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Rachel Abrams, M.A.Pat Penn, Ph.D.Michael (member)La Frontera Arizona, Tucson, AZ

BackgroundCognitive-Behavioral Model of AddictionRelapse PreventionMindfulnessMindfulness & AddictionMBRP: Mindfulness-Based Relapse PreventionDefining MBRPResearch supportGoals & Central ComponentsImplementationOur MBRP studyOur experience with implementation and evaluationImplementation suggestionsMember experiences with MBRPExperiential exercisesSummary, Questions & Comments

Participants will be able to:1) Explain the theory and related goals of MBRP2) Describe MBRP and its main components3) Learn and practice two interventions from MBRP

Substance  use  disorders  are  often  described  as  “chronic  relapsingconditions,”  with  relapse  rates  over  60%.The most commonly available treatments and mutual support groups are12-step.As an alternative to 12-step programs, Relapse Prevention, and othercognitive-behavioral treatments (CBT), focus on responses to high-risksituations, combining skills-training with cognitive interventions.

Is based on the premise that maladaptive drinking and drug use arelearned behaviors.CBT provides a framework around which interventions attempt toidentify situational, social, affective, and cognitive precipitants ofpathological substance use.Once possible causes of maladaptive behavior are identified, anindividual may decide to learn to abstain from alcohol and drugs.

Does CBT really work in substance abuse treatment?You bet!Numerous studies have described the clinical and cost-effectiveness ofCBT in promotion of abstinence and in the reduction of drinkingquantity, frequency, and duration.(Carroll, 1996; Finney & Monahan, 1996; Irvin, Bowers, Dunn, & Wang, 1999; Kadden, 2001; Longabaugh & Morganstern, 1999).

As proposed by Marlatt and colleagues (Lariner, Palmer, & Marlatt, 1999; Marlatt & Gordon, Decreasedprobability ofrelapseHigh f-efficacy positiveoutcomeexperienceInitial use ofsubstanceAbstinenceviolationeffect perceivedeffects ofsubstanceIncreasedprobability ofrelapse

Summarizing this model: if an effective coping strategy is used,then the individual will likely experience an increase in selfefficacy and is less likely to consume the previously desiredsubstance.However, if an ineffective coping strategy is used, then selfefficacy may decline and/or expecting a positive outcomeincreases, leading to an increased likelihood of consumption.

Now  let’s  explore  what  Relapse  Prevention  is But first, what are your thoughts?

Is an intervention that attempts to describe, understand,prevent, and manage relapseFor individuals who have received, or are receiving,treatment for substance use disorders.

Begins with an assessment of triggers.Identify high-risk  situations  (the  client’s  perception  of  risk).A high-risk situation: any situation that poses a threat toone’s  sense  of  perceived  control  (self-efficacy) and increasesthe risk of potential relapse.CBT approaches are then implemented (interpersonal &intrapersonal); self-management strategies.

Overall, the results show that although RP does not result inhigher abstinence rates following treatment,RP does significantly reduce the frequency and intensity ofrelapse  episodes,  helping  people  get  “back  on  track”  more  quicklyif they do fall off the wagon.

Mindfulness and how it may be incorporated in thetreatment of substance use disorders.Your thoughts:What is mindfulness?How is mindfulness beneficial?What does it mean to be mindful?How might mindfulness be beneficial to individualssuffering from substance disorders?

“One  of  the  most  significant  effects  of  regularmeditation practice is the development of mindfulness the capacity to observe the ongoing process ofexperience  without  becoming  ‘attached’  oridentifying with the content of each thought,feeling,  or  image.”As stated in Relapse Prevention (Marlatt & Gordon, 1995).

Mindfulness, as illuminated by the quote by Viktor Frankl (1946)“Between stimulus and response, there is a space. In that spaceis our power to choose our response. In our responselies  our  growth  and  freedom.”Mindfulness practices increase awareness of this space andcreate the opportunity to respond skillfully rather than reactingautomatically and habitually.

Mindfulness  has  been  described  as  “paying  attention  in  a  particularway: on purpose, in the present moment, and non-judgmentally.”Mindfulness may enhance the ability to cope with triggers byinterrupting the previous cycle of automatic substance use behavior.Mindfulness mediation provides heightened awareness and acceptanceof habitual responses without judging, analyzing, or reacting.(Bowen, Witkiewitz, Dillworth, Chawla, Simpson, Ostafin, Larimer, Blume, Parks & Marlatt, 2006; Breslin, Zack, & McMain, 2002; Davis,Flemming, Bonus & Baker, 2007; Marlatt, 2002; Roth & Creasor, 1997; Kabat-Zinn, 1994).

Neurobiological findings support the hypothesis that mediation and/ormindfulness exercises enhance awareness and the cultivation ofalternatives to compulsive behavior (Marlatt, 2002).Mindfulness may aid in the minimization of blame, guilt, and negativethinking that often increase risk of relapse.“In  the  context  of  addictions,  mindfulness  might  mean  becomingaware  of  triggers  for  craving and  choosing  to  do  something  elsethat  might    prevent  craving,  therefore  weakening  the  habitualresponse”  (Groves  &  Farmer,  p.189,  1994).

Mindfulness  can  provide  a  “skillful  means”  of  copingwith urges and cravings that involves observing themwith kindness and flexibility, thus preventing beingconsumed by them.

Please get in a comfortable sitting position“Sitting  Meditation”

Now,  let’s  at  look  at  MBRP  specifically - Research, Goals & Central Components

Until his death in 2011, he was the director ofthe Addictive Behaviors Research Center andProfessional of Psychology at the Universityof Washington.“By moving from aversion to acceptance as a means of coping withcraving, recovery is facilitated on the basis of a new compassionateapproach,  which  is  what  we  hope  to  offer  in  the  MPRP  program”(G. Alan Marlatt).

Integrating over 2 decades of research with CBT based RP with existingmindfulness-based techniques, Marlatt and colleagues developed a“new”  cognitive-behavioral intervention for substance use disorders,called mindfulness-based relapse prevention (MBRP).The goal of this relapse prevention:to develop awareness and acceptance of thoughts, feelings, andsensations through practicing mindfulness.to utilize mindfulness skills as an effective coping strategy in the faceof high-risk situations.

Populations tested:Adults in outpatient treatment for substance abuseAdults with substance use disorders who recentlycompleted intensive inpatient or outpatient treatmentIncarcerated adults with a history of substance abuseIndividuals with substance use disorders of various agesand ethnicities after intensive stabilizationUndergraduate smokers

Teach mindfulness awareness to clients suffering from addiction.Foster increased awareness of triggers and habitual responses.Cultivate the ability to pause and observe the present moment, in orderto make more skillful decisions.Ultimately, working toward freedom from deeply engrained and oftencatastrophic habitual patterns of thought and behavior.

When faced with a trigger for substance use, one can makea mindful choice that decreases the likelihood of relapse.Seeing  the  “big  picture”  provides  a  greater  sense  of  freedomand choice.A mindful approach helps reduce the tendency of the mindto increase negative emotional states by lowering thestigma, shame, blame, and guilt commonly experienced bypeople who struggle with addiction.

The identification of high-risk situations for relapse isa central component of the treatment.Client’s  are  taught  to  observe  pleasant  and  unpleasantsensations, thoughts or feelings, and they are encouragedto accept them without judgment.

A major element of the mindfulness training involvesteaching people to direct their attention to the breathin order to calm and focus the mind.

Challenging  “positive  outcome  expectancies”  andeducating  about  the  “abstinence  violation  effect”  are  amajor focus of the treatment.Maintain focus and awareness on the present moment.Not living toward, or making decisions based on, futureevents (i.e. euphoria, numbing).

IntroductionPart I. Conducting MBRPPart  II.  Facilitator’s  GuideSession 1: Automatic Pilot & RelapseSession 2: Awareness of Triggers & CravingsSession 3: Mindfulness in Daily LifeSession 4: Mindfulness in High-Risk SituationSession 5: Acceptance & Skillful ActionSession 6: Seeing Thoughts as ThoughtsSession 7: Self-Care & Lifestyle BalanceSession 8: Social Support & ContinuingPractice

Style & Structure:Session agendas including practices, worksheets, and handouts.Because  investigation  and  trust  of  one’s  own  experience  isencouraged, the core principles of MBRP:are elicited from participants whenever possibleare explored through experiential practices and inquiry

Inquiry:Sessions begin with experiential exercises, followed by a briefdiscussion  or  “inquiry.”Discussions  centered  on  the  clients’  present experience.Ensure that the inquiry sessions are redirected to involve discussionaround describing the immediate experience in the present moment(i.e. sensations in the body, thoughts, or emotions) versus theinterpretation, analysis, or story about the experience.

The observation of direct experience is the primaryintentionParticipants learn to recognize when they are caught instoriesThey realize that they have the choice to pause andreturn to present experience.

Home Practice:Is assigned each weekEach  session  includes  a  review  of  the  previous  week’s  practices.Encourage, but be careful not to provoke self-blame orjudgment.Discuss struggles with lightness, compassion, and curiosity.

Michael’s  ExperienceWith MBRP

Adapted MBRP to one of our settingsUsed evaluation methods and instrumentsQuestion: Why bother with Evaluation?

Traditional MBRPAftercare program2-2.5 hour group 1x weeklyIdeal group size 6 to 12.Closed groupHome practice essentialHome practice with CDsAssessment battery given at baseline,immediately following the 8-weekintervention period, and 2 & 4 monthspost-intervention.Assessments: The Timeline Followback(TLFB), The Penn Alcohol Craving Scale(PACS), Alcohol & Drug UseConsequences/Short Inventory ofProblems (SIP-AD), The Five FactorMindfulness Questionnaire (FFMQ).Our Study6mo residential drug/alcohol tx1 hour group 1x weeklyGroup size ranged 9 to 11Rolling enrollment groupHome practice encouraged, but unableto monitorClients did not have opportunity/meansto listen to CDs in room.Assessment battery given at baseline,immediately following interventionweeks 4 and 8.Assessments: FFMQ, PACS, and theDrug Avoidance Self-Efficacy Scale(DASES).

FFMQ: Five Facet Mindfulness QuestionnaireA reliable and valid comprehensive instrument for assessingdifferent aspects of mindfulness in community and studentsamples.Subscales (39 items total):ObservingDescribingActing with AwarenessNon-judgingNon-reacting