September Newsletter: Mindfulness for Recovery Month

How Mindfulness Meditation Improves Relapse Prevention
By Dr. Hunt, PhD – The Bergand Group

Only a small portion (estimated at around 10%) of persons with substance use problems enter treatment and, of those, a large portion (est. 40%-60%) relapse within one year. Factors associated with relapse include: interpersonal conflicts, low motivation to remain abstinent, attraction to old friends and previous life-style. In addition negative emotions such as anger, depression and/or boredom predispose individuals to relapse.
 
Relapse Prevention
Traditional relapse prevention programs (RP) offer cognitive information and suggest behavioral skills aimed at improving participants’ ability to cope with triggers, cravings and high risk situations. These programs identify both individual factors as well as social situations that may promote use. Individual factors include dealing with both negative emotions and varying degrees of motivation for recovery. Skills for coping with the stresses of “life on life’s terms” are also taught. Social situations include the influences of friends and family as well as the availability of the substance of choice.

Controlled studies have demonstrated the effectiveness of traditional relapse prevention programs when compared to no treatment. Identified shortcomings of this approach include its focus on avoidance (e.g. of high risk situations) and controlling the causes of negative emotions and cravings. Another identified limitation is RP’s lack of consideration of individual needs, values and the issues that may precipitate an individual’s problem behavior.

Mindfulness
Mindfulness itself can be described as a particular kind of awareness. It involves paying attention to our current experience, moment to moment, without judgment or evaluation.

Mindfulness Meditation involves setting aside a specific time to practice paying attention to our experience as it unfolds, without judgment or evaluation. The breath or sound are often used to help focus attention on what we are experiencing at the present moment.

While most of the world’s religions recommend some form of meditation, mindfulness meditation is not religious. Although reportedly introduced by Buddha about 2,500 years ago, it requires neither an understanding nor acceptance of Buddhist philosophy.  In recent years, it has become popular in western countries as its effectiveness in the treatment of chronic physical pain, depression, anxiety and reducing stress has been demonstrated.

Not a One-Shot. Mindfulness meditation in general, and especially, Mindfulness Based Relapse Prevention are not single time, silver bullet experiences.  They require repetition.  Like physical exercise, the more frequently one practices, the more benefit is derived. Once a week in group will have some benefit, but daily meditation is the more recommended norm. Often participants have to “work up” to a daily practice.

The Importance of Group.  Social context has an enormous effect on individual behavior. AA’s and NA’s first tradition is:  “Our common welfare should come first.  Individual recovery depends on AA unity.” Traditional Relapse Prevention Programs are conducted in groups to gain support among participants for individual recovery. The group setting is even more vital for MBRP recovery since practitioners can not only assist each other in using meditation as a tool but also help motivate one another to remain abstinent and share tips and strategies for dealing with triggers, cravings and high risk situations.

Research Support for MBRP. Between 2009 and 2012, Sarah Bowen, Ph.D. and her colleagues conducted a randomized, controlled study of 286 men and women who had recently successfully completed treatment at a private, non-profit treatment facility.(JAMA Psychiatry 2014 :71(5):547-556.) Participants were randomly assigned to one of three 8 week groups:  mindful based relapse prevention (MBRP), traditional relapse prevention (RP) and Treatment As Usual (TAU) 12 step programs plus psycho-education.

They found, “;Compared to 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 to RP and TAU.”

For those seeking recovery from substance use disorders, this study supports the benefit of a combining MBRP with the traditional relapse prevention approach. Obviously more research is needed.  However, both clinical impression as well as at least one randomized, controlled study supports the benefits of merging the two methodologies.

Mindfulness Based Relapse Prevention (MBRP)
How does the integration of Mindfulness Meditation increase the effectiveness of traditional relapse prevention?  First, neuroimaging studies have shown mindfulness meditation improves both the structure as well as the functioning of the brain.  Neuroimaging has revealed increases in the volume of brain tissue of long-term meditators in the prefrontal cortex as well as the insula. These brain areas contribute to: reasoning, attention and processing sensory information and internal bodily sensations. Changes in the brain’s functioning and structure as a result of consistent meditation  practice  demonstrate the brain’s ability to develop on the basis of focused experience; the basic principal of neuroplasticity.

Substance use disorders hijack the brain’s neuropathways and recovery requires restoring the brain to its normal – or close to normal – state. Mindfulness meditation aids in that restoration by directly improving the operation of vital areas of the brain.

MBRP also contributes to traditional Relapse Prevention through its focus on actual, present moment, experience. Rather than dealing with client issues in an abstract manner, MBRP practitioners actually experience and deal with those issues that may disposed them toward use. Thus, MBRP, as an approach based therapy, promotes self-efficacy and freedom to choose.   

Mindfulness Based Relapse Prevention (MBRP) also lowers impulsivity often associated with relapse. Rather than seeking to avoid feelings associated urges and cravings, it provides the client with more choices about how to deal with them effectively. By moving away from “automatic pilot,” and becoming more aware of both their internal as well as their outside experiences, clients becomes freer to make effective choices.

How It Works. Mindfulness Meditation slows things down. Meditation practitioners are encouraged to pause and observe what they are experiencing in the present moment without critique. Almost everyone notices their mind will not “shut off.”  It continues to present thoughts, ideas, its likes and dislikes, suggestion for action, etc. When caught up in thinking, meditators are encouraged to again, “just notice,” pause and return to the breath.  This practice helps clients become aware that the mind is always active and they can notice what the mind presents without having to act on it.  If caught up in thinking or strong emotion they can observe what is happening and, without the necessity to act, return to their breathing and continue awareness of their experience.  Impulsivity is reduced.

By slowing down experience, enabling some distance from it by simply observing it, those in MBRP can then begin to deal with issues that are associated with leading them back to use. These include: fears, frustrations, anger and resentments as well as cravings, urges, triggers and high risk situations.

By allowing these experiences to arise without resistance, judgment or the need for action, the experience changes.  Allowing what is creates the context for change since everything is in flux.

Jerry Hunt, MD
The Bergand Group