Mindfulness-Based Relapse Prevention An innovative approach to recovery from addictive behaviors Katie Hirst, MD Psychiatrist, Bold Health Encinitas, California

Disclosures None

Objectives Define the term “Mindfulness” Describe the program of Mindfulness-Based Relapse Prevention List three outcomes from clinical studies of the MBRP program

What is Mindfulness? Mindfulness means paying attention in a particular way: on purpose in the present moment and nonjudgmentally. —JON KABAT-ZINN Bowen, Chawla, Marlatt.

Having the intention to step out of “autopilot mode” First, “on purpose” Having the intention to step out of “autopilot mode” Artandzentoday.com

“in the present moment”

And – “non-judgmentally” Can we truly stop judging? Can we become aware of the judgments our minds are making?

How might mindfulness be helpful in preventing relapse in addiction?

Mindfully preventing relapse “Paying attention” can lead to greater awareness of: body sensations, emotions and thoughts triggers (external and internal) responses “In the present moment:” when we are aware of what is going on in our minds and bodies we can step out of autopilot “Non-judgmentally:” detaching from self-judgment that can lead to relapse

What is MBRP? A program that integrates cognitive-behavioral relapse prevention skills and mindfulness meditation practices. Designed to foster increased awareness of triggers, habitual patterns, and automatic reactions, these practices cultivate the ability to pause, observe what’s happening in the moment, and choose a skillful response. Bowen, Chawla, Marlatt

What are the origins of MBRP? Developed by G. Alan Marlatt of the University of Washington, who researched aversion therapy for alcoholism in 1970s designed and researched CBT-based relapse prevention in the 1980s took a meditation class to deal with his own stress began to experiment with meditation in RP groups His grad students – Sarah Bowen, Neha Chawla, and Joel Grow – now continue the research and train other MBRP facilitators

Both MBRP and traditional RP: Begin with awareness that one’s substance use or other addictive behaviors are causing significant problems/distress Place responsibility for addressing addictive behaviors on the individual Offer confidential group participation for support Encourage developing wisdom to discern the difference between what we can and cannot control

How MBRP is different: Approach to abstinence – a desired goal rather than a requirement for group participation Group members focus on moment-by-moment experience rather than telling their stories or processing their emotions Less emphasis on behavior change; more on self- awareness and acceptance Cravings seen as based in normal human needs

Core MBRP curriculum Structured protocol, usually 2-hr sessions, 8 weeks Initial 3 sessions focus on practicing mindful awareness, and integrating mindfulness practices into daily life Next 3 sessions emphasize acceptance of present experience, and application of mindfulness practices to relapse prevention Last 2 sessions address self-care, support networks, and lifestyle balance Bowen, Chawla, Marlatt.

Course objectives Develop awareness of personal triggers and habitual reactions (“autopilot”), and create a pause in this seemingly automatic process Change one’s relationship to discomfort, learning to recognize challenging physical and emotional experiences, and respond to them skillfully Adopt a non-judgmental, compassionate approach toward oneself and one’s experience Foster a lifestyle that supports continued mindfulness practice and long-term recovery Bowen, Chawla, Marlatt.

A typical MBRP session Begin with an experiential exercise, such as a breath awareness practice, followed by discussion of experience during the exercise and how it relates to relapse prevention, recovery, cravings, etc. Facilitator guides participants in exploring their direct experience, as well as linking it to habitual patterns and behaviors, while redirecting any tendency by participants to fall into familiar storytelling Close with a brief meditative practice, after reviewing home practice expectations for the week

A typical MBRP session Each 8-week group has 6 – 12 members, is closed to new participants, and full attendance is strongly recommended Each session builds on the previous one, and participants are strongly encouraged to do home practice between sessions – though not judged on the quantity or quality of their practice Home practice usually consists of listening to audio recordings of guided meditation practices; and each session includes discussion of the previous week’s home practice

MBRP Meditation practices The Body Scan Breath awareness Urge surfing False Refuge Exercise Mountain meditation SOBER breathing space Walking meditation

Remembering that urges, like waves, will eventually fade away Urge surfing Using the breath as a surfboard to ride the wave, rather than giving in to the urge and being wiped out by it Staying with the urge as it grows in intensity, rises and crests, knowing it will subside Remembering that urges, like waves, will eventually fade away

Who is best suited for MBRP? Adults who have completed residential or IOP Tx Motivated to maintain treatment goals Willing to make lifestyle changes that support well- being and recovery Seeking an alternative to traditional RP Open to learning meditation practice Willing to learn new ways of thinking about and relating to one’s experience Bowen, Chawla, Marlatt

Research Findings 3 main studies: Bowen et al 2009: n=168, outpatient treatment aftercare RCT: MBRP vs TAU Witkiewitz et al 2014: n=105, residential treatment facility, clients referred by legal system RCT: MBRP vs RP Bowen et al 2014: n=286, community inpatient treatment center RCT: MBRP vs RP vs TAU

Research Findings Bowen et al 2009: Greater decrease in days of AOD use and cravings in MBRP vs TAU group during intervention, immediately after and at 2mos post-tx Differences gone at 4mos post-treatment in MBRP group MBRP participants returned to TAU groups after completion of course

Research Findings Secondary analysis by Grow et al (2015): Greater time spent in home practice sig associated with decreased days of AOD use and cravings at 2mo and 4mo follow-ups “Treatment enactment, which entails building mindfulness practice into one’s daily life, plays a key role in ongoing recovery following MBRP treatment.”

Research Findings Secondary analysis by Witkiewitz et al (2014) Decreased craving during and immediately after MBRP treatment was mediated by a combination of acceptance, awareness, and nonjudgment

Research Findings Witkiewitz et al 2014: Women mandated to SUD facility Rolling admission to group 15-week follow-up: Relapse 1.8% MBRP vs 10.8% RP Fewer drug use days Fewer legal and medical problems related to use

Research Findings Bowen et al 2014: Significant decreased risk of relapse (>50%) for MBRP and RP vs TAU during intervention Fewer days of heavy etoh use among those drinking at 6mos for MBRP and RP vs TAU Fewer days of AOD at 12mos for MBRP vs RP and TAU

Possible Mechanisms “Top-down pathway:” executive control over craving “Bottom-up pathway:” reactive, subjective experience of craving Westbrook et al 2013

Possible Mechanisms Westbrook et al 2013: fMRI study of passive vs trained mindful attention to images of smoking by active smokers Mindful attention associated with: Decreased activity in region of brain associated with craving (subgenual ACC) Decreased connectivity of sgACC to other areas associated with craving Decreased self-reported craving

Qualifications to facilitate MBRP Established personal meditation practice Familiarity with cognitive-behavioral therapy Experience with group facilitation Knowledge and understanding of addiction Bowen, Chawla and Marlatt

Summary MBRP defines mindfulness as “paying attention in a particular way, on purpose, in the present moment and nonjudgmentally.” MBRP is an 8-week class that has been shown effective as both aftercare and during residential treatment for diverse populations including women and ethnic minorities Studies show decreased craving, days of AOD use and legal or medical problems compared to TAU and/or RP

To learn more about MBRP MindfulRP.com For a list of practitioners around the world, and to listen to guided meditation practices: http://www.mindfulrp.com/For-Clinicians.html Insight Meditation Timer (free,iOS or Android): Hirst MBRP teacher training: http://mbpti.org/mbrp- mindfulness-based-relapse-prevention/

Bibliography Bowen, S., Chawla, N., & Marlatt, G. A. (2010). Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician's Guide (1st ed.). The Guilford Press. 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. Bowen, S., Chawla N., Collins, S.E., Witkiewitz, K., Hsu, S., Grow, J., et al (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4): 295–305 Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, G., 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 Trial. JAMA Psychiatry, 71(5): 547-556. Brewer J.A., Sinha R., Chen J.A., Michalsen R.N., Babuscio T.A., Nich C., Rounsaville B.J. (2009) Mindfulness training and stress reactivity in substance abuse: Results from a randomized, controlled stage I pilot study. Substance Abuse, 30: 306–317. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present and future. Clinical Psychology: Science and Practice, 10: 144–156

Bibliography cont’d 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 Abuse, 16(6): 473-486. Grow, J.C., 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. Westbrook, C., Creswell, J.D., Tabibnia, G., Julson, E., Kober, H., Tindle, H.A. (2013) Mindful attention reduces neural and self- reported cue-induced craving in smokers. Soc Cogn Affect Neurosci. 8(1): 73–84. Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013). Mindfulness-based relapse prevention for substance craving. Addictive Behaviors, 38(2): 1563-1571. 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. 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.

Contact Information Katie Hirst, MD 858-232-8645 katiephirst@gmail.com