Letter of Intent. A Manual to Support a New Model of Addictions Treatment: The Inclusion of Mindfulness. CAAP Final Project Requirement

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1 CAAP Letter of Intent Page 1 Running head: CAAP FINAL PROJECT LETTER OF INTENT Letter of Intent A Manual to Support a New Model of Addictions Treatment: The Inclusion of Mindfulness CAAP Final Project Requirement April 14, 2006 Gary Anderson Supervisor: Dr. Maureen Angen, MSc, PhD, RPsych

2 CAAP Letter of Intent Page 2 Problem Statement This project will look at relapse prevention in addictions. Relapse or returning to using/abusing is the most prevalent problem in any individual s attempt to quit. The individual is going through a process of reducing, or stopping the active substance use, developing control over urges to use, improving personal health, and improving social functioning. O Brien (2003) describes the relapse issue in addictions treatment as similar to problems with treating a chronic disorder in the same category as hypertension, diabetes, asthma, and other chronic conditions (p ). By defining addiction as a chronic health disorder, the problem can more easily be viewed with the lens of the biopsychosocial model, and therefore treatment can incorporate all these elements. Relapse is viewed as a natural part of the learning and recovery process. During the recovery process relapse prevention becomes predominant, and any addictions intervention program must grapple with this problem. Relapse Prevention (RP) intervention as described by Marlatt & George (1984) has now been researched for several decades, in the field of addictions as well with other chronic health disorders. Efforts to prevent relapse have had limited success. Relapse rates in addictions treatment have been reported from 50% to 90% depending on the definition (Brownell, Marlatt, Lichtenstein, & Wilson 1986, p. 766). This project supports a novel clinical intervention with the addition of mindfulness meditation for prevention of relapse. Recently Witkiewitz, Marlatt, and Walker, (2005) have looked at the use of Mindfulness-Based Relapse Prevention (MBRP) as a way of increasing the effectiveness of RP with promising results. The development of MBRP into a manual is important for the transition from theory and research into practice. Meditation has been used across many centuries in many cultures. There are a wide variety of types of meditation. Germer, Siegel, and Fulton (2005) describe the two most researched forms of meditation. The first is concentration meditation, in which practitioners repeat a silent

3 CAAP Letter of Intent Page 3 word or phrase (a mantra) with the goal of quieting (and ultimately transcending) the ordinary stream of conscious thoughts. This form has commonly been represented in the west as Transcendental Meditation (TM), which was described by Maharishi Mahesh Yogi (1966). The second is mindfulness meditation, in which practitioners simply observe or attend to thoughts, emotions, sensations, perceptions, and other mental activity, (without judgment) as they arise moment by moment in the field of awareness. This second form, based in Buddhist teachings, is referred to as Vipassana or Insight meditation. S.N. Goenka, a teacher of Vipassana meditation, started Vipassana centers around the world. This form of meditation has become the basis of a wide variety of mindfulness-based therapies in the west starting with the work of individuals like Kabat-Zinn (1990). One of the underlying beliefs of mindfulness practice in all its permutations is that mindfulness meditation helps to alleviate psychological suffering (Germer et al., 2005). Marlatt and Kristeller (1999) define mindfulness as; to be aware of the full range of experiences that exist in the here and now. It is bringing one s complete attention to the present experience on a moment to moment basis (p. 68). Kabat-Zinn (1994) describes mindfulness as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (p. 4). Kabat-Zinn also describes the practice of mindfulness as simply a practical way to be more in touch with the fullness of your being through a systematic process of self-observation, self-inquiry, and mindful action (p. 6). Mindfulness-based interventions have been discussed in the literature as Mindfulness-Based Stress Reduction (MBSR), Dialectic Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Cognitive Therapy (MBCT) (Baer, 2003). All of these interventions deal with chronically relapsing mental health problems. This project will examine the theory and research behind the use of MBRP in addictions, and, with supporting documentation from MBSR, DBT, ACT, and MBCT interventions, will produce a manual for a MBRP program.

4 CAAP Letter of Intent Page 4 Project Rationale A MBRP manual that draws on the RP programs in addictions, and the current mindfulness-based interventions will support the use of mindfulness as an active ingredient in an addictions intervention. The purpose of this Campus Alberta Applied Psychology project is to extract from the literature the active ingredients of RP and mindfulness-based treatments. These ingredients will be examined for similarities and differences that may offer clues as to how a MBRP manual for addictions may be developed. The end product would be an example of a MBRP manual that can be used to support recovery from addictions in a clinical setting. The intent is to develop a set of core ingredients in the manual for a group intervention that can be adapted for use in a variety of venues and time frames. The same core ingredients may be able to be used in individual psychotherapy sessions but this would not have the benefit of the group interaction and may not be as effective. The rationale for the production of a MBRP manual for addictions is threefold: (a) to support the standardization of a treatment intervention that is based on the effectiveness of mindfulness as an additional ingredient to treatment of addictions, (b) to provide an example of how treatment may proceed with mindfulness as a central focus, and (c) to provide an innovative alternative for individuals seeking addictions treatment. Supporting Literature A Dynamic Model of Addiction, Recovery and Relapse A number of explanatory mechanisms have been suggested for an individual s addiction related decline in functioning. These include genetic predispositions (McClung et al., 2004), acquired neurological adaptation (Gerdeman, Partridge, Lupica & Lovinger, 2003; Kelley & Berridge, 2002), learning negative behavioural patterns (Robinson & Berridge, 2003), deeply ingrained feelings of low self-worth, self-medication of underlying physical or emotional pain,

5 CAAP Letter of Intent Page 5 and lack of family and community support for positive function (O Brien, 2003). Each individual adapts through the process of addictions and is changed by the process based on their individual differences. A model that has been developed to look at change and the readiness for treatment is the Transtheoretical Model (TTM) of change through the six stages of pre-contemplation, contemplation, preparation, action, maintenance, and relapse or recycle (Prochaska, DiClemente & Norcross, 1992). The authors say that TTM was originally seen as a linear process but now is seen as nonlinear with movement forward, or back in the process with multiple impacting factors. TTM has also been applied to the change process for the development of addiction (Pallonen, Prochaska, Velicer, Prokhorov & Smith, 1998). DiClemente (1999) stated about the addictions and recovery process: Becoming dependent on a substance as well as recovering from dependence on alcohol or drugs is being described increasingly in dynamic, process-oriented terms. researchers and clinicians began to envision a course of the development of abuse and dependence that included not only a progression toward dependence but also a progression toward recovery. (p. 477) The TTM will be important when looking at how candidates fit into the intervention planned as well as how the intervention is planned to fit the stage the individual is in. The MBRP intervention would fit as a treatment for the maintenance and the relapse stage. Originally, Marlatt and George (1984) developed a linear model of RP, which started from a high-risk situation and the individual s coping response (see also Marlatt, 1996; Marlatt, Baer, Donovan & Kivlahan, 1988). Irvin, Bowers, Dunn, and Wang (1999) give a review of the research on RP. They looked at 26 studies and found an effect size of 0.14 with a significantly greater effect size for treatment of alcohol and polysubstance usage than smoking and cocaine

6 CAAP Letter of Intent Page 6 usage. Boker and Graham (1998) found that mathematical models applied to research previously done with a group of adolescents in the addictions process had small changes that led to amplified changes in a brief time span, which indicated a system with dynamic instability. Piasecki, Fiore, McCarthy, and Baker (2002) argued that, we need to understand what the relevant forces are, how they combine with one another and which forces predominate in the composite at any given time if we are to mine treatment lessons from relapse data (p. 1106), and so to move forward with relapse prevention. Hufford, Witkiewitz, Shields, Kodya, and Caruso (2003) have proposed that a Nonlinear Dynamic System model is a better predictor of relapse. This has recently been given a boost as the mathematical models have become available to describe dynamic, nonlinear natural systems. Witkiewitz and Marlatt (2004) have now changed the RP model to a view of the dynamic nature of relapse. The complexity of factors involved in relapse has led the authors to state; synthesizing recent empirical findings into a unified theory involves reconceptualizing relapse as a multidimensional, complex system. the proposed model of relapse focuses on situational dynamics (p. 229), which allows for distal and proximal relapse risks. Witkiewitz and Marlatt state: This self-organizing process incorporates the interaction between background factors (e.g., years of dependence, family history, social support, and comorbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, outcome expectancies, craving, the abstinence violation effect, motivation), and coping skills. (p. 229) Given the multi-dimensional nature of relapse prevention, and the success of mindfulness as an additional element in other therapies, Witkiewitz, et al. (2005) have proposed, and started to research MBRP. We will now look at how mindfulness has been used in other interventions. Mindfulness-Based Treatment

7 CAAP Letter of Intent Page 7 The problem is: What would a MBRP manual look like for a clinical setting? There is a similar problem with relapse in mental health treatment, an arena in which mindfulness-based interventions have been successfully used. Baer (2003) reviewed the research on mindfulnessbased treatment programs and describes the variety of areas of application such as management of pain, stress reduction, stress due to chronic illness (such as cancer patients), binge eating disorder, fibromyalgia, psoriasis, anxiety disorder, panic disorder, borderline personality disorder, major depressive disorder, and depression relapse prevention, as well as it s use in the treatment of addictions (Baer, 2003; Kabat-Zinn, 2003). Baer (2003) reported an overall mean effect size of 0.59 or moderate range for MBSR, DBT, ACT and MBCT. The author felt that this was a very conservative estimate based on the limited information in many of the studies. The use of MBSR as developed by Kabat-Zinn (1990) has become the basis of much of the current research. Segal, Williams, and Teasdale (2002) developed and researched MBCT as a recent treatment based on combining cognitive therapy, and MBSR, for relapse prevention with people with depression. It has shown a significantly increased effect size over treatment as usual in a large multi-site study. There is extensive literature for the use of mindfulness as a component of treatment programs for a variety of issues (Germer et al., 2005; Hayes, Follette & Linehan, 2004). The manuals developed from this line of research will form the basis for the development of a MBRP manual. Bishop (2002) provides a review of the literature on mindfulness and he pointed out the need for an accepted definition of the construct of mindfulness. Dimidjian and Linehan (2003) in their commentary on the current issues for the study of mindfulness also looked at the construct. These authors raised the critical issue of the therapist s own knowledge of the practice of mindfulness as an issue for research. Currently both MBSR (Kabat-Zinn, 2003) and MBCT (Segal et al., 2002; Teasdale et al., 2000; Teasdale, Williams & Segal, 1995) require an on-going

8 CAAP Letter of Intent Page 8 personal practice, by the therapist, of the mindfulness practices that are being asked of the participants in the program. ACT and DBT do not require mindfulness meditation practice by the therapist because it is not a required part of the therapy. The issue of training, daily practice, and authenticity by the clinician as well as fidelity in the use of mindfulness will be discussed in the project, and in the manual. The literature around the specific use of mindfulness in the treatment of addictions is less developed. Breslin, Zack, and McMain (2002) analysed mindfulness-based therapy from an information-processing model, and provided a framework for integrating mindfulness meditation into substance abuse treatment. The authors suggest that because of the moderating effects of mindfulness practice on attention and awareness, and the central nature of attention in urges, cravings, and relapse, the match for addictions interventions is ideal. These authors state, as promising approaches such as mindfulness are integrated into existing treatments, further progress can be made in reducing the risk of relapse (p. 294). A review by Kavanagh, Andrade, and May (2004) discusses the use of mindfulness in the management of intrusive thoughts, reduction of cravings, and developing an attitude of acceptance, and ability to move on. They reviewed the more recent literature about the ineffectiveness of thought suppression in cognitive therapy for the reduction of intrusive thoughts related to usage. The authors propose that mindfulness therapy supports the development of a calm detachment to thoughts, which reduces the escalation of intrusive thoughts. They state, there is clearly a potential for the wider application of the method to be evaluated (p. 1365). McMain, Korman, and Dimeff (2001) describe the use of DBT in the treatment of severely disordered, chronically suicidal, and substance-dependent individuals with Borderline Personality Disorder (BPD). The authors reviewed the research, and found DBT to be effective over treatment as usual in reducing many of the symptoms of BPD, such as parasuicidal behaviour, hospital care, and drug use, and

9 CAAP Letter of Intent Page 9 treatment retention in substance-dependent BPD clients. It is important to recognize that BPD presents as very resistant to treatment, so any change is important. Plasse (2001) in a study of two residential programs gives a qualitative look at the use of TM in a drug treatment center and a women s shelter. This study supported TM s use embedded within a complex array of treatment modalities including narrative story telling, visualization, cognitive therapy, and interpersonal growth. Alterman, Koppenhaver, Mulholland, Ladden, and Baime (2004) and Marcus, et al. (2003) have both completed studies with substance abuse subjects with promising results but they also indicate the complexity of integrating mindfulness into a treatment program. Khurana and Dhar (2000) of the Indian Institute of Technology have summarized the success of some studies within prisons in India, which used a 10-day Vipassana meditation intervention, in a report to the Vipassana Research Institute. The success in India has lead to pilot studies in prisons in the United States (Coulter, 2002). Marlatt, et al. (2004) give a summary of Vipassana meditation, and its use as a treatment in the US pilot prison study, which has provided some promising initial outcome data (Also see Marlatt & Witkiewitz, 2005; Witkiewitz et al., 2005). The authors are also researching a group of non-incarcerated individuals but results are not available. As indicated earlier these authors have now suggested the development of MBRP. Overall there is considerable literature on the use of mindfulness interventions, which can be drawn on to support the development of a MBRP manual. In conclusion the dynamic model of addiction, recovery and relapse discussed above requires a multicomponent relapse prevention treatment program, which deals with all parts of the individual s experience. One of the proposed ingredients from the early example of RP to the current example of MBRP is the metacognitive approach to treatment. When the relapse process is interrupted with a mindfulness state of awareness, a state of metacognitive awareness and relaxation replaces the positive and negative reinforcement previously associated with engaging

10 CAAP Letter of Intent Page 10 in the addictive behaviour (Marlatt et al., 2004, p. 269). Teasdale, et al. (2002) found that it is the change in the relationship to thoughts that supports the person who is vulnerable to relapse in depression and MBCT is effective in increasing accessibility of metacognitive thoughts. A metacognitive or mindfulness-based approach appears to work with the underlying mechanisms for change in a dynamic system. The literature review and rationale for a MBRP intervention undertaken in this project will look at the possible mechanisms and suitability of mindfulness. This material will be outlined in the completed manual, for the benefit of program facilitators. Project Procedures Definitions Both relapse and mindfulness will be explicated through the relevant literature. The issues and debates will be explored. In order to do this a number of issues pertinent to the addictions field will be examined such as: the use of nonlinear dynamic systems modelling, the controversy about defining relapse, the issues around harm reduction verses abstinence, the development of the RP intervention and it s application to addictions, the development of the use of spirituality and mindfulness in treatment, and how the above issues are dealt with in the application to MBRP for addictions. The need for authenticity in the facilitation of a mindfulness-based program will be discussed and a review of the current positions of the contributing research will be given. These definitions and literature reviews will be included in the manual. Finally the rational will be given for the inclusion of the active ingredients into the manual so potential facilitators will understand the intent of the process. Procedures The literature was searched primarily through PsycINFO from 1967 to the present in English, as well as the ERIC database, and the Allied and Complementary Medicine database. The searches were limited to articles that could be retrieved in full text through the SFX search

11 CAAP Letter of Intent Page 11 system. Manuals and articles were also retrieved from government websites for addictions counselling such as the National Institute on Drug Addictions, National Institute on Alcohol Abuse and Alcoholism, The Matrix Institute on Addictions, The Canadian Centre on Substance Abuse, The Centre For Addictions and Mental Health, Alberta Alcohol and Drug Abuse Commission, the Vipassana Research Institute, The Santa Barbara Institute for Consciousness Studies, The Mindful Awareness Research Center at UCLA, The Centre for Mindfulness at the University of Massachusetts Medical School, and some specific searches such as for information on Vipassana Meditation. As well a number of current books on the field of mindfulness-based therapies were purchased. There are a number of published manuals for mindfulness-based therapies for a variety of conditions (Fishman, 2002; Kabat-Zinn, 1990; Segal et al., 2002; Weiss, 2004). There are also a number of manuals for relapse prevention in additions treatment for adults (Budney & Higgins, 1998; Carroll, 1998; Daley, Mercer & Carpenter, 2002; Matrix Institute on Addictions, 2002; Mercer & Woody, 1999; National Institute on Drug Abuse, 1999, 2000). The Matrix model is supported by extensive research (Farabee, Rawson & McCann, 2002; Rawson, Gonzales & Brethen, 2002; Rawson, Marinelli-Casey et al., 2004; Rawson, Shoptaw et al., 1995; Shoptaw, Rawson, McCann & Obert, 1994). A manual based on the Transtheoretical Model of change (Velasquez, Maurer, Crouch & DeClemente, 2001) will also be reviewed in the process. These manuals will be reviewed in developing a MBRP program and manual for addictions. Literature reviews on critical ingredients will be utilized to support the choice of ingredients to be included in the program. Consideration of and a rational for the length of a program will be given in the project. An effort will be made to allow for flexibility in the use of the manual as either an intensive short program or weekly program. Potential Implications of the Project One implication of this project is that it will give another innovative option to individuals

12 CAAP Letter of Intent Page 12 seeking support in preventing relapse. A second implication is that the effective implementation of a mindfulness-based intervention will support people who are struggling with addictions to find a way to change their lives and to maintain those changes. Thirdly, the development of a manual will provide movement towards a consistent front line implementation in the use of this new form of relapse prevention. Fourthly, this project will open a discussion of the importance of the elements and their positioning in treatment. Finally, if a manual can be developed that can be used in the field then the distance between research and clinical practice can be reduced and both will benefit. This project can put a tool into the hands of addictions counsellors that supports a reduction of the relapse rate for their clients. It will give a flexible option to those who do not fit into the current methodologies of addictions treatment such as the traditional twelve step programs. It also supports the individual in a very concrete way to retrain or manage the adaptation back from the neurological adaptation that is addiction. This everyday practice is like supporting a person in starting an exercise program to reduce cardiac and weight problems. It is about supporting the individual in making choices in a situation where the addictions have taken away most of the choices. By developing mindfulness the individual becomes more aware of the choice points as they learn how to change from the autopilot of addictive behaviour.

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