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Mindfulness and Recovery from Addictions

G. Alan Marlatt, Ph.D.

Addictive Behaviors Research Center

University of Washingtonhttp://depts.washington.edu/abrc/

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Introduction

There is evidence that spiritual interventions other than AA, particularly those that are meditation-based, are associated with reduced alcohol and substance use.

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Introduction

Two types of spiritually-based meditation techniques, Transcendental Meditation, and to a lesser extent Vipassana meditation, have been evaluated as treatments for substance abuse, with encouraging results (Alexander et al., 1994; Marlatt, 1994; Marlatt & Kristeller, 1998).

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Examining TM

Marlatt et al. (1984) examined the effects of Transcendental Meditation, progressive relaxation, and bibliotherapy among heavy social drinkers.

They found significant reductions in alcohol consumption during the treatment and follow-up period for the treatment groups compared to the control groups.

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Vipassana Meditation

Vipassana meditation, the intervention addressed in this study, is rooted in traditional Buddhist teachings and has been made available to practitioners around the world by the revered Buddhist teacher, S. N. Goenka (Hart, 1987).

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Vipassana and Addiction

Groves and Farmer (1994) describe Vipassana meditation as a means of overcoming addiction problems:

“In the context of addictions, mindfulness might mean becoming aware of triggers of craving, and choosing to do something else which might ameliorate or prevent craving, so weakening this habitual response…”

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Vipassana in a Correctional Facility

The first Vipassana course in a North American correctional facility was conducted at the North Rehabilitation Facility (NRF) near Seattle, Washington in 1997.

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Participants

305 participants (244 men and 61 women) agreed to participate in the study while incarcerated at NRF.

Participants completed a baseline assessment, and either attended the Vipassana course or participated in Treatment as Usual; then completed a post-course assessment (n=173), and a follow-up 3 months after release (n=87).

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Mean Changes from Baseline to 3-month Follow-up: Peak Weekly

Alcohol Use

Drinks per Peak Week

3 MonthsBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

60

50

40

30

20

10

0

control

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Mean Changes from Baseline to 3-month Follow-up: Alcohol-Related Negative

Consequences

SIP - Alcohol-Related Negative Consequences

3 MonthsBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

1.4

1.2

1.0

.8

.6

.4

control

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Mean Changes from Baseline to 3-month Follow-up: Peak Weekly

Marijuana Use

Peak Weekly Marujuana Use

3 MonthsBaseline

% D

ays

Use

d (

x10

0)

.4

.3

.2

.1

0.0

control

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Mean from Baseline to 3-month Follow-up: Peak Weekly Crack Cocaine

Use

Peak Weekly Crack Use

3 MonthsBaseline

%

Da

ys U

sed

(x

10

0)

.4

.3

.2

.1

0.0

control

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Mean Changes from Baseline to 3-month Follow-up: Locus of Control

DRIE - Drinking Related Locus of Control

3 MonthsBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

.26

.24

.22

.20

.18

.16

.14

control

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Mean Changes from Baseline to 3-month Follow-up: Brief Symptom

Inventory

Brief Symptom Inventory

3 MonthBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

.8

.7

.6

.5

control

vipassana

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Mean Changes from Baseline to 3-month Follow-up: Optimism

LOT - Optimism

3 MonthsBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

2.7

2.6

2.5

2.4

2.3

control

vipassana

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Mean Changes from Baseline to 3-month Follow-up: Psychopathology (Depression)

3-monthsBaseline

Est

ima

ted

Ma

rgin

al M

ea

ns

7.0

6.5

6.0

5.5

5.0

4.5

4.0

3.5

3.0

Treatment group

Control (TAU)

Meditation (TAU+V)

BSI Depression Scale Score

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Discussion

Alcohol and drug addiction are described in the Buddhist literature as problems related to ego-attachment, with an emphasis on “craving” as the major process underlying the motivational dynamic.

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Overview of Mindfulness-Based Relapse

Prevention(MBRP) Session 1 - 8

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MBRP: Delivery

1. MBRP Practitioners adopt a Person-Centered, Rogerian approach

2. MBRP Practitioners use a motivational interviewing style

3. The MBSR (MBRP) Program is characterized by the qualities of authenticity, unconditional acceptance, empathy, humor, present moment experience through which both teacher and student experience the group process; with each being changed as a result (Santorelli)

4. MBRP Practitioners have their own ongoing mindfulness meditation practice similar to what they teach to the group

5. MBRP Practitioners deliver the program according to the MBRP Treatment Manual, but are spontaneous and creative within those parameters

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Session 1: Automatic Pilot and Craving

Theme: Introduce the idea of automatic pilot

Agenda:

Introductions (10)

Rules for confidentiality and privacy (5)

Orientation to the class (10)

Basic Mindfulness Exercise (5-10)

What is mindfulness? (10)

Introduce MBRP (10)

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MBRP Session 1, Continued

Theme: Introduce the idea of automatic pilot

Agenda, continued:

Break (10)

Raisin exercise (15)

Discuss cravings / urges, how we react to them (15)

Body Scan Practice: Feedback & Discussion (15)

Discussion, practice for the week & worksheets (10)

Distribute CDs and Session 1 handouts (2)

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Session 2:Triggers, Thoughts, Emotions & Cravings

Theme: Observe thoughts, see how they affect emotions & behavior

Agenda

Body Scan practice and debrief (15)

Practice Review (15)

Walking Down the Street Exercise / Discussion (30)

Mountain Meditation (10-15)

Discussion of Triggers (25)

Distribute worksheets, discuss outside practice (10)

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Session 3: Mindfulness in Everyday Life

Theme: Increasing awareness during everyday activities

Agenda

“Seeing” or “Hearing” exercise (10) Practice review (15) Sitting Meditation and review (15) Breathing Space and review (10) Kabat-Zinn Video (45) Mindful Walking and review (10) Handouts and discussion of Home Practice (10)

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Session 4:Staying Present and Aware in High-Risk

Situations

Theme: Recognizing temptations to seek and use drugs

Agenda

Five-minute seeing or hearing exercise (5)

Sitting Meditation (20)

Practice review (10)

Define high-risk situations, identifying individual risk scenarios (20)

Breathing Space and review (10)

Mindful stretching/yoga (10)

Handouts and Home Practice (10)

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Session 5:Balancing Acceptance & Change

Theme: Accepting our experience, acting with awareness

Agenda

Sitting Meditation (with Rumi poem) (20)

Practice Review (15)

Breathing Space (brief) (5)

Discuss how techniques are useful in difficult situations (20)

Guided Breathing Space and review (20)

Discussion of Acceptance and Change (20)

Handouts and Home Practice (10-15)

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Session 6:Thoughts are not Facts

Theme: Experiencing thoughts as merely thoughts, even when they feel like the truth

Agenda Sitting meditation and discussion (20) Discussion of metaphors (10) Practice and Worksheet review (10) Relationship between thoughts and relapse (10) Lapse is not relapse and discussion of thoughts as

triggers for relapse (20) Breathing Space focusing on thoughts and discussion (15) Mention preparation for end of course (10) Handouts, CDs and Home Practice (2)

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Session 7: How can I best take care of myself?

Theme: Building Support Networks & Coping Cards

Agenda

Sitting Meditation (20)

Practice review (15)

Where does relapse begin? (25)

Coping Cards (45)

Handouts and Home Practice (5)

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Session 8: Balanced Living and Using What Has

Been Learned

Theme: “Balance” and the ability to manage different aspects of one’s life.

Agenda

Body Scan Practice (15)

Practice review (20)

Balance Sheet Review, Ways to Develop a Support Network, and Barriers to Asking for Help (10)

Looking Back Exercise (20)

Looking Forward (20)

Concluding meditation (15)

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Mindfulness Meditation Outcomes for MBRP group

Percent reporting weekly meditation practice 67% at midcourse 80% at postcourse 65% at the 2-month follow-up

5.4 (1.7) days per week, and 28.9 (17.9) minutes per day across all time points

MBRP participants at postcourse Increases in mindfulness skills (p = .01)

Decreases in experiential avoidance (p = .01)

Decreases in thought suppression (p = .02)

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Alcohol or illicit drug use:MBRP = 1; TAU = 6

χ2(1, N = 87) = 6.10, p = .01

Days use after initial lapse: MBRP = 2.25 (3.2); TAU = 11.6 (22.2) days

Preliminary Results: Substance Use Outcomes Postcourse

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Relapse Risk Factors and Mechanisms of Change at

PostcourseAs compared to TAU, the MBRP group reported:

Significant improvements in emotion regulation skills

f (2, 67) = 3.19, p = .05

Significantly lower craving f (2, 43) = 3.21, p = .05

Significant increases in mindfulness f (2, 37) = 4.38, p = .02

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Moderating Factors

Depression and Craving

Prospectively: MBRP moderated the relation between BDI at midcourse and craving at postcourse. βBDIxTreatment = -.35, p=.01

Cross-sectionally: MBRP moderated the relation between BDI at postcourse and craving at postcourse

βBDIxTreatment = -.50, p<.005

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Moderating Factors, continued

Depression and substance-related consequences

MBRP moderated relation between BDI at post-course and SIP scores at the 2-month follow-up

βBDIxTreatment = -.48, p=.03

Moderated regression analyses (Aiken & West, 1991)

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Results: Depression and Craving

p=.005

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Results: SU-Related Problems and BDI

p=.03

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Mediating Factors

Midcourse scores on the “Nonjudgment” subscale of the FFM and “Nonacceptance” subscale of the DERS mediated the relation between treatment and craving.

The decreases in craving in the MBRP group can be partially explained by changes in judgment and acceptance over the course of treatment.

Baron and Kenny (1986) approach and the difference of coefficients test (MacKinnon et al., 2002)

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Conclusions

Preliminary evidence suggests promise for MBRP for:

Decreasing rates and/or severity of substance use in individuals who have completed IP or IOP programs.

Reducing the effects of relapse risk factors (e.g., negative affect, craving) .

Increasing acceptance and non-judgment.

Decreasing strength of relation between negative affect and craving, and negative affect and problematic substance-related behaviors.

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Mindfulness Meditation: Immediate Effects

Lowers heart rateLowers blood pressure

Activates the soothing relaxation response parasympathetic nervous system (PNS)

Settles “fight or flight” stress responsesympathetic nervous system (SNS)

Activates sensory awareness and control of attention

©2007 Lisa Dale Miller, MFT

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Mindfulness Meditation: Long-term Effects

Dampens reactivity to stress Increases positive emotions through left frontal lobe

activation (Richardson, 2004) Enhanced neural integration and self-regulation from

increased activity in the middle prefrontal cortex Monitors and inhibits limbic firing Greater response reflexivity for pausing before acting Enhanced empathetic resonance “seeing the mind of

the other” Increased insight and self-awareness Modulation of fear though release of GABA into the

lower limbic areas Modulation of morality (Siegel, MD, ©2007)

©2007 Lisa Dale Miller, MFT

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Mindfulness Meditation: Long-term Effects (continued)

Primes brain to enter states of coherent neural activity across broad regions of the brain (Lutz, 2004)

Davidson RJ. (2004) Well-being and affective style: neural substrates and biobehavioural correlates. Philosophical Transactions of the Royal Society (London). 359:1395-411.

Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ. (2004) Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. Proceedings of the National Academy of Sciences. 101:16369-73.

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“It is on the very ground of suffering that we can contemplate well-being.

It is exactly in the muddy waterthat the lotus grows and blooms.”

Thich Nhat Hanh, 2006

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Thank You!