interactions?

27 COURSE COMPLETION Appreciations! Closing! Contact: Therissa Libby, or 105