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Mindfulness-Based Relapse Prevention

for Addictive Behaviors

Holly Cook, LPC-MHSPIntegrative Life Center

Breathing in,I calm my body,

Breathing out,I smile.

Dwelling in the present moment,

I know this is a wonderful moment.

-- Thich Nhat Hanh 2

How Does Relapse Happen?The Cognitive-Behavioral Model

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High-Risk Situation

Effective Coping Response

Increased Self-Efficacy

Decreased Probability of

Relapse

Ineffective Coping

Response

Decreased Self-Efficacy

+Positive Outcome

Expectancies(for the initial effects of the substances)

Lapse(initial use of

the substance)

“Abstinence violation effect”

Increased probability of relapse

Slides: Bowen et al. 2011 Marlatt & Gordon, 1985

Relapse Prevention Therapy

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Ineffective Coping

Response

High Risk Situation

Coping Skills Training

Stress Management,

Relaxation

Education about Immediate vs

Delayed Effects

Decreased Self-Efficacy

+Positive Outcome

Expectancies(for the initial effects of the substances)

Lapse(initial use of

the substance)

“Abstinence Violation Effect”

Self Monitoring, Inventory

of Situations

Contract to Limit Use,

Reminder Card (what to do if you

lapse)

Cognitive RestructuringLapse is a mistake

versus a failure

Marlatt & Gordon, 1985

AA and Meditation

• Step 11: “Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.” – Big Book: p 86 – 87– Twelve Steps and Twelve Traditions:

p 1005

Mindfulness

“Awareness that emerges through paying attention in a particular way: on purpose, in

the present moment, and nonjudgmentally"

(Kabat-Zinn, 1994).

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Mindfulness and Substance Abuse

Paying attention… Greater awareness of triggers and responses, interrupting previously automatic behavior

(Bresslin, et al., 2002)

Nonjudgmentally…

In the presentmoment…Accepting present experience rather than using substances to avoid it.

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Nonjudgmentally… Detach from attributions and “automatic” thoughts that often lead to relapse.

Formal Practices

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Body Scan

Mindful Movement

Sitting Meditation

“Lovingkindness” or “Metta”

Walking Meditation

Mountain Meditation

“Informal” Practices

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Create “SOBER” breathing

space

Mindfulness of daily activities

Riding this wave, rather than succumbing to the urge and being wiped out by it.

Staying with the urge as it grows in intensity, riding it to it’s 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.

Urge Surfing

What is Mindfulness-Based Relapse

Prevention (MBRP)?•An aftercare program integrating

cognitive-behavioral relapse prevention skills and mindfulness meditation.

• Intended for individuals who have completed initial (primary) treatment for substance use disorders. 10

MBRP• Designed to bring practices of mindful

awareness to individuals caught in the addictive trappings of the mind.

• Practices are intended to foster increased awareness of triggers, habitual patterns, and “automatic” reactions that seem to control many of our lives.

• Practices cultivate the ability to pause, observe present experience, and bring awareness to the range of choices before each of us in every moment.

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MBRP Structure• Integrates mindfulness practices with Relapse Prevention• Patterned after MBSR (Kabat-Zinn)and MBCT (Segal et

al.)• 8 weekly 2 hour sessions; daily home practice• Components of MBRP• Formal mindfulness practice• Informal practice• Coping strategies

(Witkiewitz, Marlatt& Walker, 2005; Bowen, Chawla& Marlatt, 2008)

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Intentions of MBRP

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Awareness:From automatic pilot to awareness and choice

Triggers:Awareness of triggers, interrupting habitual interactions

Acceptance:Change one’s relationship with discomfort, decrease need to “fix” the present moment

Balance and Lifestyle:Supporting recovery and maintain a mindfulness practiceSlide: Bowen et al. 2011

Inquiry

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Direct Experien

ce

(pain)

Reaction(judgment,

story) suffering

Reaction

Reaction

Mind’s Process

Inquiry

What was the initial direct experience?

How did the mind and body react to that?

Is this process familiar? Is it related to craving, relapses, recovery, daily life experiences?

Not Personal:This is what minds do. No need for judgment.

Adapted from Segal et al., 2002

Facilitating MBRP • Person-Centered, Rogerian approach• Motivational interviewing style• Authenticity, unconditional acceptance,

empathy, humor, present moment experience

• Embodiment of these qualities• Ongoing personal mindfulness meditation

practice • Spontaneity and creativity

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ResearchSeveral Treatments

• Acceptance and Commitment Therapy

• Dialectical Behavior Therapy

• MBCT• MBSR• Vipassana Meditation

Populations and Disorders

• Stress• Cancer• Psoriasis• Anxiety • Depression• Chronic pain• Psychosis• Trichotillomania• Epilepsy• Borderline PD• Substance Use

16**Few studies of mindfulness and substance use

MBRP Session Themes• Structured protocol with session-by-session

agendas– Session 1: Automatic Pilot and Craving

Awareness,

– Session 2: Triggers, Thoughts, Emotions & Cravings Presence

– Session 3: Mindfulness in Everyday Life– Session 4: Mindfulness in High-Risk Situations

Mindfulness and

– Session 5: Balancing Acceptance & Change relapse

– Session 6: Thoughts are not Facts – Session 7: How can I best take care of myself?

Bigger picture,

– Session 8: Balanced Living and Using What Has Been Learned a balanced life

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Session 1- Automatic Pilot and Craving

• Primary intention of the first session is to introduce some basics of mindfulness practice, to offer an experiential sense of the automatic pilot mode, and to begin discriminating between automatic versus mindful awareness.

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Body Awareness•taking focus of your attention away from mind/thought and anchoring it in the now of being in your body

•being in the body frees vast amounts of consciousness that previously had been trapped in useless and compulsive thinking

•let the breath take you into the body

•inhabit and experience all aspects of body

•imagery may help direct attention initially, but leave it behind as soon as possible, to directly experience being the body don’t just think with your head, but with your entire body

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Session 2: Awareness of Triggers and Cravings

• Focus is on learning to experience triggers, cravings, and thoughts of using without automatically reacting. – Focus on recognizing triggers and what

the reaction feels like in the body, specifically the sensations, thoughts, and emotions that often accompany craving.

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Session 3: Mindfulness in Daily Life

• Learn about the SOBER space as a way to expand the quality of mindfulness from formal sitting or lying down practice to the daily situations we encounter.– Begin the practice of formal sitting

meditation

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“SOBER” Breathing Space

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Stop

Observe

Breath

Expand

Respond

Session 4: Mindfulness in High-Risk Situations

• Focus on being present in situations or with people that have previously been associated with substance use, using mindfulness to learn to experience pressures or urges to use without automatically reaching for a substance.– Identify individual relapse risks and explore

ways to cope with the intensity of the feelings that come up in high-risk situation.

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Session 5: Acceptance and Skillful Action

• Focus is on acceptance of present experience as an important foundation for truly taking care of oneself and seeing more clearly the best action to take.– Practice techniques such as breathing space

and focus on using these in challenging situations.

– This session moves from noticing warning signs and learning to pause to taking skillful action in both high-risk situations and in daily life.

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The Three-Minute Breathing Space

a mini-meditation in which we do three steps:

1. Stepping out of automatic pilot to ask “Where am I?” “What’s going on here?” The aim is to recognize and acknowledge one’s experience at the moment.

2. Bring your attention to the breath, gathering the scattered mind to focus on your breath.

3. Expand your attention to include the sense of breath and body as a whole.

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Session 6: Seeing Thoughts as Thoughts

• Focus is on furthering exploration of and relationship to thinking, with a focus on experiencing thoughts as merely thoughts (even when they feel like the truth).– Look at what role thoughts play in the

relapse cycle, specific thoughts that seem especially problematic, and ways to work more skillfully with these.

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Session 7: Self-Care and Lifestyle Balance

• This session focuses on personal warning signs for relapse and how to best respond when these warning signs arise.– Includes discussion of broader lifestyle

choices, balance, self-compassion, and the importance of including nourishing activities as part of a full, healthy life.

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Session 8: Social Support and Continuing Practice

• Review of skills and practices learned in the course and discuss the importance of building a support system.– Reflect on what has been learned and

share individual plans for incorporating mindfulness practices into daily life.

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All you really need to do

is accept this moment fully.

You are then at ease in the here and now

and at ease with yourself.

-- Eckhart Tolle

The Power of Now

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1. There is a difference between actual pain (emotional and physical) and the suffering that we create in our minds.

2. The suffering is not only optional, but there are many ways to remove it, as it is unnecessary, and a tremendous waste of time, energy and enjoyment of life.

Some basic observations which underlie most of the mindfulness approaches:

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3.3. The way out of this self-created cell of suffering is accepting absolutely everything about ourselves and our lives, by embracing with wakefulness and care our moment-to-moment experience. This does not mean putting up with a truly harmful circumstance with ourselves or others.

4. “It is remarkable how liberating it feels to be able to see that your thoughts are just thoughts and that they are not ‘you’ or ‘reality.’ . . . . the simple act of recognizing your thoughts as thoughts can free you from the distorted reality they often create and allow for more clear-sightedness and a greater sense of manageability in your life”

--Kabat-Zinn.

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