Mindfulness Based Relapse Prevention (MBRP)
Treatment for Addictive Behaviors
Research on Mindfulness and Substance Use
Our team, and many colleagues around the world, have been involved in studies over the past 2 decades on effects of mindfulness and meditation on substance use and relapse. Below are summaries of sample journal articles assessing the efficacy, effectiveness and mechanisms of mindfulness-based approaches to addictions treatment.
Zhang, J., Chen, T., Tan, H., Wu, Q., Chen, L., Yuan, C., Ding, X., Zhang, L., Du, C., Li, J., Lu, E., Wu, Y., Zhao, M., & Du, J. (2022). Mindfulness-based intervention on chinese patients with amphetamine-type stimulant use disorders: An eeg functional connectivity study.
Mindfulness.
Objectives: Amphetamine-type stimulants (ATS) have become the most used drugs in China, and increasing evidence indicates that ATS can induce a series of cognitive deficits, including impacts to functional connectivity (FC). This study investigates FC defects among ATS patients in China, and examines the mechanism and effects of a 10-day abbreviated mindfulness-based relapse prevention (MBRP) program with electroencephalography (EEG). Methods: First, resting-state EEG of 12 healthy non-ATS users and 40 male ATS patients were recorded by using a 64-channel EEG. Then, ATS users were randomly divided into two groups; the control group (n = 20) received treatment as usual, while the intervention group (n = 20) received the MBRP treatment. Resting-state EEG, mindful attention awareness, and self-reported craving, as well as anxiety and depression levels, were tested before and after the intervention. The weighted phase lag index was computed to reflect brain FC. Results: Compared with healthy controls, ATS patients showed lower mean FC at the gamma and high gamma bands during the eye-open state. Besides, the lower EEG pairwise FC in the theta, alpha, beta, low gamma, and high gamma bands were also identified. After MBRP, the intervention group revealed increased FC in the low gamma band during the eye-open state, and significantly higher levels of mindful attention awareness when compared with those of the control group (F = 12.926, p = 0.001). Conclusions: FC is disrupted in people with ATS use disorders, and MBRP can help treat this deficit, specifically regarding low gamma bands.
Massaro, Alessandro F.; Lecuona, Oscar; García-Rubio, Carlos; Castro-Paredes, Antonieta (2022). Bringing mindfulness-based relapse prevention for substance use disorders into individual therapy with spanish population: A feasibility and effectiveness study.
Mindfulness
Objectives: High relapse rates following a substance use disorder (SUD) treatment highlight the importance of effective therapies. The mindfulness-based relapse prevention (MBRP) program stands as a potentially effective group-based treatment. The present study examines the feasibility and effectiveness of an individualized adaptation of the MBRP (I-MBRP).MethodsThe feasibility of the I-MBRP was examined according to eight dimensions: demand, acceptability, implementation, practicality, adaptation, integration, expansion, and effectiveness. A randomized controlled trial (RCT) was designed to examine the I-MBRP program’s effectiveness compared to individual relaxation training (I-RT). A sample of 108 Spanish detoxified outpatients in treatment as usual (TAU) treatment (i.e., relapse prevention program) for SUDs were randomized to a TAU + I-MBRP group (n = 54) or TAU + I-RT group (n = 54). Participants completed self-reports measuring substance use, craving, impulsivity, well-being, and mindfulness at pre-treatment, post-treatment, and follow-up at 2 months and 4 months.ResultsI-MBRP was feasible in all domains. The I-MBRP, compared with the I-RT, significantly reduced the frequency of substance use and craving and improved mindfulness skills at the end of treatment. The benefits were maintained at 4 months.ConclusionsI-MBRP is a feasible program for the SUD treatment as a complementary treatment to TAU interventions and shows potential effects on relapse prevention.
Gibson, B. C., Votaw, V. R., Stein, E. R., Clark, V. P., Claus, E., & Witkiewitz, K. (2022). Transcranial direct current stimulation provides no additional benefit to improvements in self-reported craving following mindfulness-based relapse prevention.
Mindfulness, 13(1), 92–103.
Objectives: Mindfulness-Based Relapse Prevention (MBRP) and transcranial direct current stimulation (tDCS) have each demonstrated efficacy in improving outcomes in those with alcohol use disorder (AUD); however, a recent study that combined MBRP with tDCS found tDCS provided no additional benefit to MBRP for AUD. Differences in treatment adherence between active versus sham tDCS groups may have contributed to this result. The current study examined whether treatment adherence interacted with tDCS condition in predicting post-treatment mindfulness and craving. Methods: This study was a secondary data analysis from a randomized sham-controlled trial comparing MBRP paired with tDCS. Linear regression analyses were conducted examining the interaction between tDCS condition and two measures of treatment adherence (i.e., number of groups attended, number of tDCS administrations) on post-treatment mindfulness and craving. Results: There was no effect of treatment adherence by tDCS condition in predicting mindfulness; however, the interaction between treatment adherence and tDCS condition significantly predicted post-treatment craving. There was a significant negative association between treatment adherence and post-treatment craving in the sham group, but there was no association in the active tDCS group. Conclusions: MBRP coupled with sham stimulation led to significant reductions in self-reported craving when patients attended more sessions and received a greater number of sham tDCS administrations, while no relationship was observed between treatment adherence and craving among those who received active tDCS. This result provides tentative evidence that, rather than improve the effects of MBRP on craving, this active tDCS protocol provides no additional benefit to MBRP in reducing craving.
Zullig, K. J., Lander, L. R., Tuscano, M., Garland, M., Hobbs, G. R., & Faulkenberry, L. (2021). Testing mindfulness-based relapse prevention with medications for opioid use disorder among adults in outpatient therapy: A quasi-experimental study.
Mindfulness, 12(12), 3036–3046.
Objectives: This study aimed to explore the effectiveness of mindfulness-based relapse prevention (MBRP) with individuals receiving medication for opioid use disorder (MOUD) in a naturalistic, open-ended outpatient group treatment setting. Methods: Eighty participants (mean age 36.3) who had at least 90 consecutive days substance free self-selected into treatment (MBRP, n = 35) or comparison groups (treatment as usual, TAU, n = 45). Outcomes tracked included treatment retention and relapse, and self-reported craving, anxiety, depression, and mindfulness at baseline, 12 weeks, 24 weeks, and 36 weeks post-recruitment. MBRP group participants attended biweekly 60-min sessions for 24 weeks. A linear mixed model analysis of variance determined the significance of the MBRP intervention on changes in craving, anxiety, depression, and mindfulness. Results: No significant differences in sex, education level, insurance status, relationship status, or employment status were detected at baseline between groups. The 36-week retention (74%, MBRP/MOUD; 71%, TAU/MOUD) and relapse rates (43%, MBRP/MOUD; 47%, TAU/MOUD) were similar for the groups. There were only four relapses on opioids. Significant reductions (p < .05) were observed in the MBRP/MOUD group for craving, anxiety, and depression in addition to significant increases in mindfulness compared to those in TAU/MOUD. Conclusions: Although state and federal resources are available to expand MOUD, no standard of behavioral therapy has been established as most complimentary to MOUD. The current study results suggest MBRP can be implemented as an outpatient therapy for individuals in MOUD.
Barros, V. V., Opaleye, E. S., Demarzo, M., Curado, D. F., Bowen, S., Hachul, H., & Noto, A. R. (2021). Effects of mindfulness-based relapse prevention on the chronic use of hypnotics in treatment-seeking women with insomnia: A randomized controlled trial.
International Journal of Behavioral Medicine.
Background: Hypnotics are one of the most frequently prescribed drugs worldwide, especially for women, and their chronic use may lead to tolerance, dosage escalation, dependence, withdrawal syndrome, and cognitive impairments, representing a significant public health problem. Consistent evidence from previous studies shows benefits of mindfulness-based interventions (MBIs) for substance use disorders (SUD) and insomnia. However, to date, there is a lack of research about effects of MBIs on reduction/cessation of chronic hypnotic use among women with insomnia. Method: The present randomized trial evaluated the efficacy of the 8-week group-delivered mindfulness-based relapse prevention (MBRP) program in an intervention group (IG, n = 34) compared with weekly phone monitoring only in the control group (CG, n = 36) in reducing hypnotic use and insomnia severity over a 6-month follow-up period. Results: There were significant differences between groups at baseline regarding hypnotic use but not insomnia. Group effects on hypnotic use were found immediately after the intervention (bT1 = 2.01, p < 0.001) and at the 2-month follow-up (bT2 = 2.21, p < 0.001), favoring the IG. The IG also had a greater reduction from baseline levels than the control group in insomnia severity at the 4-month (bT3 = 0.21, p = 0.045) and 6-month (bT4 = 0.32, p = 0.002) follow-ups. Conclusions: The findings provide preliminary evidence of benefits of MBRP for reducing insomnia severity and potentially chronic hypnotic use. However, IG effects on chronic hypnotic use may have resulted from IG and control group differences in chronic hypnotic use at baseline.
Dingle, T., & Bowen, S. (2021). Evaluating substance use treatment efficacy for younger and older adults.
Addictive Behaviors, 112.
The purpose of this study was to examine the differential efficacy of aftercare substance use treatments for younger (below 40, n = 107) versus older (40+, n = 114) adults (N = 221), using data from a randomized controlled trial in a community-based substance abuse treatment center. The younger adult sample had a mean age of 28.9 while the older adult sample had a mean age of 48.1. Primary outcomes were rates of abstinence and percent use days at 1-year follow-up. Outcomes were compared between standard cognitive behavioral relapse prevention (RP), Mindfulness-Based Relapse Prevention (MBRP), and 12-step-based treatment as usual (TAU). Results showed significant differences by treatment in the older, but not in younger, subsample of participants. Specifically, the older participants in MBRP had significantly higher abstinence rates compared with those in TAU. Further, the older individuals in MBRP had a significantly lower percent of days on which they used compared with those in TAU and RP. Overall, findings suggest that age group may impact aftercare treatment substance use outcomes.
Holas, P., Draps, M., Kowalewska, E., Lewczuk, K., & Gola, M. (2020). A pilot study of mindfulness-based relapse prevention for compulsive sexual behaviour disorder.
Journal of Behavioral Addictions, 9(4), 1088–1092.
Background and aims: Compulsive sexual behaviour disorder (CSBD) is a medical condition that can impair social and occupational functioning and lead to severe distress. To date, treatment effectiveness studies of CSBD are under-developed; typically, treatment for CSBD is based on guidelines for substance or other behavioural addictions. Mindfulness-based relapse prevention (MBRP) is an evidence-based treatment for substance addiction aimed at, among other things, reducing craving and negative affect—i.e. processes that are implicated in the maintenance of problematic sexual behaviours. However, to our knowledge no prior research has been published evaluating mindfulness-based intervention (MBI) in the treatment of CSBD, except two clinical case reports. Therefore, the aim of the current pilot study was to examine whether MBRP can lead to clinical improvement in CSBD. Methods: Participants were 13 adult males with a diagnosis of CSBD. Before and after the eight-week MBRP intervention, participants completed a booklet of questionnaires including measurements of porn viewing, masturbation and emotional distress. Results: As expected, we found that after MBRP participants spent significantly less time engaging in problematic pornography use and exhibited a decrease in anxiety, depression and obsessive-compulsive (OC) symptoms. Discussion and Conclusions: The findings indicate that MBRP could be beneficial for CSBD individuals. Further clinical effectiveness studies with bigger sample sizes, delayed post-training measurements and randomised control trial design are warranted. In conclusion, MBRP leads to a decrease in time spent watching porn and a decrease in emotional distress in CSBD patients.
Roos, C., Bowen, S., & Witkiewitz, K. (2020).
Approach coping and substance use outcomes following mindfulness-based relapse prevention among individuals with negative affect symptomatology.
Mindfulness, 11(10), 2397–2410.
Objectives: Mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs) appears to be particularly effective among individuals with high levels of co-occurring affective symptoms. We sought to understand whether changes in approach and avoidance coping may explain the effects of MBRP among this subpopulation. Methods: The sample included 286 individuals with SUDs randomized to MBRP, relapse prevention (RP), or treatment as usual (TAU) as an aftercare treatment. We conducted conditional indirect effect models with treatment condition as the predictor, baseline affective symptoms as the moderator, changes in approach and avoidance coping over time from baseline through 6 months post-treatment as mediators, and substance use and substance-related problems at 12 months post-treatment as the outcome. Affective symptomatology at baseline was modeled as a latent factor indicated by depression, anxiety, and PTSD symptoms. Change in approach and avoidance coping were modeled using latent growth curve analyses. Results: We found significant conditional indirect effects of MBRP, such that the interaction of MBRP vs. TAU by affective symptoms predicted increases in approach coping, which in turn predicted fewer heavy drinking days and substance-related problems at month 12. Follow-up analyses showed that increases in approach coping mediated the therapeutic effect of MBRP on these outcomes among those with high, but not low or moderate, affective symptoms. We did not find indirect or conditional indirect effects when comparing RP with TAU, or when avoidance coping was the mediator. Conclusions: The pronounced therapeutic effects of MBRP among individuals with SUD and relatively higher negative affective symptoms may be due to increases in approach coping over time.
Weiss, F., Aslan, A., Zhang, J., Gerchen, M. F., Kiefer, F., & Kirsch, P. (2020).
Using mind control to modify cue-reactivity in AUD: The impact of mindfulness-based relapse prevention on real-time fMRI neurofeedback to modify cue-reactivity in alcohol use disorder: A randomized controlled trial.
BMC Psychiatry, 20.
Background: Alcohol Use Disorder is a severe mental disorder affecting the individuals concerned, their family and friends and society as a whole. Despite its high prevalence, novel treatment options remain rather limited. Two innovative interventions used for treating severe disorders are the use of real-time functional magnetic resonance imaging neurofeedback that targets brain regions related to the disorder, and mindfulness-based treatments. In the context of the TRR SFB 265 C04 'Mindfulness-based relapse prevention as an addition to rtfMRI NFB intervention for patients with Alcohol Use Disorder (MiND)' study, both interventions will be combined to a state-of-the art intervention that will use mindfulness-based relapse prevention to improve the efficacy of a real-time neurofeedback intervention targeting the ventral striatum, which is a brain region centrally involved in cue-reactivity to alcohol-related stimuli. Methods/design: After inclusion, N = 88 patients will be randomly assigned to one of four groups. Two of those groups will receive mindfulness-based relapse prevention. All groups will receive two fMRI sessions and three real-time neurofeedback sessions in a double-blind manner and will regulate either the ventral striatum or the auditory cortex as a control region. Two groups will additionally receive five sessions of mindfulness-based relapse prevention prior to the neurofeedback intervention. After the last fMRI session, the participants will be followed-up monthly for a period of 3 months for an assessment of the relapse rate and clinical effects of the intervention. Discussion: The results of this study will give further insights into the efficacy of real-time functional magnetic resonance imaging neurofeedback interventions for the treatment of Alcohol Use Disorder. Additionally, the study will provide further insight on neurobiological changes in the brain caused by the neurofeedback intervention as well as by the mindfulness-based relapse prevention. The outcome might be useful to develop new treatment approaches targeting mechanisms of Alcohol Use Disorder with the goal to reduce relapse rates after discharge from the hospital.
Brown, D. R., Jackson, T. C. J., Claus, E. D., Votaw, V. R., Stein, E. R., Robinson, C. S. H., Wilson, A. D., Brandt, E., Fratzke, V., Clark, V. P., & Witkiewitz, K. (2020).
Decreases in the late positive potential to alcohol images among alcohol treatment seekers following mindfulness-based relapse prevention.
Alcohol and Alcoholism, 55(1), 78–85.
Aim: Heightened craving among individuals with alcohol use disorder (AUD) has been attributed to a hypersensitivity to alcohol cues in attentional brain networks. Active mindfulness training has been shown to help improve attentional control. Here, we examined alcohol cue-related hypersensitivity among individuals with AUD who received rolling group mindfulness-based relapse prevention (MBRP) in combination with transcranial direct current stimulation (tDCS), over right inferior frontal gyrus. Methods: Participants (n = 68) viewed a series of emotionally negative, emotionally neutral and alcohol-related images. Following image presentation, participants were asked to rate their level of craving for the alcohol cues, and their level of negative affect evoked by neutral and negative cues. During the task, electroencephalogram (EEG) was recorded to capture an event-related component shown to relate to emotionally salient stimuli: the late positive potential (LPP). Participants who completed a follow-up EEG (n = 37) performed the task a second time after up to eight sessions of MBRP coupled with active or sham tDCS. Results: We found that both craving ratings and the LPP significantly decreased in response to alcohol cues from pre- to post-treatment, but not for other image cues. The magnitude of alcohol image craving reductions was associated with the number of MBRP group sessions attended. Active tDCS was not associated with craving ratings, but it was associated with greater LPP amplitudes across image types. Conclusions: Taken together, these results suggest that disruption of alcohol-cue hypersensitivity in people with AUD may be a target mechanism of MBRP.
Vowles, K. E., Witkiewitz, K., Cusack, K. J., Gilliam, W. P., Cardon, K. E., Bowen, S., Edwards, K. A., McEntee, M. L., & Bailey, R. W. (2019).
Integrated behavioral treatment for veterans with co-morbid chronic pain and hazardous opioid use: A randomized controlled pilot trial.
The Journal of Pain.
Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PERSPECTIVE: Opioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.
Dakwar, E., Nunes, E. V., Hart, C. L., Foltin, R. W., Mathew, S. J., Carpenter, K. M., “Jean” Choi, C. J., Basaraba, C. N., Pavlicova, M., & Levin, F. R. (2019).
A single ketamine infusion combined with mindfulness-based behavioral modification to treat cocaine dependence: A randomized clinical trial.
The American Journal of Psychiatry, 176(11), 923–930.
Objective: Research has suggested that subanesthetic doses of ketamine may work to improve cocaine-related vulnerabilities and facilitate efforts at behavioral modification. The purpose of this trial was to test whether a single ketamine infusion improved treatment outcomes in cocaine-dependent adults engaged in mindfulness-based relapse prevention. Methods: Fifty-five cocaine-dependent individuals were randomly assigned to receive a 40-minute intravenous infusion of ketamine (0.5 mg/kg) or midazolam (the control condition) during a 5-day inpatient stay, during which they also initiated a 5-week course of mindfulness-based relapse prevention. Cocaine use was assessed through self-report and urine toxicology. The primary outcomes were end-of study abstinence and time to relapse (defined as first use or dropout). Results: Overall, 48.2% of individuals in the ketamine group maintained abstinence over the last 2 weeks of the trial, compared with 10.7% in the midazolam group (intent-to treat analysis). The ketamine group was 53% less likely (hazard ratio = 0.47; 95% CI = 0.24, 0.92) to relapse (dropout or use cocaine) compared with the midazolam group, and craving scores were 58.1% lower in the ketamine group throughout the trial (95% CI = 18.6, 78.6); both differences were statistically significant. Infusions were well tolerated, and no participants were removed from the study as a result of adverse events. Conclusions: A single ketamine infusion improved a range of important treatment outcomes in cocaine-dependent adults engaged in mindfulness-based behavioral modification, including promoting abstinence, diminishing craving, and reducing risk of relapse.
McClintock, A. S., Goldberg, S. B., Coe, C. L., & Zgierska, A. E. (2019).
Mindfulness practice predicts interleukin-6 responses to a mindfulness-based alcohol relapse prevention intervention.
Journal of Substance Abuse Treatment, 105, 57–63.
Chronic alcohol misuse can result in chronically elevated interleukin (IL)-6, a pro-inflammatory cytokine, in the bloodstream. Given that Mindfulness-Based Relapse Prevention (MBRP) has been shown to reduce alcohol misuse, MBRP might also be effective in reducing IL-6 concentrations. Past research has found, however, that IL-6 does not respond consistently to mindfulness-based interventions. Building on prior studies, we examined whether between-person variability in engagement with mindfulness training (i.e., formal mindfulness practice time) is associated with between-person variability in changes in serum IL-6, using data from a randomized controlled trial evaluating MBRP for Alcohol Dependence (MBRP-A). Participants were 72 alcohol dependent adults (mean age = 43.4 years, 63.9% male, 93.1% White) who received a minimum dose (i.e., at least four sessions) of MBRP-A either at the start of the trial (n = 46) or after a 26-week delay (n = 26). IL-6 concentrations did not significantly change from pre- to post-intervention for the full sample. Nevertheless, greater mindfulness practice time was significantly associated with reduced IL-6 levels (r = −0.27). The association between practice time and IL-6 changes remained significant when controlling for intervention timing (i.e., immediate or after the 26-week delay), demographic characteristics, and changes in mindful awareness, obsessive-compulsive drinking, and depressive symptoms. The association between practice time and IL-6 changes was not significant when omitting the minimum treatment dose requirement. Overall, results suggest that the level of engagement in mindfulness training may predict changes in the inflammatory pathophysiology in adults with alcohol dependence.
Davis, J. P., Barr, N., Dworkin, E. R., Dumas, T. M., Berey, B., DiGuiseppi, G., & Cahn, B. R. (2019). Effect of mindfulness-based relapse prevention on impulsivity trajectories among young adults in residential substance use disorder treatment.
Mindfulness, 10(10), 1997–2009.
Objectives: Impulsivity has been identified as an important construct in predicting the initiation and maintenance of substance use among at-risk populations. Interventions emphasizing mindfulness strategies appear particularly promising in reducing substance use and marking change in various aspects of impulsivity. Methods: The current study used a rolling group mindfulness-based relapse prevention (MBRP) intervention for young adults in residential substance use disorder treatment. We examined change in impulsivity facets measured by the S-UPPS for youth randomly assigned to MBRP (n = 45) versus those assigned to treatment as usual plus 12 step/self-help (n = 34). We also examined how change in impulsivity mediated changes in substance use post-treatment. Results: In general, results indicated that MBRP is effective at reducing facets of trait impulsivity in treatment-seeking individuals with SUDs. Only positive and negative urgency mediated the relation between treatment assignment and substance use. Conclusions: MBRP is a viable and useful intervention for young adults in residential treatment for substance use disorders and can aid in marked change in facets of impulsivity. Both positive and negative urgency were significant mechanisms of change in reducing substance use following treatment. Results are discussed focused on the utility ofMRBP as a clinical intervention for atrisk, marginalized, and young adults.
Roos, C. R., Stein, E., Bowen, S., & Witkiewitz, K. (2019).
Individual gender and group gender composition as predictors of differential benefit from mindfulness-based relapse prevention for substance use disorders.
Mindfulness, 10(8), 1560–1567.
Objectives: Mindfulness-based relapse prevention (MBRP) is an effective group-based aftercare treatment for substance use disorders (SUDs), yet few studies have examined moderators of MBRP efficacy. This secondary data analysis evaluated individual gender and group gender composition (e.g., proportion of women relative to men in each therapy group) as treatment moderators of MBRP. Methods: The analysis sample included 186 individuals with SUDs randomized to MBRP or relapse prevention (RP) as an aftercare treatment. Outcomes included number of heavy drinking days and drug use days at the 12-month follow-up. Results: There were no treatment moderation effects for models with heavy drinking days as the outcome (all ps > .05). Group gender composition, but not individual gender, moderated the effect of treatment condition on drug use days (p < .01). Individuals who received MBRP had significantly fewer drug use days at 12 months than those who received RP, but only among individuals in therapy groups comprising one-third or more women (p < 0.0001). Specifically, all women and men who received MBRP in groups with one third or more women were abstinent from drugs at month 12, whereas those in RP groups with one third or more women had an average of about eight drug use days at month 12 (corresponding to a large between-treatment condition effect size). Conclusions: Group-based MBRP may be more efficacious than group-based RP, particularly when women compose at least one third of the therapy group. Further research is warranted on gender and group gender composition as moderators of MBRP.
Abed, M., & Ansari Shahidi, M. (2019).
Mindfulness-based relapse prevention to reduce lapse and craving.
Journal of Substance Use.
Background: Lapse and craving are common phenomena observed in patients undergoing addiction treatment programs such as Methadone Maintenance Therapy (MMT). Therefore, the purpose of the present study was to find whether Mindfulness-Based Relapse Prevention (MBRP) can help reduce lapse and craving in such patients. Methods: a total of 55 Iranian adult males undergoing MMT were selected through multistage random sampling and were randomly assigned to experimental (n = 26) and control (n = 29) groups. The experimental group received eight sessions of MBRP while the control group received no intervention. To collect data, the Heroin Craving Questionnaire (HCQ) was distributed among both groups and they were required to take the urine drug tests in the three follow-up phases of the study to find the possible instances of lapse. Results: The results revealed that three out of the five subscales of HCQ, i.e., intention to use, anticipation of relief from withdrawal and desire to use significantly decreased due to MBRP. Moreover, the results of urine drug tests revealed fewer lapse percentages in the experimental group. Conclusions: it is recommended to complement the common substance treatment programs with those that enhance awareness and acceptance and reduce the desire to use the substance.
Roos, C. R., Kirouac, M., Stein, E., Wilson, A. D., Bowen, S., & Witkiewitz, K. (2019).
An open trial of rolling admission mindfulness-based relapse prevention (rolling MBRP): Feasibility, acceptability, dose-response relations, and mechanisms.
Mindfulness, 10(6), 1062–1073.
Mindfulness-based relapse prevention (MBRP) is an effective treatment for substance use disorders (SUD). However, evidence is primarily based on studies of closed groups, and few studies support flexible formats of MBRP, such as rolling groups. This non-randomized, open trial evaluated the feasibility, acceptability, dose-response relations, and mechanisms of rolling admission MBRP ('Rolling MBRP') offered as part of short-term residential treatment for SUD. Rolling MBRP was developed prior to the trial through an iterative process over several years. Participants included 109 adults (46% female, 74.3% racial/ethnic minorities, mean age = 36.40). Rolling MBRP was offered to all patients in the program 2×/week, and attendance was tracked. Outcomes were craving, self-efficacy, mental health, mindfulness, and self-compassion at discharge. Self-reported out-of-session mindfulness practice was examined as a mediator of attendance-outcome relations. Analyses involved multiple regression and mediation models. Feasibility was demonstrated by good attendance rates. Acceptability was demonstrated by high engagement in mindfulness practice and high satisfaction ratings. Total sessions attended did not predict outcomes at discharge. However, attending 2+ sessions (versus one or none) significantly predicted better mental health and higher mindfulness at discharge, and these effects were mediated by informal and formal mindfulness practice. Total sessions attended had significant indirect effects on craving, self-compassion, mindfulness, and mental health, via mindfulness practice. Results support the feasibility and acceptability of Rolling MBRP and suggest mindfulness practice may be a key mechanism driving effects of MBRP on other key mechanisms during the recovery process, such as decreased craving and improved mental health.
Witkiewitz, K., Stein, E. R., Votaw, V. R., Wilson, A. D., Roos, C. R., Gallegos, S. J., Clark, V. P., & Claus, E. D. (2019).
Mindfulness‐based relapse prevention and transcranial direct current stimulation to reduce heavy drinking: A double‐blind sham‐controlled randomized trial.
Alcoholism: Clinical and Experimental Research, 43(6), 1296–1307.
Background: Mindfulness‐based relapse prevention (MBRP) and transcranial direct current stimulation (tDCS) have independently shown benefits for treating alcohol use disorder (AUD). Recent work suggests tDCS may enhance mindfulness. The combination of MBRP and tDCS may provide synergistic benefits and may target both behavioral and neurobiological dysfunctions in AUD. The goal of this double‐blind sham‐controlled randomized trial was to examine the efficacy of a rolling group MBRP treatment combined with tDCS among individuals interested in reducing their drinking. Methods: Individuals who were interested in reducing their alcohol use (n = 84; 40.5% female; mean age = 52.3; 98.9% with current AUD) were randomized to receive active (2.0 milliamps) or sham (0.0 milliamps) anodal tDCS (5 cm × 3 cm electrode) of the right inferior frontal gyrus with the 5 cm × 3 cm cathodal electrode applied to the left upper arm, combined with 8 weeks of outpatient MBRP rolling group treatment. Assessments were conducted at baseline, posttreatment, and 2 months following treatment. The primary outcome was drinks per drinking day, and secondary outcomes were percent heavy drinking days, self‐reported craving, alcohol cue reactivity in an alcohol cue task, and response inhibition in a stop signal reaction time task. Results: Results indicated significant reductions in drinks per drinking day over time, B(SE) = −0.535 (0.16), p = 0.001, and a significant dose effect for number of groups attended, B(SE) = −0.259 (0.11), p = 0.01. There were also significant effects of time and dose for number of groups attended on secondary outcomes of percent heavy drinking days and alcohol cue reactivity. There were no effects of active versus sham tDCS on primary or secondary outcomes. Conclusions: Findings from the current study provide initial support for the effectiveness of rolling group MBRP as an outpatient treatment for drinking reduction. The current study did not find additive effects of this tDCS protocol in enhancing MBRP among individuals with drinking reduction goals.
Zgierska, A. E., Burzinski, C. A., Mundt, M. P., McClintock, A. S., Cox, J., Coe, C. L., Miller, M. M., & Fleming, M. F. (2019).
Mindfulness-based relapse prevention for alcohol dependence: Findings from a randomized controlled trial.
Journal of Substance Abuse Treatment, 100, 8–17.
Objectives: To assess the effects of mindfulness-based relapse prevention for alcohol dependence (MBRP-A) intervention on drinking and related consequences. Methods: 123 alcohol-dependent adults in early recovery, recruited from outpatient treatment programs, were randomly assigned to MBRP-A (intervention plus usual-care; N = 64) or Control (usual-care-alone; N = 59) group. MBRP-A consisted of eight-weekly sessions and home practice. Outcomes were assessed at baseline, 8 weeks and 26 weeks (18 weeks post-intervention), and compared between groups using repeated measures analysis. Results: Outcome analysis included 112 participants (57 MBRP-A; 55 Control) who provided follow-up data. Participants were 41.0 ± 12.2 years old, 56.2% male, and 91% white. Prior to 'quit date,' they reported drinking on 59.4 ± 34.8% (averaging 6.1 ± 5.0 drinks/day) and heavy drinking (HD) on 50.4 ± 35.5% of days. Their drinking reduced after the 'quit date' (before enrollment) to 0.4 ± 1.7% (HD: 0.1 ± 0.7%) of days. At 26 weeks, the MBRP-A and control groups reported any drinking on 11.5 ± 22.5% and 5.9 ± 11.6% of days and HD on 4.5 ± 9.3% and 3.2 ± 8.7% of days, respectively, without between-group differences (ps ≥ 0.05) in drinking or related consequences during the follow-up period. Three MBRP-A participants reported 'relapse,' defined as three-consecutive HD days, during the study. Subgroup analysis indicated that greater adherence to session attendance and weekly home practice minutes were associated with improved outcomes. Conclusions: MBRP-A as an adjunct to usual-care did not show to improve outcomes in alcohol-dependent adults in early recovery compared to usual-care-alone; a return to drinking and relapse to HD were rare in both groups. However, greater adherence to MBRP-A intervention may improve long-term drinking-related outcomes.
Lyons, T., Womack, V. Y., Cantrell, W. D., & Kenemore, T. (2019).
Mindfulness-based relapse prevention in a jail drug treatment program.
Substance Use & Misuse, 54(1), 57–64.
Background: More than half of prisoners in the United States are estimated to suffer from a substance use disorder. Mindfulness involves attention to the present moment, and nonjudgmental acceptance of sensations, thoughts, and emotional states. Mindfulness-based relapse prevention (MBRP) following substance use disorder treatment has been shown to reduce substance use. Objective: We sought to adapt and test MBRP for a jail substance use disorder treatment setting. Methods: We enrolled successive cohorts of incarcerated men participating in a drug treatment program in a large urban jail (n = 189) into six weekly sessions of either MBRP or an comparison communication skills intervention, between 2013 and 2015. MBRP was delivered by a culturally competent African–American trainer. Pre- and post-test measures included mindfulness, anxiety, posttraumatic stress disorder (PTSD), and drug craving. Results: At baseline, measures of mindfulness were significantly inversely correlated with anxiety, PTSD symptoms and drug cravings. Anxiety, PTSD symptoms and cravings declined significantly in both treatment arms, and mindfulness increased. Comparison of the two study arms using maximum likelihood estimation suggested a small but significantly greater increase in mindfulness in the treatment arm. Conclusions/Importance: An attention control trial of a mindfulness intervention, delivered by a culturally competent trainer, is feasible in a jail setting.
Vadivale, A. M., & Sathiyaseelan, A. (2019).
Mindfulness-based relapse prevention—A meta-analysis.
Cogent Psychology, 6.
Addiction is of varied types and over the years the focus has not only been on the growing issues of addiction but also on how to prevent relapse on recovering clients. According to Buddhist teaching craving is the cause of suffering and suffering festers itself due to attachment. Once an individual is enlightened he will be able to find a path that ceases such suffering. Mindfulness helps bring about such enlightenment through being conscious and reflective of every moment’s experience. Mindfulness does not stop at being aware alone but extends its teaching to accepting such experiences as they are and letting go. Relapse prevention has long been researched on and new therapies developed to facilitate the same. This conceptual paper looks at how Mindfulness-based relapse prevention therapy works to prevent relapses. The paper focuses on understanding each of the eight-week therapy process and how it progresses in changing thoughts and reducing stress. The paper shows how Mindfulness-based relapse prevention helps clients understand their craving and how to change thoughts in order to deal with a craving thus preventing relapse.
Davis, J. P., Berry, D., Dumas, T. M., Ritter, E., Smith, D. C., Menard, C., & Roberts, B. W. (2018). Substance use outcomes for mindfulness based relapse prevention are partially mediated by reductions in stress: Results from a randomized trial.
Journal of Substance Abuse Treatment, 91, 37–48.
Objective: Mindfulness based relapse prevention (MBRP) has demonstrated efficacy in alleviating substance use, stress, and craving but how MBRP works for marginalized young adults has not been investigated. The current study used a novel rolling group format for MBRP as an additional intervention for young adults in residential treatment. We tested the hypothesis that MBRP (plus Treatment as usual (TAU)) would reduce stress, craving, and substance use among young adults in residential treatment relative to treatment-as-usual plus 12-step/self-help meetings (TAU only). Further, we examined whether reduced stress during treatment was a potential mechanism of change operating in MBRP. Method: Seventy-nine young adults (Mage = 25.3, SD = 2.7;35 % female) were randomly assigned to MBRP (n = 44) or TAU (n = 35). Follow-up assessments were conducted bi-monthly for self-reported measures of stress, craving, and substance use. Results: At treatment completion young adults receiving MBRP had lower substance use (d = −0.58, [−0.91, −0.26]), craving (d = −0.58, [−1.0, −0.14]), and stress (d = −0.77 [−1.2, −0.30]) relative to TAU condition. Reduced stress during treatment partially mediated observed outcome differences between MBRP and TAU for substance use (βindirect = −0.45 [−0.79, −0.11]). Conclusions: Results suggest that MBRP is a useful and appropriate intervention for marginalized young adults. Further, our results suggest that the effects of MBRP on long-term substance use outcomes may be partially explained by reduced stress.
Greenfield, B. L., Roos, C., Hagler, K. J., Stein, E., Bowen, S., & Witkiewitz, K. A. (2018).
Race/ethnicity and racial group composition moderate the effectiveness of mindfulness-based relapse prevention for substance use disorder.
Addictive Behaviors, 81, 96–103.
Introduction: Mindfulness-based relapse prevention has shown promise as a treatment for substance use disorder but its efficacy according to racial/ethnic minority status and group composition is unknown. Method: This is a secondary analysis of existing data (Bowen et al., 2014) testing individual race/ethnicity and racial/ethnic group composition as moderators of mindfulness-based relapse prevention (MBRP). Participants (N = 191; 29% female; 47% racial/ethnic minority; mean age = 39) with substance use disorder were randomized to MBRP or relapse prevention (RP). Outcomes were heavy drinking days (HDD) and drug use days (DUD) 12 months after treatment completion. Negative binominal regression models were conducted. Results: Analyses accounted for drug of choice. Individual race/ethnicity was a significant moderator of substance use outcomes. White participants had lower HDD in MBRP than RP (IRR = 0, 95% CI: 0,0), whereas for minority participants, there was no treatment difference in HDD. Conversely, minorities had lower DUD in MBRP than RP (IRR = 0.03, 95% CI: 0.01, 0.10), whereas for whites there was no treatment difference in DUD. Group racial/ethnic composition was a significant moderator. Participants in groups with more than half whites had lower HDD in MBRP than RP (IRR = 0.01, 95% CI: 0, 0.09), whereas for participants in groups with more than half minorities there was no treatment difference in HDD. Exploratory analyses suggested MBRP resulted in better outcomes than RP when individual race/ethnic status was reflected in the group race/ethnicity (i.e., whites in groups with more than half whites or minorities in groups with more than half minorities). Conclusions: Among whites, MBRP appears to be more effective than RP in preventing heavy drinking relapse. However, among racial/ethnic minorities, MBRP appears to more effective than RP in preventing drug use relapse. This suggests that the interaction between individual race/ethnicity and group composition may influence primary outcomes.
Zullig, K. J., Lander, L. R., Sloan, S., Brumage, M. R., Hobbs, G. R., & Faulkenberry, L. (2018). Mindfulness-based relapse prevention with individuals receiving medication-assisted outpatient treatment for opioid use disorder.
Mindfulness, 9(2), 423–429.
The effectiveness of Mindfulness-Based Relapse Prevention (MBRP) in a naturalistic outpatient setting for those in recovery from opioid use disorder receiving medication-assisted treatment is unknown. The purpose of this pilot study was to test the effectiveness of MBRP in a naturalistic outpatient setting for those in recovery from opioid use disorder. Participants were recruited from a comprehensive opioid addiction treatment program who were in the intermediate stage of medication-assisted treatment (MAT) (at least 90 consecutive days substance free). Participants who completed the MBRP intervention served as their own controls [i.e., each participant participated in 8 weeks of treatment-as-usual (TAU) with MAT before the 8-week MBRP was initiated]. Pre/post-data analysis with study completers and non-completers (i.e., participants who did not complete the mindfulness intervention, but remained in TAU) was performed. Thirty-two participants were recruited (mean age, 36; range 21–47). No significant differences in baseline demographics were detected between the completers and non-completers. Analyses suggest significant reductions (p < 0.05) were observed in reported depression in completers compared to non-completers, and significant increases were observed in reported mindfulness (p < 0.05) in completers among those completed the MBRP intervention study phase. Trends in the hypothesized direction were also observed for anxiety (p = 0.17), but not for craving (p = 0.43). Although significant attrition was experienced, results suggest MBRP can be incorporated into a MAT in an outpatient setting, and significant positive findings were observed despite the small sample size. An unexpected finding was that patients in MAT still reported clinically significant levels of anxiety and depression that were not reduced in TAU.
Carroll, H., & Lustyk, M. K. B. (2018).
Mindfulness-based relapse prevention for substance use disorders: Effects on cardiac vagal control and craving under stress.
Mindfulness, 9(2), 488–499.
Mindfulness-based relapse prevention (MBRP) is a therapy for addictive behaviors that incorporates cognitive-behavioral relapse prevention (RP) skills with mindfulness training to increase awareness and skillful action in high-risk situations. Stress is a common reason reported for substance use relapse, and using physiological measures to measure stress engagement may help us identify mechanisms of clinical improvement. Specifically, salutatory changes in HF-HRV post-treatment may serve as a marker of treatment efficacy. We investigated tonic and phasic heart rate variability (HRV) to a cognitive stressor (i.e., arithmetic challenge) following 8 weeks of RP, MBRP, or post-detox treatment known as treatment as usual (TAU; n = 34). MBRP was related to higher levels of tonic and phasic HF-HRV, lower levels of anxiety, and lower heart rate reactivity (than TAU only) compared to RP and TAU. This suggests that those who completed MBRP are engaging with stress, but perhaps in a more adaptive, flexible manner. MBRP is associated with higher cardiac vagal control and lower stress/anxious reactivity. Given that negative emotions are an important component of relapse, these results lend further support to say that mindfulness may be helpful for those with substance use disorders.
Roos, C. R., Bowen, S., & Witkiewitz, K. (2017).
Baseline patterns of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention.
Journal of Consulting and Clinical Psychology, 85(11), 1041–1051.
Objective: Few studies have evaluated moderators of mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs). We tested whether baseline patterns of scores for SUD symptom severity and depression and anxiety symptoms moderated the efficacy of MBRP. Method: We used a latent class moderation approach with data from a randomized trial of MBRP compared to cognitive–behavioral relapse prevention and treatment as usual (TAU; Bowen et al., 2014; N = 286, 71.8% male, 48.4% non-White, mean age = 38.44 years, SD = 10.92) and a randomized trial comparing MBRP to TAU (Bowen et al., 2009; N = 168, 63.7% male, 44.6% non-White, mean age = 40.45, SD = .28). Indicators for the latent class models were measures of SUD severity (Severity of Dependence Scale and Short Inventory of Problems), depression symptoms (Beck Depression Inventory), and anxiety symptoms (Beck Anxiety Inventory). Results: In both trials, 3 latent classes provided the best fit: a high–high class characterized by high SUD severity and depression and anxiety symptoms, a high–low class characterized by high SUD severity and low depression and anxiety symptoms, and a low–low class characterized by low SUD severity and depression and anxiety symptoms. In both trials, we found significant latent Class × Treatment interaction effects: There were significant and large effects of MBRP on substance use outcomes in the high–high and high–low classes, but no MBRP effect in the low–low class. Conclusion: MBRP may be an optimal treatment for preventing relapse among clients with severe levels of SUD symptoms and depression and anxiety symptoms, as well as clients with only severe SUD symptoms.
Enkema, M. C., & Bowen, S. (2017).
Mindfulness practice moderates the relationship between craving and substance use in a clinical sample.
Drug and Alcohol Dependence, 179, 1–7.
Relapse following treatment for substance use disorders is highly prevalent, and craving has been shown to be a primary predictor of relapse. Mindfulness-Based Relapse Prevention (MBRP) is a psychosocial aftercare program integrating mindfulness and cognitive-behavioral approaches, aimed at reducing the risk and severity of relapse. Results from a recent randomized clinical trial demonstrate enhanced remission resilience for MBRP participants versus both cognitive-behavioral and treatment-as-usual controls. The current study investigated between-session formal and informal mindfulness practice, a hypothesized primary mechanism of action in this treatment, as an attenuating factor in the relationship between craving and substance use. Participants in this secondary analysis were 57 eligible adults who completed either inpatient treatment or intensive outpatient treatment for substance use disorders, were randomized in the parent study to receive MBRP, and completed relevant follow-up assessments. For formal mindfulness practice at post-intervention, both number of days per week and number of minutes per day significantly moderated the relationship between craving at post-intervention and number of substance use days at 6-month follow up. Informal practice did not significantly influence the craving-use relationship in this analysis. These results indicate that increasing formal mindfulness practice may reduce the link between craving and substance use for MBRP participants and enhance remission resiliency.
Bowen, S., Somohano, V. C., Rutkie, R. E., Manuel, J. A., & Rehder, K. L. (2017).
Mindfulness-based relapse prevention for methadone maintenance: A feasibility trial.
The Journal of Alternative and Complementary Medicine, 23(7), 541–544
Objectives: As rates of opiate misuse rise in the United States, so do significant associated health and financial consequences to afflicted individuals, their families, and society at large. Methadone maintenance therapy (MMT) is one evidence-based approach to treating opiate addiction, yet supplemental psychosocial treatment to support this approach is lacking. Mindfulness-based relapse prevention (MBRP) has shown to be efficacious in various substance use populations, but has yet to be assessed with MMT clients. Design: The current mixed methods study was designed to inform protocol adaptation for MMT clients and to evaluate the feasibility, acceptability, and preliminary efficacy of MBRP for this population. Subjects: The sample consisted of adults (N = 15) recruited from a methadone clinic to participate in a 6-week MBRP course. Outcome measures: Data from focus groups and course satisfaction surveys supported feasibility and acceptability of the intervention. Self-report outcome measures included depression, anxiety, craving, symptoms of post-traumatic stress, and experiential avoidance, and were assessed at baseline and postcourse. Results: Mean scores on all primary outcomes changed in the expected direction at postcourse, and baseline to postcourse changes in depression, craving, and trauma symptoms reached statistical significance. Conclusions: Results from this initial pilot trial support feasibility and acceptability, and provide preliminary data on outcomes for future trials of mindfulness-based approaches within the MMT community.
Li, W., Howard, M. O., Garland, E. L., & Lazar, M. (2017).
Mindfulness treatment for substance misuse: A systematic review and meta-analysis. Journal of Substance Abuse Treatment, 75, 62-96.
High rates of relapse following substance misuse treatment highlight an urgent need for effective therapies. Although the number of empirical studies investigating effects of mindfulness treatment for substance misuse has increased dramatically in recent years, few reviews have examined findings of mindfulness studies. Thus, this systematic review examined methodological characteristics and substantive findings of studies evaluating mindfulness treatments for substance misuse published by 2015. The review also includes the first meta-analysis of randomized controlled trials of mindfulness treatments for substance misuse. Comprehensive bibliographic searches in PubMed, PsycInfo, and Web of Science, identified 42 pertinent studies. Meta-analytic results revealed significant small-to-large effects of mindfulness treatments in reducing the frequency and severity of substance misuse, intensity of craving for psychoactive substances, and severity of stress. Mindfulness treatments were also effective in increasing rates of posttreatment abstinence from cigarette smoking compared to alternative treatments. Mindfulness treatment for substance misuse is a promising intervention for substance misuse, although more research is needed examining the mechanisms by which mindfulness interventions exert their effects and the effectiveness of mindfulness treatments in diverse treatment settings.
Glasner, S., Mooney, L. J., Ang, A., Garneau, H. C., Hartwell, E., Brecht, M., & Rawson, R. A. (2017). Mindfulness-based relapse prevention for stimulant dependent adults: A pilot randomized clinical trial.
Mindfulness, 8 (1), 126-135.
In light of the known associations between stress, negative affect, and relapse, mindfulness strategies hold promise as a means of reducing relapse susceptibility. In a pilot randomized clinical trial, we evaluated the effects of Mindfulness-Based Relapse Prevention (MBRP), relative to a health education control condition (HE) among stimulant-dependent adults receiving contingency management. All participants received a 12-week contingency management (CM) intervention. Following a 4-week CM-only lead in phase, participants were randomly assigned to concurrently receive MBRP (n = 31) or HE (n = 32). The primary outcomes were stimulant use, measured by urine drug screens weekly during the intervention and at 1 month post-treatment, negative affect, measured by the Beck Depression Inventory and Beck Anxiety Inventory, and psychiatric severity, measured by the Addiction Severity Index. Medium effect sizes favoring MBRP were observed for negative affect and overall psychiatric severity outcomes. Depression severity changed differentially over time as a function of group, with MBRP participants reporting greater reductions through follow-up (p = 0.03; effect size = 0.58). Likewise, the MBRP group evidenced greater declines in psychiatric severity (p = 0.01; effect size = 0.61 at follow-up). Among those with depressive and anxiety disorders, MBRP was associated with lower odds of stimulant use relative to the control condition (odds ratio (OR) = 0.78, p = 0.03 and OR = 0.68, p = 0.04). MBRP effectively reduces negative affect and psychiatric impairment, and is particularly effective in reducing stimulant use among stimulant-dependent adults with mood and anxiety disorders.
Zemestani, M., & Ottaviani, C. (2016).
Effectiveness of mindfulness-based relapse prevention for co-occurring substance use and depression disorders.
Mindfulness, 7(6), 1347-1355.
Depression and substance use disorders are highly comorbid and have significant clinical and public health implications. The current study was conducted in Iran with the aim to evaluate the effectiveness of an 8-week outpatient mindfulness-based relapseprevention (MBRP) program compared to treatment as usual (TAU) for substance use disorders with comorbid depression. Participants were 74 adults with substance use disorders randomly assigned to either MBRP (n = 37) or TAU (n = 37). Scores on the Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI), and Penn Alcohol Craving Scale (PACS) were used as outcome measures. Assessments were administered pre-intervention, post-intervention, and at a 2-month follow-up. Effectiveness of MBRP was supported by significantly lower post-intervention rates of depression, anxiety, and craving in those who received MBRP as compared to those in TAU. In the MBRP group, these beneficial effects were stable at follow-up. Results suggest that MBRP could be implemented as an effective intervention for patients with comorbid depression and substance use disorders.
Grow, J., Collins, S. E. Harrop, E.N., & Marlatt, G. A. (2015).
Enactment of home practice following mindfulness-based relapse prevention and its association with substance-use outcomes.
Addictive Behaviors, 40, 16-20.
Mindfulness- based treatments have received increasing interest and empirical support in the clinical psychology literature. There are, however, no studies to date that have systematically examined treatment enactment, which is the amount and type of home practice participants incorporate into their daily lives. Because treatment enactment has been cited as a key aspect of treatment fidelity, this study examined the relationships between treatment enactment (i.e., home mindfulness practice) and alcohol and other drug (AOD) use and craving in the context of a larger study of mindfulness-based
relapse prevention (MBRP). Methods: Participants (N = 93) in this secondary analysis had been randomized in the parent study to receive MBRP. AOD use, craving, and home
mindfulness practice were assessed at baseline, post-treatment, 2-month and 4-month follow-up time points. Results: MBRP participants significantly increased the amount of time spent in home mindfulness practice over the course of the study. Further, greater time spent in home practice was associated with less AOD use and craving at the 2- and 4-month follow-ups. Of note, the significant treatment gains in home practice faded somewhat at the 2- and 4-month follow-ups as participants returned to standard aftercare, which did not involve mindfulness-based practice. Conclusions: Participation in MBRP was associated with a significant increase in home mindfulness practice, and increased involvement in home practice was associated with significantly lower AOD use and craving over the course of the study. This suggests that treatment enactment, which entails building mindfulness practice into one's daily life, plays a key role in ongoing recovery following MBRP treatment. Teaching mindfulness skills for daily use versus for only in high-risk situations has the potential to boost the longevity of MBRP treatment effects. These findings also suggest that MBRP clinicians should target the post-intervention decline in home practice (e.g., with ongoing mindfulness practice groups) to maximize the benefits of mindfulness meditation in decreasing AOD use and craving.
Harris, A. H. (2015).
A qualitative study on the introduction of mindfulness based relapse prevention (MBRP) into a therapeutic community for substance abusers.
Therapeutic Communities, 36(2), 111-123.
ABSTRACT: Purpose: Research has shown mindfulness-based therapies to be an effective therapeutic intervention for a wide range of illnesses and disorders. However, little is known about how it may be helpful to individuals with addiction problems. The purpose of this paper is to evaluate by qualitative approach the impact of the newly introduced mindfulness-based relapse prevention programme (MBRP) programme on the TC to which it was introduced and to explore clients perception of and attitude to the programme. More specifically it aimed to examine how it may be helpful for individuals with substance abuse problems. Design/methodology/approach: A qualitative approach was drew upon using both focus group methods and individual semi-structured interviews with clients of the TC to which it was introduced. Thematic analysis was performed on data collected. Findings: Notwithstanding implementation issues, findings suggest MBRP to be a valuable and worthwhile programme with real perceived benefits. Research limitations/implications: Clients’ detoxing cited real perceived gains as a result of participating which has clear implications for a TC which offers methadone detoxification. Originality/value: It is noted that MBRP research is in its infancy, and whilst a number of quantitative studies have been carried out, little qualitative research exists. If MBRP is to be considered an effective relapse prevention strategy, research must clarify the process underlying participant’s use of mindfulness in a drug-free setting.
Penberthy, J. K., Konig, A., Gioia, C. J., Rodríguez, V. M., Starr, J. A., Meese, W. Worthington-Stoneman, D., Kersting, K., & Natanya, E. (2015).
Mindfulness-based relapse prevention: History, mechanisms of action, and effects.
Mindfulness, 6(2), 151-158.
ABSTRACT: Mindfulness-based relapse prevention (MBRP) is an intervention for persons recovering from addiction which integrates mindfulness practices and cognitive and behavioral-based relapse prevention techniques, with the goal of helping individuals avoid a return to substance use. MBRP has shown promise in reducing relapse rates among individuals recovering from substance use disorders, but literature examining the effectiveness and mechanisms of action of MBRP is still rather limited. The current paper is a theoretical review of the development of MBRP and research evidence supporting the effectiveness of this intervention. Proposed psychological and physiological mechanisms of action of MBRP and directions for future research are also examined with a specific focus on treating individuals recovering from alcohol use disorders.
Witkiewitz, K., Warner, K., Sully, B., Barricks, A., Stauffer, C., Thompson, B. L., & Luoma, J. B. (2014). Randomized trial comparing mindfulness-based relapse prevention with relapse prevention for women offenders at a residential addiction treatment center.
Substance Use & Misuse, 49(5), 536-546.
Reincarceration rates are high among substance-involved criminal offenders. This study (conducted during 2010–2011 in an urban area and funded by a Washington State University-Vancouver mini-grant) used a randomized design to examine the effectiveness of mindfulness-based relapse prevention (MBRP) as compared to relapse prevention (RP), as part of a residential addictions treatment program for women referred by the criminal-justice system (N= 105). At 15-week follow up, regression analyses found women in MBRP, compared to RP, reported significantly fewer drug use days and fewer legal and medical problems. Study limitations and future research directions for studying the efficacy of MBRP are discussed.
Bowen, S., & Enkema, M. C. (2014).
Relationship between dispositional mindfulness and substance use: Findings from a clinical sample.
Addictive Behaviors, 39(3), 532-537.
ABSTRACT: There has been rapidly increasing interest over the past decade in the potential of mindfulness-based approaches to psychological and medical treatment, including a recent growth in the area of substance abuse. Thus, the relationship between trait mindfulness and substance use has been explored in several studies. Results, however, have been mixed. While several studies of college student populations have evinced positive correlations between levels of trait mindfulness and substance use, the opposite seems to be true in clinical samples, with multiple studies showing a negative association. The current study reviews research in both non-treatment seeking college students and in clinical samples, and examines the relationship between trait mindfulness and substance dependence in a clinical sample (N = 281). Further, the study assesses the moderating effect of avoidant coping that might explain the disparate findings in the clinical versus nonclinical samples.
Witkiewitz, K., Bowen, S., Harrop, E. N., Douglas, H., Enkema, M., & Sedgwick, C. (2014).
Mindfulness-based treatment to prevent addictive behavior relapse: Theoretical models and hypothesized mechanisms of change.
Substance Use & Misuse, 49(5).
ABSTRACT: Mindfulness-based treatments are growing in popularity among addiction treatment providers, and several studies suggest the efficacy of incorporating mindfulness practices into the treatment of addiction, including the treatment of substance use disorders and behavioral addictions (i.e., gambling). The current paper provides a review of theoretical models of mindfulness in the treatment of addiction and several hypothesized mechanisms of change. We provide an overview of mindfulness based relapse prevention (MBRP), including session content, treatment targets, and client feedback from participants who have received MBRP in the context of empirical studies. Future research directions regarding operationalization and measurement, identifying factors that moderate treatment effects, and protocol adaptations for specific populations are discussed
Bowen, S., PhD; Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., Carroll, H. A., Harrop, E., Collins, S. E., Lustyk, M. K., & Larimer, M. E. (2014)
Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders: A Randomized Trail
JAMA Psychiatry, 71(5), 547-556.
Importance Relapse is highly prevalent following substance abuse treatments, highlighting the need for improved aftercare interventions. Mindfulness-based relapse prevention (MBRP), a group-based psychosocial aftercare, integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral relapse prevention (RP) approaches. Objective To evaluate the long-term efficacy of MBRP in reducing relapse compared with RP and treatment as usual (TAU [12-step programming and psychoeducation]) during a 12-month follow-up period. Design, Setting, and Participants Between October 2009 and July 2012, a total of 286 eligible individuals who successfully completed initial treatment for substance use disorders at a private, nonprofit treatment facility were randomized to MBRP, RP, or TAU aftercare and monitored for 12 months. Participants medically cleared for continuing care were aged 18 to 70 years; 71.5% were male and 42.1% were of ethnic/racial minority. Interventions Participants were randomly assigned to 8 weekly group sessions of MBRP, cognitive-behavioral RP, or TAU. Main Outcomes and Measures Primary outcomes included relapse to drug use and heavy drinking as well as frequency of substance use in the past 90 days. Variables were assessed at baseline and at 3-, 6-, and 12-month follow-up points. Measures used included self-report of relapse and urinalysis drug and alcohol screenings. Results Compared with TAU, participants assigned to MBRP and RP reported significantly lower risk of relapse to substance use and heavy drinking and, among those who used substances, significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive-behavioral RP showed an advantage over MBRP in time to first drug use. At the 12-month follow-up, MBRP participants reported significantly fewer days of substance use and significantly decreased heavy drinking compared with RP and TAU. Conclusions and Relevance For individuals in aftercare following initial treatment for substance use disorders, RP and MBRP, compared with TAU, produced significantly reduced relapse risk to drug use and heavy drinking. Relapse prevention delayed time to first drug use at 6-month follow-up, with MBRP and RP participants who used alcohol also reporting significantly fewer heavy drinking days compared with TAU participants. At 12-month follow-up, MBRP offered added benefit over RP and TAU in reducing drug use and heavy drinking. Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes
Witkiewitz, K., Greenfield, B. L., & Bowen, S. (2013).
Mindfulness-based relapse prevention with racial and ethnic minority women.
Addictive Behaviors, 38(12), 2821-2824.
ABSTRACT: Racial and ethnic disparities in the treatment of addiction have been acknowledged for several years, yet little is known about which empirically supported treatments for substance use disorders are more or less effective in treating racial and ethnic minority clients. The current study was a secondary analysis of a randomized clinical trial of two evidence-based treatments, mindfulness-based relapse prevention (MBRP) and relapse prevention (RP), as part of a residential addiction treatment program for women referred by the criminal justice system (n = 70). At 15-week follow-up, regression analyses found that racial and ethnic minority women in MBRP, compared to non-Hispanic and racial and ethnic minority women in RP, reported significantly fewer drug use days (d = .31) and lower addiction severity (d = .65), based on the Addiction Severity Index. Although the small sample size is a limitation, the results suggest that MBRP may be more efficacious than traditional treatments for racial and ethnic minority women.
Witkiewitz, K., Lustyk, M. B., & Bowen, S. (2013).
Retraining the addicted brain: A review of hypothesized neurobiological mechanisms of mindfulness-based relapse prevention.
Psychology Of Addictive Behaviors, 27(2), 351-365.
ABSTRACT: Addiction has generally been characterized as a chronic relapsing condition (Leshner, 1999). Several laboratory, preclinical, and clinical studies have provided evidence that craving and negative affect are strong predictors of the relapse process. These states, as well as the desire to avoid them, have been described as primary motives for substance use. A recently developed behavioral treatment, mindfulness-based relapse prevention (MBRP), was designed to target experiences of craving and negative affect and their roles in the relapse process. MBRP offers skills in cognitive–behavioral relapse prevention integrated with mindfulness meditation. The mindfulness practices in MBRP are intended to increase discriminative awareness, with a specific focus on acceptance of uncomfortable states or challenging situations without reacting “automatically.” A recent efficacy trial found that those randomized to MBRP, as compared with those in a control group, demonstrated significantly lower rates of substance use and greater decreases in craving following treatment. Furthermore, individuals in MBRP did not report increased craving or substance use in response to negative affect. It is important to note, areas of the brain that have been associated with craving, negative affect, and relapse have also been shown to be affected by mindfulness training. Drawing from the neuroimaging literature, we review several plausible mechanisms by which MBRP might be changing neural responses to the experiences of craving and negative affect, which subsequently may reduce risk for relapse. We hypothesize that MBRP may affect numerous brain systems and may reverse, repair, or compensate for the neuroadaptive changes associated with addiction and addictive-behavior relapse.
Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013).
Mindfulness-based relapse prevention for substance craving.
Addictive Behaviors, 38(2), 1563-1571.
ABSTRACT: Craving, defined as the subjective experience of an urge or desire to use substances, has been identified in clinical, laboratory, and preclinical studies as a significant predictor of substance use, substance use disorder, and relapse following treatment for a substance use disorder. Various models of craving have been proposed from biological, cognitive, and/or affective perspectives, and, collectively, these models of craving have informed the research and treatment of addictive behaviors. In this article we discuss craving from a mindfulness perspective, and specifically how mindfulness-based relapse prevention (MBRP) may be effective in reducing substance craving. We present secondary analyses of data from a randomized controlled trial that examined MBRP as an aftercare treatment for substance use disorders. In the primary analyses of the data from this trial, Bowen and colleagues (2009) found that individuals who received MBRP reported significantly lower levels of craving following treatment, in comparison to a treatment-as-usual control group, which mediated subsequent substance use outcomes. In the current study, we extend these findings to examine potential mechanisms by which MBRP might be associated with lower levels of craving. Results indicated that a latent factor representing scores on measures of acceptance, awareness, and nonjudgment significantly mediated the relation between receiving MBRP and self-reported levels of craving immediately following treatment. The mediation findings are consistent with the goals of MBRP and highlight the importance of interventions that increase acceptance and awareness, and help clients foster a nonjudgmental attitude toward their experience. Attending to these processes may target both the experience of and response to craving.
Bowen, S. & Vieten, C. (2012).
A Compassionate Approach to the Treatment of Addictive Behaviors: The Contributions of Alan Marlatt to the Field of Mindfulness-Based Interventions.
Addiction Research and Theory, 20 (3), 243-249.
ABSTRACT: Dr Alan Marlatt dedicated the last decade of his research career to development and assessment of mindfulness-based treatments for addictive behaviors. From his research in the 1970s on effects of transcendental meditation to several recent trials of vipassana and other mindfulness-based practices, Alan inspired and laid the foundation for the development of numerous interventions and studies on mindfulness and acceptance-based treatments for substance use disorders. In collaboration with his colleagues, Alan developed Mindfulness-Based Relapse Prevention (MBRP), an outpatient program that integrates skills from cognitive behavioral relapse prevention (RP) and training in mindfulness meditation practices. MBRP is designed to help clients increase awareness of triggers and subsequent physical, emotional, and cognitive experiences, learning to respond skillfully rather than react habitually. Aligned with Alan’s previous work in harm reduction and RP, this approach offers a nonjudgmental, client-centered, and acceptance-based approach to the treatment of addictive behaviors. Research and foundational theory behind MBRP and similar mindfulness-based programs developed by other researchers in the field of addictive behaviors are reviewed.
Bowen, S. & Kurz, A. S. (2012).
Between-session practice and therapeutic alliance as predictors of mindfulness after mindfulness-based relapse prevention.
Journal of Clinical Psychology 68 (3), 236-245.
ABSTRACT: Objectives: Mindfulness-based treatments have demonstrated efficacy in reducing symptoms in clinical populations. Not surprisingly, research suggests increases in client mindfulness might be a mechanism of change in these treatments. However, little is known about specific factors that lead to increased mindfulness. Design: The present study is a secondary analysis of 93 adults in outpatient treatment for substance abuse, assessing effects of between-session mindfulness practice and therapeutic alliance on levels of mindfulness after an 8-week Mindfulness-Based Relapse Prevention (MBRP) program. Results: Between-session practice over the course of the 8 weeks was predictive of mindfulness at postcourse, although not at the 2-month or 4-month follow-up assessments. Client rated therapeutic alliance was a significant predictor at the 2-month follow-up, although not at 4 months. Conclusions: These findings suggest that between-session practice and therapeutic alliance might be important factors in the initial increases in mindfulness after mindfulness-based treatments, but factors supporting longer term mindfulness might shift over time.
Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2012).
Mindfulness-Based Relapse Prevention for Substance Craving.
Addictive Behaviors.
ABSTRACT: Craving, defined as the subjective experience of an urge or desire to use substances, has been identified in clinical, laboratory, and preclinical studies as a significant predictor of substance use, substance use disorder, and relapse following treatment for a substance use disorder. Various models of craving have been proposed from biological, cognitive, and/or affective perspectives, and, collectively, these models of craving have informed the research and treatment of addictive behaviors. In this article we discuss craving from a mindfulness perspective, and specifically how mindfulness-based relapse prevention (MBRP) may be effective in reducing substance craving. We present secondary analyses of data from a randomized controlled trial that examined MBRP as an aftercare treatment for substance use disorders. In the primary analyses of the data from this trial, Bowen and colleagues (2009) found that individuals who received MBRP reported significantly lower levels of craving following treatment, in comparison to a treatment-as-usual control group, which mediated subsequent substance use outcomes. In the current study, we extend these findings to examine potential mechanisms by which MBRP might be associated with lower levels of craving. Results indicated that a latent factor representing scores on measures of acceptance, awareness, and nonjudgment significantly mediated the relation between receiving MBRP and self-reported levels of craving immediately following treatment. The mediation findings are consistent with the goals of MBRP and highlight the importance of interventions that increase acceptance and awareness, and help clients foster a nonjudgmental attitude toward their experience. Attending to these processes may target both the experience of and response to craving.
Witkiewitz, K., Lustyk, M. K., & Bowen, S. (2012).
Re-Training the Addicted Brain: A Review of Hypothesized Neurobiological Mechanisms of Mindfulness-Based Relapse Prevention.
Psychology of Addictive Behaviors.
ABSTRACT: Addiction has generally been characterized as a chronic relapsing condition (Leshner, 1999). Several laboratory, preclinical, and clinical studies have provided evidence that craving and negative affect are strong predictors of the relapse process. These states, as well as the desire to avoid them, have been described as primary motives for substance use. A recently developed behavioral treatment, mindfulness-based relapse prevention (MBRP), was designed to target experiences of craving and negative affect and their roles in the relapse process. MBRP offers skills in cognitive–behavioral relapse prevention integrated with mindfulness meditation. The mindfulness practices in MBRP are intended to increase discriminative awareness, with a specific focus on acceptance of uncomfortable states or challenging situations without reacting “automatically.” A recent efficacy trial found that those randomized to MBRP, as compared with those in a control group, demonstrated significantly lower rates of substance use and greater decreases in craving following treatment. Furthermore, individuals in MBRP did not report increased craving or substance use in response to negative affect. It is important to note, areas of the brain that have been associated with craving, negative affect, and relapse have also been shown to be affected by mindfulness training. Drawing from the neuroimaging literature, we review several plausible mechanisms by which MBRP might be changing neural responses to the experiences of craving and negative affect, which subsequently may reduce risk for relapse. We hypothesize that MBRP may affect numerous brain systems and may reverse, repair, or compensate for the neuroadaptive changes associated with addiction and addictive-behavior relapse.
Lee, K-H., Bowen, S., & Bai, A-F. (2011).
Psychosocial outcomes of Mindfulness-Based Relapse Prevention in incarcerated substance abusers in Taiwan: A preliminary study.
Journal of Substance Use, 16(6), 476–483.
Introduction: The current study evaluated effects of an adapted version of Mindfulness-Based Relapse Prevention (MBRP) on several psychosocial indices in a sample of incarcerated adult males with substance use disorders. Method: This study used a 2 (baseline vs post-session) × 2 (MBRP vs. treatment-as-usual (TAU) mixed design. Twenty-four incarcerated individuals with a history of substance abuse were randomly assigned to either MBRP or TAU. At pre- and post-session assessment points, participants completed the Drug Use Identification Disorders Test- Extended(DUDIT-E), the Drug Avoidance Self-Efficacy Scale (DASE) and positive/negative outcome expectancies(Ep/En). The Beck Depression Inventory-II (BDI-II) was completed in each weekly session of MBRP. MANOVA and repeated measures ANOVA examined changes between and within subjects,with the significant level set at 0.05.Results: No between-group differences were found on positive outcome expectancies or self-efficacy.Differences BDI-II scores among MBRP participants showed a downward trend over time. A Group ×Time effect emerged for negative outcome expectancies, with significant differences between groups at post-course assessment.Conclusions: Results from this randomized trial suggest pre- to post-intervention trend-level effects ofMBRP on depression, and significant group differences over time and at post-course on negative outcome expectancies, with the MBRP group reporting increases.
Witkiewitz, K., Bowen, S., Villarael, N, & Donovan, D. (2011).
The Relation between Changes in Negative Mood and Heavy Drinking: Moderating Effects of a Craving Intervention.
Journal of Consulting and Clinical Psychology, 79(1), 54–63.
Abstract: Negative affect is a significant predictor of alcohol relapse and the relation between negative affect and drinking has been shown to be strongly mediated by craving for alcohol. Thus, targeting craving during treatment could potentially attenuate the relation between negative affect and drinking. Method: The current study is a secondary analysis of data from the COMBINE study, a randomized clinical trial that combined pharmacotherapy with behavioral intervention in the treatment of alcohol dependence. The goal of the current study was to examine whether a treatment module that targeted craving would predict changes in negative mood during the 16-week Combined Behavioral Intervention (CBI; n=776) and the relation between changes in mood, craving, and changes in heavy drinking during treatment and one year posttreatment. Results: Changes in negative mood were significantly associated with changes in heavy drinking during treatment (f=0.78). Participants (n=432) who received the craving module had significantly fewer heavy drinking days during treatment (d = 0.31) and receiving the module moderated the relation between negative mood and heavy drinking during treatment (f=0.31) and one year posttreatment (f=0.03). Moderating effects of the craving module were mediated by changes in craving during treatment. Within subject analyses indicated significant pre- to post-module reductions in negative mood. Additionally, post-module craving significantly mediated the association between negative mood and heavy drinking during treatment and posttreatment. Conclusions: The craving module of CBI may weaken the relation between negative affect and heavy drinking by fostering greater decreases in craving during treatment.
Chawla, N., Collins, S., Bowen, S., Hsu, S., Grow, J., Douglas, A., & Marlatt, G. A. (2010).
The Mindfulness-Based Relapse Prevention Adherence and Competence Scale: Development, Interrater Reliability and Validity.
Psychotherapy Research, 20, 388-397.
Abstract: The present study describes the development of the Mindfulness-Based Relapse Prevention Adherence and Competence Scale(MBRP-AC),a measure of treatment integrity for Mindfulness-Based Relapse Prevention (MBRP). MBRP is a newly developed treatment integrating core aspects of relapse prevention with mindfulness practices. The MBRP-AC was developed in the context of a randomized controlled trial (RCT) of MBRP efficacy and consists of two sections: Adherence (adherence to individual components of MBRP and discussion of key concepts), and Competence (ratings of therapist style/approach and performance). Audio recordings from 44 randomly selected group treatment sessions (50%) were rated by independent raters for therapist adherence and competence in the RCT. Findings evinced high interrater reliability for all treatment adherence and competence ratings, and adequate internal consistency for Therapist Style/Approach and Therapist Performance summary scales. Ratings on the MBRP-AC suggested that therapists in the recent RCT adhered to protocol, discussed key concepts in each session, and demonstrated the intended style and competence in treatment delivery. Finally, overall therapist performance was positively related to therapeutic alliance, and overall ratings on the Adherence section were positively related to changes in mindfulness over the course of the treatment.
Witkiewitz, K. & Bowen, S. (2010).
Depression, Craving and Substance Use Following a Randomized Trial of Mindfulness-Based Relapse Prevention.
Journal of Consulting and Clinical Psychology, 78, 362-374.
Abstract: A strong relation between negative affect and craving has been demonstrated in laboratory and clinical studies, with depressive symptomatology showing particularly strong links to craving and substance abuse relapse. Mindfulness-based relapse prevention (MBRP), shown to be efficacious for reduction of substance use, uses mindfulness-based practices to teach alternative responses to emotional discomfort and lessen the conditioned response of craving in the presence of depressive symptoms. The goal in the current study was to examine the relation between measures of depressive symptoms, craving,and substance use following MBRP. Method: Individuals with substance use disorders (N 168; mean age 40.45 years, SD 10.28; 36.3% female; 46.4% non-White) were recruited after intensive stabilization,then randomly assigned to either 8 weekly sessions of MBRP or a treatment-as-usual control group. Approximately 73% of the sample was retained at the final 4-month follow-up assessment.Results: Results confirmed a moderated-mediation effect, whereby craving mediated the relation between depressive symptoms (Beck Depression Inventory) and substance use (Timeline Follow-Back)among the treatment-as-usual group but not among MBRP participants. MBRP attenuated the relation between postintervention depressive symptoms and craving (Penn Alcohol Craving Scale) 2 months following the intervention (f 2 .21). This moderation effect predicted substance use 4 months following the intervention (f 2 .18). Conclusion: MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in postintervention substance use among the MBRP group. Although results are preliminary, the current study provides evidence for the value of incorporating mindfulness practice into substance abuse treatment and identifies a potential mechanism of change following MBRP.
Brewer, J. A., Bowen, S., Smith, J.T., Marlatt, G. A., & Potenza, M. N. (2010).
Applying Mindfulness-Based Treatments to Co-Occurring Disorders: What Can We Learn from the Brain?
Addiction, 105, 1698- 1706.
Abstract: Both depression and substance use disorders represent major global public health concerns and are often co-occurring.Although there are ongoing discoveries regarding the pathophysiology and treatment of each condition, common mechanisms and effective treatments for co-occurring depression and substance abuse remain elusive. Mindfulness training has been shown recently to benefit both depression and substance use disorders, suggesting that this approach may target common behavioral and neurobiological processes. However, it remains unclear whether these pathways constitute specific shared neurobiological mechanisms or more extensive components universal to the broader human experience of psychological distress or suffering.We offer a theoretical, clinical and neurobiological perspective of the overlaps between these disorders, highlight common neural pathways that play a role in depression and substance use disorders and discuss how these commonalities may frame our conceptualization and treatment of co-occurring disorders. Finally, we discuss how advances in our understanding of potential mechanisms of mindfulness training may offer not only unique effects on depression and substance use, but also offer promise for treatment of co-occurring disorders.
Bowen, S., Chawla, N., Collins, S., Witkiewitz, K., Hsu, S.,Grow, J., Clifasefi, S., Garner, M., Douglass, A., Larimer, M., & Marlatt, A. (2009).
Mindfulness-Based Relapse Prevention for Substance Use Disorders: A Pilot Efficacy Trial.
Substance Abuse, 30, 205-305.
ABSTRACT. The current study is the first randomized-controlled trial evaluating the feasibility an initial efficacy of an 8-week outpatient Mindfulness-Based Relapse Prevention (MBRP) program as compared to treatment as usual (TAU). Participants were 168 adults with substance use disorders who had recently completed intensive inpatient or outpatient treatment. Assessments were administered pre-intervention, post-intervention, and 2 and 4 months post-intervention. Feasibility of MBRP was demonstrated by consistent homework compliance, attendance, and participant satisfaction. Initial efficacy was supported by significantly lower rates of substance use in those who received MBRP as compared to those in TAU over the 4-month post-intervention period. Additionally,MBRP participants demonstrated greater decreases in craving, and increases in acceptance and acting with awareness as compared to TAU. Results from this initial trial support the feasibility and initial efficacy of MBRP as an aftercare approach for individuals who have recently completed an intensive treatment for substance use disorders.
Collins, S. E., Chawla, N., Hsu, S. H., Grow, J., Otto, J. M., & Marlatt, G. A. (2009).
Language-based measures of mindfulness: Initial validity and clinical utility.
Psychology of Addictive Behaviors, 23, 743-749.
Abstract: This study examined relationships among language use, mindfulness, and substance-use treatment outcomes in the context of an efficacy trial of mindfulness-based relapse prevention (MBRP) for adults with alcohol and other drug use (AOD) disorders. An expert panel generated two categories of mindfulness language (ML) describing the mindfulness state and the more encompassing mindfulness practice and MBRP. Findings supported concurrent validity of ML categories: ML words appeared more frequently in the MBRP manual compared to the 12-step Big Book. Further, ML categories correlated with other linguistic variables related to the mindfulness construct. Finally, predictive validity was supported: greater use of ML predicted fewer AOD use days during the 4-month follow-up. This study provided initial support for ML as a valid, clinically useful mindfulness measure. If future studies replicate these findings, ML could be used in conjunction with self-report to provide a more complete picture of the mindfulness journey,” which included words describing challenges of developing a practice. MBRP participants (n = 48) completed baseline sociodemographic and AOD measures, and participated in the 8-week MBRP program. AOD data were collected during the 4-month follow-up. A word count program assessed the frequency of ML and other linguistic markers in participants’ responses to open-ended questions about their postintervention impressions of experience
Bowen, S. & Marlatt, G. A. (2009).
Surfing the Urge: Brief Mindfulness-Based Intervention for College Student Smokers.
Psychology of Addictive Behaviors, 666-671.
Abstract: The current study investigates effects of a brief mindfulness-based instruction set, based on Marlatt’s urge surfing” technique (Marlatt & Gordon, 1985), on smoking-related urges and behavior. Undergraduate smokers (N 123) who were interested in changing their smoking, but not currently involved in a cessation program, participated in a cue exposure paradigm designed to elicit urges to smoke. They were randomly assigned either to a group receiving brief mindfulness-based instructions or to a no-instruction control group. Results suggest that groups did not differ significantly on measures of urges. However,those in the mindfulness group smoked significantly fewer cigarettes over a 7-day follow-up period as compared to those in the control group. These findings suggest that the mindfulness techniques may not initially reduce urges to smoke but may change the response to urges. The study provides preliminary data for future studies examining both mechanisms and effectiveness of mindfulness-based interventions for cigarette smoking.
Lustyk, K., Chawla, N., Nolan, R., & Marlatt, G. A. (2009).
Mindfulness Meditation Research: Issues of participant screening, safety procedures, and researcher training.
Advances in Mind-Body Medicine, 24, 20-30.
Abstract: Increasing interest in mindfulness meditation (MM) warrants discussion of research safety. Side effects of meditation with possible adverse reactions are reported in the literature. Yet participant screening procedures, research safety guidelines, and standards for researcher training have not been developed and disseminated in the MM field of study. The goal of this paper is to summarize safety concerns of MM practice and offer scholars some practical tools to use in their research. For example, we offer screener schematics aimed at determining the contraindication status of potential research participants. Moreover, we provide information on numerous MM training options. Ours is the first presentation of this type aimed at helping researchers think through the safety and training issues presented herein. Support for our recommendations comes from consulting 17 primary publications and 5 secondary reports/literature reviews of meditation side effects. Mental health consequences were the most frequently reported side effects, followed by physical health then spiritual health consequences. For each of these categories of potential adverse effects, we offer MM researchers methods to assess the relative risks of each as it pertains to their particular research programs.
Zgierska, A., Rabago, D., Chawla, N., Kushner, K., Kohler, R., Marlatt, A. (2009).
Mindfulness Meditation for Substance Use Disorders: A Systematic Review.
Journal of Substance Abuse, 30, 266-294.
Abstract: Relapse is common in substance use disorders (SUDs), even among treated individuals. The goal of this article was to systematically review the existing evidence on mindfulness meditation-based interventions (MM) for SUDs. The comprehensive search for and review of literature found over 2000 abstracts and resulted in 25 eligible manuscripts (22 published, 3 unpublished: 8 randomized controlled trials, 7 controlled nonrandomized, 6 noncontrolled prospective, and 2qualitative studies, and 1 case report). When appropriate, methodological quality,absolute risk reduction, number needed to treat, and effect size were assessed.Overall, although preliminary evidence suggests MM efficacy and safety, conclusive data for MM as a treatment of SUDs are lacking. Significant methodological limitations exist in most studies. Further, it is unclear which persons with SUDs might benefit most from MM. Future trials must be of sufficient sample size toanswer a specific clinical question and should target both assessment of effect size and mechanisms of action.
Bowen, S. Witkiewitz, K., Dillworth, T.M., & Marlatt, G. A. (2007).
The role of thought suppression in the relationship between mindfulness meditation and substance use.
Addictive Behaviors, 32, 2324-2328.
Abstract: Previous studies have demonstrated that attempts to suppress thoughts about using substances may actually lead to increases in substance use. Vipassana, a mindfulness meditation practice, emphasizes acceptance, rather than suppression, of unwanted thoughts. A study by Bowen and colleagues examining the effects of a Vipassana course on substance use in an incarcerated population showed significant reductions in substance use among the Vipassana group as compared to a treatment—usual control condition [Bowen S.,Witkiewitz K., Dillworth T.M., Chawla N.,Simpson T.L., Ostafin B.D., et al. (2006). Mindfulness Meditation and Substance Use in an Incarcerated Population.Psychology of Addictive Behaviors.]. The current study further examines the mediating effects of thought suppression in the relationship between participation in the course and subsequent alcohol use. Those who participated in the course reported significant decreases in avoidance of thoughts when compared to controls. The decrease in avoidance partially mediated effects of the course on post-release alcohol use and consequences.
Simpson, T. L., Kaysen, D., Bowen, S., MacPherson, L. M., Chawla, N., Blume, A., Marlatt, G. A., & Larimer (2007).
PTSD symptoms, substance use, and Vipassana mediation among incarcerated individuals. Journal of Traumatic Stress, 20, 239-249.
Abstract: The present study evaluated whether Posttraumatic Stress Disorder (PTSD) symptom severity was associated with participation and treatment outcomes comparing a Vipassana meditation course to treatment as usual in an incarcerated sample. This study utilizes secondary data. The original study demonstrated that Vipassana meditation is associated with reductions in substance use. The present study found that PTSD symptom severity did not differ significantly between those who did and did not volunteer to take the course. Participation in the Vipassana course was associated with significantly greater reductions in substance use than treatment as usual, regardless of PTSD symptom severity levels.These results suggest that Vipassana meditation is worthy of further study for those with comorbid PTSD and substance use problems.
Bowen, S. Witkiewitz, K., Dillworth, T.M., Chawla, N., Simpson, T.L., Ostafin, B., Larimer, M.E., Blume, A.W., Parks, G.A. and G. Alan Marlatt, G.A. (2006).
Mindfulness meditation and substance use in an incarcerated population.
Psychology of Addictive Behaviors, 20, 343-347.
Abstract: Despite the availability of various substance abuse treatments, alcohol and drug misuse and related negative consequences remain prevalent. Vipassana meditation (VM), a Buddhist mindfulness-based practice, provides an alternative for individuals who do not wish to attend or have not succeeded with traditional addiction treatments. In this study, the authors evaluated the effectiveness of a VM course on substance use and psychosocial outcomes in an incarcerated population. Results indicate that after release from jail, participants in the VM course, as compared with those in a treatment-as-usual control condition, showed significant reductions in alcohol, marijuana, and crack cocaine use. VM participants showed decreases in alcohol-related problems and psychiatric symptoms as well as increases in positive psychosocial outcomes. The utility of mindfulness-based treatments for substance use is discussed.
Ostafin, B.D., Chawla, N., Bowen, S., Dillworth, T.M., Witkiewitz, K. & Marlatt, G.A. (2006).
Intensive mindfulness training and the reduction of psychological distress: A preliminary study.
Cognitive and Behavioral Practice, 13, 191-197.
Abstract: There is increasing evidence for the utility of mindfulness training as a clinical intervention. Most of this research has examined secular based mindfulness instruction. The current study examined the effects of a 10-day Buddhist mindfulness meditation course on the psychological symptoms of 53 participants. A repeated-measures analysis of variance indicated reductions in overall psychological distress from the pre-course baseline to a 3-month follow-up. Correlation analyses indicated that the reported reduction in psychological distress was not influenced by social desirability bias and that the effect was not dependent on daily meditation between course completion and follow-up. Issues regarding modality of mindfulness training (secular versus Buddhist) are discussed.
Leigh, J., Bowen. S. & Marlatt, G.A. (2005).
Spirituality, mindfulness & substance abuse.
Addictive Behaviors, 30, 1335-1341.
Abstract: A growing body of research suggests that mindfulness-based therapies may be effective in treating a variety of disorders including stress, chronic pain, depression and anxiety. However, there are few valid and reliable measures of mindfulness. Furthermore, mindfulness is often thought to be related to spirituality, given its roots in Buddhist tradition, but empirical studies on this relationship are difficult to find. The present study: (1) tested the reliability and validity of a new mindfulness measure, the Freiburg Mindfulness Inventory (FMI), (2) explored the relationship between mindfulness and spirituality, and (3) investigated the relationship between mindfulness and/or spirituality and alcohol and tobacco use in an undergraduate college population (N=196). Results support the reliability of the FMI and suggest that spirituality and mindfulness may be separate constructs. In addition, smoking and frequent binge-drinking were negatively correlated with spirituality scores; as spirituality scores increased the use of alcohol and tobacco decreased. Thus, spirituality may be related to decreased substance use. In contrast, a positive relationship between mindfulness and smoking/frequent binge drinking behavior was uncovered, and warrants further investigation.
(Research funded in part by National Institute of Drug Abuse, National Institute of Alcohol and Alcoholism, Alcohol and Drug Abuse Institute and Robertwood Johnson)
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