1. “Using Mindfulness Techniques to Prevent Relapse in Addicted Clients” Mark Schwarze, Ph.D., LPCS, NCC, LCAS, CCS Assistant Professor & Program Director Clinical Mental Health Counseling Program Appalachian State University Boone, NC

3. Learning Objectives Participants will gain an understanding of the concept of mindfulness and be able to discuss its application in counseling. Participants will review cognitive models of relapse and how mindfulness can play a part in the models. Participants will engage in mindfulness exercises and discuss how to teach clients to integrate them in a relapse prevention plan.

4. Mindfulness Derived from Zen Buddhism Described as a commitment to bringing awareness back to the present moment (Harrington & Pickles, 2009) Brown & Ryan (2003) describe mindfulness as “the state of being attentive to and aware of what is taking place in the present.”

5. Mindfulness is: Mindfulness is not: A particular attitude toward experience or “awareness of present experience with acceptance.” (Siegel, 2010) Relaxation Concentration A technique

6. Depression Past Regret Sadness Anger Anxiety Future Anxiety Fear Worry

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

8. Mindlessness Indicates Level of Mindfulness I run on automatic without much awareness of what I’m doing. I become preoccupied with the future or the past. I snack without being aware that I am eating. I drive on “automatic pilot” without paying attention to what I am doing. I daydream or think of other things when doing chores such as cleaning or laundry.

9. Operationally Defining Mindfulness ( Bishop et al., 2004) Component 1Component 2 Self-Regulation of Attention Sustained Attention Switching Inhibition of Elaborative Processing 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

10. Building Mindfulness is Equivalent to Pruning

11. Time Out Exercise

12. This is mindfulness!

15. 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)

16. 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.

17. 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 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. MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in post intervention substance use among the MBRP group.

18. 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.

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

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

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

22. Incorporating Mindfulness into Treatment

23. Mindfulness-Based Interventions Mindfulness has been rooted in Buddhist philosophy and it’s inclusion into western counseling has been slow. Mindfulness is a central construct in: Dialectical Behavioral Therapy (DBT; Linehan, 1993) Acceptance & Commitment Therapy (ACT; Hayes et al., 1999) Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002)

24. Integration with Clients (Brown, Marquis, & Guiffrida, 2013) Start with psychoeducation on the foundations of mindfulness Instruct on basic mindfulness-based meditation techniques A) Thoughts as clouds B) Directing awareness to breath C) Ongoing practice with guided meditations

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

26. 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

27. 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.

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

29. Techniques and Exercises

30. 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

31. 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 http://depts.washington.edu/abrc/mbrp/recordings/SOBER%20space.mp3

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

33. 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) http://depts.washington.edu/abrc/mbrp/recordings/Urge%20Surfing.mp3

34. Increasing Awareness Gratitude Meditation

35. The Breathing Meditation http://www.meditationoasis.com/how-to- meditate/simple-meditations/breathing- meditations/

36. Increasing Mindfulness Clients will need to practice sitting meditations daily to increase mindfulness and reap the benefits. At least 5 to 10 minutes daily, but more is better.

37. 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).

38. Apps and Technology https://www.meditationoasis.com/smartphone- apps/iphone-ipod-touch-ipad-apps/https://www.meditationoasis.com/smartphone- apps/iphone-ipod-touch-ipad-apps/ www.meditationoasis.com http://www.mindfulrp.com/For-Clinicians.html

39. Mindfulness Resources http://www.mindful.org/resources http://marc.ucla.edu/workfiles/PDFs/MARC_ mindfulness_biblio_0609.pdfhttp://marc.ucla.edu/workfiles/PDFs/MARC_ mindfulness_biblio_0609.pdf http://www.geneseo.edu/webfm_send/5592 http://www.mindfulnet.org/

40. 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. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848. Harrington, N., & Pickles, C. (2009). Mindfulness and cognitive-behavioral therapy: Are they compatible concepts? Journal of Cognitive Psychology: International Quarterly, 23, 315–323. Marlat, G. A. & Gordon, J. R. (Eds.). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press 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.

41. Contact Info Mark Schwarze schwarzem@appstate.edu