How Does Relapse Happen? The Cognitive Behavioral Model · 2018-11-20 · 5/17/2011 5 MBRP...

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How Does Relapse Happen?The Cognitive Behavioral Model

Effective Increased Decreased

High-RiskSituation

EffectiveCoping Response

IncreasedSelf-Efficacy Probability

of Relapse

DecreasedSelf-Efficacy

Marlatt & Gordon, 1985

Ineffective Coping

Response

Self Efficacy+

Positive Outcome

Expectancies(for initial effects of the substance)

LAPSE(Initial Use

of Substance))

Increased Probability of Relapse

“Abstinence Violation Effect”

Slides: Bowen et al. 2011

Relapse Prevention Therapy

High-RiskSituation

Self Monitoring, Inventory of Situations

Contract to limit use,

Reminder Card (what to do if you lapse)

Cognitive Restructuring: Lapse is a

Ineffective Coping

Response

DecreasedSelf-Efficacy

+Positive Outcome

Expectancies(for initial effects

LAPSE(Initial Use

of Substance))

“Abstinence Violation Effect”

you lapse) g: Lapse is a mistake vs a

failure

Marlatt & Gordon, 1985

of the substance)

Coping Skills Training

Stress Management, Relaxation

Education about

Immediate vsDelayed Effects


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Research on Relapse Prevention

Meta-analyses and reviews (Irvin, et al., 1999; Carroll, 1996) support RP as any ppeffective treatment across disorders

Alcohol (Dimeff & Marlatt, 1998; Kadden et al., 1992; Larimer & Marlatt, 1990; Monti et al., 2002)

Cocaine (Schmitz, et al., 2001)

Marijuana (Roffman, et al., 1990)

Smoking (Killen, et al., 1984)

Eating disorders (Mitchell & Carr, 2000)

Gambling (Echeburua, et al., 2000)

Sexual Offenses (Laws, 1995)


Review of 24 Randomized Trials(Carroll, 1996)

Does not prevent a lapse better than other treatments but is moreDoes not prevent a lapse better than other treatments, but is more effective at delaying and reducing duration and intensity of

lapses

Effective at maintaining treatment effects over long term follow-up (1-2 years or more)

“Delayed emergence effects” - greater improvement in coping over time

May be most effective for more severe substance abuse, greater levels of negative affect, and greater deficits in coping skills


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Enhancing Relapse PreventionEnhancing Relapse Prevention with Mindfulness


What is Mindfulness?

“Awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding

of experience moment by moment”

(Kabat-Zinn 2003)(Kabat-Zinn, 2003)


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Paying attention: In the present moment …

Mindfulness and Substance Use

Greater awareness of Accepting present

triggers and responses, interrupting previously automatic behavior (Breslin et al., 2002)

experience, rather than using substances to avoid it

Nonjudgmentally: Detach from attributions and “automatic” thoughts that often lead to relapse


MindfulnessMindfulness--Based Based Relapse Prevention Relapse Prevention

(MBRP)(MBRP)(MBRP)(MBRP)

NIDA Grant # R21 DA010562; PI MarlattSlides: Bowen et al. 2011

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MBRP StructureIntegrates mindfulness with Relapse Prevention

Patterned after Mindfulness-Based Stress Reduction (Kabat-

Zinn) and Mindfulness-Based Cognitive Therapy for d idepression (Segal et al.)

Outpatient Aftercare Treatment8 weekly 2 hour sessions; daily home practice

Therapists have ongoing meditation practice

Components of MBRPFormal mindfulness practice

Informal practiceCoping strategies

(Bowen, Chawla & Marlatt, 2010; Witkiewitz et al., 2005)Slides: Bowen et al. 2011

Awareness:From “automatic pilot” to awareness and choice

Intentions of MBRP

Triggers:Awareness of triggers, interrupting habitual reactions

Acceptance:Change relationship to discomfort, decrease need to “fix” the present moment

Balance and Lifestyle:Supporting recovery and maintaining a mindfulness


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Session 1: Automatic Pilot and Relapse

Session 2: Awareness of Triggers and CravingAwareness,

MBRP Session Themes

Session 3: Mindfulness in Daily Life

Session 4: Mindfulness in High-Risk Situations

Session 5: Acceptance and Skillful Action

Session 6: Seeing Thoughts as Thoughts

,Presence

Mindfulness and Relapse

Session 7: Self-Care and Lifestyle Balance

Session 8: Social Support and Continuing Practice

Bigger Picture: A Balanced Life


“Formal” Practices

Body Scan

Sitting Meditation

Mindful Movement “Lovingkindness” or “metta”

Walking Meditation

Mountain Meditation


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Direct Direct

InquiryPain in left knee, Restlessness

Emotionaldiscomfort (depression,

anxiety)

ExperienceExperience((painpain))

Reactions, Stories, Reactions, Stories, Judgment Judgment

((sufferingsuffering))

“I can’t do this”“I can’t handle this. I need an escape. I

need a drink.”

(( ff gff g))

Adapted from Segal et al., 2002

- Relationship to Craving, Relapse, Recovery

- Not personal


“Informal” Practices

Mindfulness of daily activities

“SOBER” breathing spacedaily activities

Urge surfing


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Stop

“SOBER” Breathing Space

Observe

Breath

Expand

Respond


Urge SurfingRiding the wave, rather than

giving into the urge and being wiped out by it.

Staying with the urge as it grows in intensity, riding it to its peak. using the breath to stay steady as it rises and

crests, knowing it will subside.

Trusting that without any action on your part, all the

waves of desire, like waves on the ocean, arise and

eventually fade away.

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urge

itime


Awareness of Triggers

Situation/

Trigger

What moods, feelings or

What sensations did you

What thoughts arose?

What did you do?

An argument

with my

girlfriend.

gemotions did you notice?

Anxiety, hurt, anger

yexperience?

Tightness in chest, sweaty palms, heart beating fast, shaky all over

“I can’t do this.”

“I need a drink.”

Yelled, slammed door, went for a walk

shaky all over

“Forget it. I don’t care anymore”


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Mindfulness and Substance Use Mindfulness and Substance Use Disorders: The ResearchDisorders: The Research


N = 168

MBRP Study Design

Completed Inpatient or Intensive

Outpatient

8 weeks

MBRP

TAU

PostCourse (61%)

2months (57%)

4months (73%)

Baseline

Funded by National Institute on Drug Abuse Grant R21 DAO 10562-01A1; PI: G. Alan Marlatt

TAU


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Participants

• 50% Caucasian

• Age 40.5 (10.3); 64% male

• 72% completed high-school

• 41% unemployed

50% Caucasian

• 28% African American

• 15% Multiracial

• 7% Native AmericanAlcohol 46%

Opiates/Heroin 7%

Marijuana 5%

Meth 14%

Other 2%

41% unemployed

• 33% public assistance

• 62% less than $4,999 / year

• Homeless/unstably housed

Crack/Cocaine 26%


Results: Feasibility% of MBRP Participants

practicing Formal Meditation

• Attendance86

6354

40

60

80

10065% of sessions(M = 5.18, SD = 2.41)

• Formal Practice4.74 days/week (SD = 4.0)

0

20

Post-Course

2-Month 4-MonthAssessment

y ( )

29.94 minutes/day (SD =19.5)

(Bowen et al., 2009)

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Results: Mindfulness & AcceptanceResults: Mindfulness & Acceptance

Across 4-month follow-up, significant differencesAcross 4 month follow up, significant differences between groups:

• Mindfulness (awareness) (p =.01)

• AcceptanceAcceptance(p =.045)


Results: Craving

Time x treatment: p =.02Time2 x treatment: p =.02

PACS, Flannery et al., 1999Slides: Bowen et al. 2011

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Results: Substance Use

Per

cent

age

Any

AO

D U

se

MBRP = 2.1 days of useTAU = 5.4 days of use

Time x group interaction: p= .02Time2 x group interaction: p= .01

P


Comorbidity

40% (in the U.S.) with depressive/anxiety disorders have co occurring substance use disorders

Depression has particularly strong relationship with craving and relapse (Gordon et al., 2006; Zilberman et al., 2007; Curran et al., 2000 ; Levy, 2008)

have co-occurring substance use disorders (NCS; Kessler, Nelson, McGonagle, Liu, et al., 1996)

Worse substance use treatment outcomes (e.g., Hodgins, el Guebaly, & Armstrong, 1995; Witkiewitz & Villarroel, in press)


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Results: Depression and CravingResults: Depression and Craving

SubstanceUseCravingDepression

MBRP

(Witkiewitz & Bowen, 2010)Slides: Bowen et al. 2011

Results: Depression and CravingResults: Depression and Craving

Substance Use


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Summary of Results

Increased awareness and acceptance

Reduction in craving

Decreased rates of substance use

Weaker relationship between depressive symptoms d band substance

Thereby weakened relationship between depression and substance use


Implications• Findings consistent with intention and hypothesized mechanisms

• Experience discomfort without “automatically” reacting

• Decrease craving in the presence of internal (e.g., depression) and external (e.g., environment) cues.

• Consistent with findings from other mindfulness-based interventions

(Dahl et al., 2004; Bowen & Marlatt, 2009; Gifford et al., 2004; Hayes et al., 1999; Levitt, et al., 2004)

• Relationship between depression and craving: Negative affect doesn’t have to lead to relapse (Gifford et al 2004; Bowen & Marlatt 2009)doesn t have to lead to relapse (Gifford et al, 2004; Bowen & Marlatt, 2009)

• May be helpful in treating dual-diagnosis clients

• May enhance Relapse Prevention by offering additional skills


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• Is this for everyone? • Gender • Dependence severity • Dual diagnosis (depression anxiety trauma)

Future Directions

Dual diagnosis (depression, anxiety, trauma)

• Long term effects• Latency to first lapse• Pattern of use following the first lapse

• Physiological and Neurological effects • Stress reactivity to triggers• Brain activation• Brain activation• Neuroplasticity

• Underlying “Automatic” Cognitive Processes• Cognitive Inhibition (ability to disengage attention from triggers)• Metacognition


Thank you!


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Mindfulness‐Based Relapse Prevention for Addictive Behaviors: A

l ’ dClinician’s Guide

Guilford Press, November 2010

www.mindfulrp.com


How Does Relapse Happen? The Cognitive Behavioral Model · 2018-11-20 · 5/17/2011 5 MBRP...

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