1. UW/ABRC Mindfulness and Recovery from Addictions G. Alan Marlatt, Ph.D. Addictive Behaviors Research Center University of Washington http://depts.washington.edu/abrc/

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

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

7. UW/ABRC Examining TM Marlatt et al. (1984) examined the effects of Transcendental Meditation, progressive relaxation, and bibliotherapy among heavy social drinkers. They found significant reductions in alcohol consumption during the treatment and follow-up period for the treatment groups compared to the control groups.

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

9. UW/ABRC Vipassana and Addiction Groves and Farmer (1994) describe Vipassana meditation as a means of overcoming addiction problems: In the context of addictions, mindfulness might mean becoming aware of triggers of craving, and choosing to do something else which might ameliorate or prevent craving, so weakening this habitual response…

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

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12. Participants 305 participants (244 men and 61 women) agreed to participate in the study while incarcerated at NRF. Participants completed a baseline assessment, and either attended the Vipassana course or participated in Treatment as Usual; then completed a post-course assessment (n=173), and a follow-up 3 months after release (n=87).

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14. Mean Changes from Baseline to 3-month Follow-up: Peak Weekly Alcohol Use

15. UW/ABRC Mean Changes from Baseline to 3-month Follow-up: Alcohol-Related Negative Consequences

16. UW/ABRC Mean Changes from Baseline to 3-month Follow-up: Peak Weekly Marijuana Use

17. UW/ABRC Mean from Baseline to 3-month Follow-up: Peak Weekly Crack Cocaine Use

18. UW/ABRC Mean Changes from Baseline to 3-month Follow-up: Locus of Control

19. UW/ABRC Mean Changes from Baseline to 3- month Follow-up: Brief Symptom Inventory

20. UW/ABRC Mean Changes from Baseline to 3- month Follow-up: Optimism

21. UW/ABRC Mean Changes from Baseline to 3-month Follow-up: Psychopathology (Depression) BSI Depression Scale Score

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

24. UW/ABRC Overview of Mindfulness-Based Relapse Prevention (MBRP) Session 1 - 8

25. UW/ABRC MBRP: Delivery 1.MBRP Practitioners adopt a Person-Centered, Rogerian approach 2.MBRP Practitioners use a motivational interviewing style 3.The MBSR (MBRP) Program is characterized by the qualities of authenticity, unconditional acceptance, empathy, humor, present moment experience through which both teacher and student experience the group process; with each being changed as a result (Santorelli) 4.MBRP Practitioners have their own ongoing mindfulness meditation practice similar to what they teach to the group 5.MBRP Practitioners deliver the program according to the MBRP Treatment Manual, but are spontaneous and creative within those parameters

26. UW/ABRC Session 1: Automatic Pilot and Craving Theme: Introduce the idea of automatic pilot Agenda: Introductions (10) Rules for confidentiality and privacy (5) Orientation to the class (10) Basic Mindfulness Exercise (5-10) What is mindfulness? (10) Introduce MBRP (10)

27. UW/ABRC MBRP Session 1, Continued Theme: Introduce the idea of automatic pilot Agenda, continued: Break (10) Raisin exercise (15) Discuss cravings / urges, how we react to them (15) Body Scan Practice: Feedback & Discussion (15) Discussion, practice for the week & worksheets (10) Distribute CDs and Session 1 handouts (2)

28. UW/ABRC Session 2: Triggers, Thoughts, Emotions & Cravings Theme: Observe thoughts, see how they affect emotions & behavior Agenda Body Scan practice and debrief (15) Practice Review (15) Walking Down the Street Exercise / Discussion (30) Mountain Meditation (10-15) Discussion of Triggers (25) Distribute worksheets, discuss outside practice (10)

29. UW/ABRC Session 3: Mindfulness in Everyday Life Theme: Increasing awareness during everyday activities Agenda Seeing or Hearing exercise (10) Practice review (15) Sitting Meditation and review (15) Breathing Space and review (10) Kabat-Zinn Video (45) Mindful Walking and review (10) Handouts and discussion of Home Practice (10)

30. UW/ABRC Session 4: Staying Present and Aware in High-Risk Situations Theme: Recognizing temptations to seek and use drugs Agenda Five-minute seeing or hearing exercise (5) Sitting Meditation (20) Practice review (10) Define high-risk situations, identifying individual risk scenarios (20) Breathing Space and review (10) Mindful stretching/yoga (10) Handouts and Home Practice (10)

31. UW/ABRC Session 5: Balancing Acceptance & Change Theme: Accepting our experience, acting with awareness Agenda Sitting Meditation (with Rumi poem) (20) Practice Review (15) Breathing Space (brief) (5) Discuss how techniques are useful in difficult situations (20) Guided Breathing Space and review (20) Discussion of Acceptance and Change (20) Handouts and Home Practice (10-15)

32. UW/ABRC Session 6: Thoughts are not Facts Theme: Experiencing thoughts as merely thoughts, even when they feel like the truth Agenda Sitting meditation and discussion (20) Discussion of metaphors (10) Practice and Worksheet review (10) Relationship between thoughts and relapse (10) Lapse is not relapse and discussion of thoughts as triggers for relapse (20) Breathing Space focusing on thoughts and discussion (15) Mention preparation for end of course (10) Handouts, CDs and Home Practice (2)

33. UW/ABRC Session 7: How can I best take care of myself? Theme: Building Support Networks & Coping Cards Agenda Sitting Meditation (20) Practice review (15) Where does relapse begin? (25) Coping Cards (45) Handouts and Home Practice (5)

34. UW/ABRC Session 8: Balanced Living and Using What Has Been Learned Theme: Balance and the ability to manage different aspects of ones life. Agenda Body Scan Practice (15) Practice review (20) Balance Sheet Review, Ways to Develop a Support Network, and Barriers to Asking for Help (10) Looking Back Exercise (20) Looking Forward (20) Concluding meditation (15)

35. UW/ABRC Mindfulness Meditation Outcomes for MBRP group Percent reporting weekly meditation practice 67% at midcourse 80% at postcourse 65% at the 2-month follow-up 5.4 (1.7) days per week, and 28.9 (17.9) minutes per day across all time points MBRP participants at postcourse Increases in mindfulness skills (p =.01) Decreases in experiential avoidance (p =.01) Decreases in thought suppression (p =.02)

36. UW/ABRC Alcohol or illicit drug use: MBRP = 1; TAU = 6 χ 2 (1, N = 87) = 6.10, p =.01 Days use after initial lapse: MBRP = 2.25 (3.2); TAU = 11.6 (22.2) days Preliminary Results: Substance Use Outcomes Postcourse

37. UW/ABRC Relapse Risk Factors and Mechanisms of Change at Postcourse As compared to TAU, the MBRP group reported: Significant improvements in emotion regulation skills f (2, 67) = 3.19, p =.05 Significantly lower craving f (2, 43) = 3.21, p =.05 Significant increases in mindfulness f (2, 37) = 4.38, p =.02

38. UW/ABRC Moderating Factors Depression and Craving Prospectively: MBRP moderated the relation between BDI at midcourse and craving at postcourse. βBDIxTreatment = -.35, p=.01 Cross-sectionally: MBRP moderated the relation between BDI at postcourse and craving at postcourse βBDIxTreatment = -.50, p<.005

39. UW/ABRC Moderating Factors, continued Depression and substance-related consequences MBRP moderated relation between BDI at post-course and SIP scores at the 2-month follow-up βBDIxTreatment = -.48, p=.03 Moderated regression analyses (Aiken & West, 1991)

40. UW/ABRC Results: Depression and Craving p=.005

41. UW/ABRC Results: SU-Related Problems and BDI p=.03

42. UW/ABRC Mediating Factors Midcourse scores on the Nonjudgment subscale of the FFM and Nonacceptance subscale of the DERS mediated the relation between treatment and craving. The decreases in craving in the MBRP group can be partially explained by changes in judgment and acceptance over the course of treatment. Baron and Kenny (1986) approach and the difference of coefficients test (MacKinnon et al., 2002)

43. UW/ABRC Conclusions Preliminary evidence suggests promise for MBRP for: Decreasing rates and/or severity of substance use in individuals who have completed IP or IOP programs. Reducing the effects of relapse risk factors (e.g., negative affect, craving). Increasing acceptance and non-judgment. Decreasing strength of relation between negative affect and craving, and negative affect and problematic substance-related behaviors.

44. UW/ABRC Mindfulness Meditation: Immediate Effects Lowers heart rate Lowers blood pressure Activates the soothing relaxation response parasympathetic nervous system (PNS) Settles fight or flight stress response sympathetic nervous system (SNS) Activates sensory awareness and control of attention ©2007 Lisa Dale Miller, MFT

45. UW/ABRC Mindfulness Meditation: Long-term Effects Dampens reactivity to stress Increases positive emotions through left frontal lobe activation (Richardson, 2004) Enhanced neural integration and self-regulation from increased activity in the middle prefrontal cortex Monitors and inhibits limbic firing Greater response reflexivity for pausing before acting Enhanced empathetic resonance seeing the mind of the other Increased insight and self-awareness Modulation of fear though release of GABA into the lower limbic areas Modulation of morality (Siegel, MD, ©2007) ©2007 Lisa Dale Miller, MFT

46. UW/ABRC Mindfulness Meditation: Long-term Effects (continued) Primes brain to enter states of coherent neural activity across broad regions of the brain (Lutz, 2004) Davidson RJ. (2004) Well-being and affective style: neural substrates and biobehavioural correlates. Philosophical Transactions of the Royal Society (London). 359:1395-411. Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ. (2004) Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. Proceedings of the National Academy of Sciences. 101:16369-73.

47. It is on the very ground of suffering that we can contemplate well-being. It is exactly in the muddy water that the lotus grows and blooms. Thich Nhat Hanh, 2006

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49. Thank You!