“Mindfulness-Based Relapse Prevention Techniques in Addiction Group Counseling” Mark Schwarze, Ph.D., LPCS, NCC, LCAS, CCS Appalachian State University

Learning Objectives 1. To provide an overview of mindfulness and it’s application to addiction and relapse prevention. 2. Explore the benefits of group work with addicted clients within the mindfulness framework. 3. Demonstrate three mindfulness techniques within a group format.

Depression Past Regret Sadness Anger Anxiety Future Anxiety Fear Worry

Mindlessness as an Indicator Your level of mindfulness can be measured by looking at your level of mindlessness!

Operationally Defining Mindfulness ( Bishop et al., 2004) Component 1 Self-Regulation of Attention Sustained Attention Switching Inhibition of Elaborative Processing Component 2 Developing an Orientation to Experience All thoughts, feelings, and sensations are acknowledged Do not reframe or evaluate as in CBT, but just accept with open mind. Leads to heightened sense of awareness

Building Mindfulness is Equivalent to Pruning

Time Out Exercise

This is mindfulness!

Why Mindfulness and Addiction? Relapse rates are high (40-60% after 1 year (Bowen, et al., 2014) Traditional treatment outcomes are marginal. Addictive thinking and behavior are comprised of anticipatory thinking and reactivity. Empirical studies using mindfulness to treat addiction are promising (Witkiewitz & Bowen, 2010; Fernandez et al., 2010; Garland, 2011)

Research Bowen, et al. (2014) – JAMA - Psychiatry Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders: A Randomized Clinical Trial Researchers at the University of Washington studied 286 people who had successfully completed a substance abuse treatment program, and randomly assigned them to one of three groups: mindfulness meditation, a 12-step program, and a traditional relapse-prevention program. One year after treatment, about 9 percent of participants in the mindfulness program reported drug use, compared with 14 percent of those in a 12-step program, and 17 percent in a traditional relapse- prevention program. About 8 percent of participants in the mindfulness program also reported heavy drinking after one year, compared with about 20 percent in the other two groups.

Research Witkiewitz & Bowen (2010) – Journal of Consulting and Clinical Psychology Depression, Craving, and Substance Use Following a Randomized Trial of Mindfulness-Based Relapse Prevention. The goal of the study was to examine the relation between measures of depressive symptoms, craving, and substance use following MBRP. Individuals with substance use disorders (N = 168; mean age 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. MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in post intervention substance use among the MBRP group.

Research Brewer et al., (2009) - Substance Abuse Mindfulness Training and Stress Reactivity in Substance Abuse: Results from a Randomized, Controlled Stage I Pilot Study The goals of this study were to assess MT compared to cognitive behavioral therapy (CBT) in substance use and treatment acceptability, and specificity of MT compared to CBT in targeting stress reactivity. Thirty-six individuals with alcohol and/or cocaine use disorders were randomly assigned to receive group MT or CBT in an outpatient setting. There were no differences in treatment satisfaction or drug use between groups. The laboratory paradigm suggested reduced psychological and physiological indices of stress during provocation in MT compared to CBT.

Relapse ●Relapse can be seen in two dimensions:  The “event”  The “process”

The RP Model (Cognitive-Behavioral) (Marlatt & Gordon, 1985)

Two Biggest Relapse Risk Factors (Witkiewitz & Lustyk, 2012) Craving Negative Affect

Group Work in Addiction Counseling Group Therapy=Common form of therapy in addiction treatment The field is rooted in AA and the therapeutic community that heavily use group work. “Addiction is a disease of isolation.” (Miller, 2015, p. 111) Addicted clients frequently have interpersonal problems.

Group Work in Addiction Counseling Group Therapy is the Treatment of Choice because: Group therapy is powerful [“compassionate accountability”]. The client can learn about self through interactions with others [“microcosm of the real world.”-Yalom, 1985]. Group provides opportunity for social support and feedback [“catches us at being ourselves”]. The client can experience hope for change [“Stories teach us how to live.”-Native American elder].

Group Work in Addiction Counseling Specific Addiction Group Issues: Relapse Countertransference Mistrust of others References Miller, G. (2015). Learning the language of addiction counseling (4 th ed.). Hoboken, NJ: Wiley. Miller, G. (2012). Group exercises for addiction counseling. Hoboken, NJ: Wiley

Techniques and Exercises

Key Elements of Mindfulness Interventions Involve three interdependent elements: 1) awareness 2) of present experience 3) with acceptance

Awareness Stop – stop automatic thoughts by stopping automatic behaviors Observe – a focal point, such as breathing. Most likely our mind will wander. Return – bring attention back to focal point

Present Experience One goal of mindfulness is to be unified with our activities. Csikszentmihalyi (1991) called this “being in the flow.” When not in the flow, we need to refocus our efforts.

Acceptance The present is colored by how we receive it. Acceptance is an acquired skill. Cultivate acceptance with the appropriate exercises and practice.

The Breathing Meditation meditate/simple-meditations/breathing- meditations/

Mindfulness-Based Relapse Prevention (MBRP) (Bowen et.al., 2009) Integrates mindfulness meditation with CBT relapse prevention skills Increase awareness of external triggers Increase awareness of internal cognitive and affective processes Increase tolerance to challenging cognitive, affective, and physical experiences

SOBER Space Exercise (Bowen et al., 2009) S = Stop O = Observe B = Breathe E = Expand awareness R = Respond mindfully Purpose= Break immediate stimulus-response patterns that seek to “fix” craving

Urge Surfing Exercise (Bowen et al., 2009) Craving is often perceived as an upward slope increasing in intensity Craving

Urge Surfing Exercise (Bowen et al., 2009) Craving is really more like a wave….ebbing and flowing. Clients look “above” & “underneath” the craving. “Underlying the overwhelming desire for a substance is often a deeper need” (Bowen, et al., 2009)

Measuring Mindfulness The Five Facet Mindfulness Questionnaire: is a 39 item measure consisting of five subscales (observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience). The Mindful Attention Awareness Scale (MAAS: is a 15 item measure assessing mindfulness of moment to moment experience. The Philadelphia Mindfulness Scale: is a 20 item measure consisting of 2 sub-scales (acceptance and present moment awareness).

Apps and Technology e-apps/iphone-ipod-touch-ipad-apps/ e-apps/iphone-ipod-touch-ipad-apps/ Clinicians.html Clinicians.html

Mindfulness Resources mindfulness_biblio_0609.pdf mindfulness_biblio_0609.pdf

References Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J.,…Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230–241. Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J.... Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), Miller, G. (2015). Learning the language of addiction counseling (4 th ed.). Hoboken, NJ: Wiley. Miller, G. (2012). Group exercises for addiction counseling. Hoboken, NJ: Wiley. Schwarze, M. J., & Gerler Jr, E. R. (2015). Using mindfulness-based cognitive therapy in individual counseling to reduce stress and increase mindfulness: An exploratory study with nursing students. The Professional Counselor, 39. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression. New York: The Guilford Press. Siegel, R. D. (2010). The mindfulness solution: Everyday practices for everyday problems. New York: The Guilford Press. 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(3),