John M. Talmadge, M.D.

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Mindfulness Based Relapse Prevention

Dr. Sarah Bowen has published a study on mindfulness and relapse prevention in JAMA Psychiatry, a specialty journal of the American Medical Association. According to Bowen, substance abuse is another example of that too-human automatic drive to move toward pleasure and away from pain—one that affects an estimated 24 million Americans, according to the National Survey on Drug Use and Health.

Traditional treatment for substance abuse often focuses on avoiding or controlling triggers that result in negative emotion or craving. While research has shown that this approach can help, substance abuse relapse remains a problem: about half of those who seek treatment are using again within a year.

Bowen has spent much of her career studying another approach: mindfulness, which involves cultivating moment-to-moment, nonjudgmental awareness of thoughts, feelings, and surroundings. She and her colleagues have developed a program called Mindfulness-Based Relapse Prevention (MBRP), which combines practices like sitting meditation with standard relapse prevention skills, such as identifying events that trigger relapse. Rather than fighting or avoiding the difficult states of mind that arise when withdrawing from a substance, this combination tries to help participants to name and tolerate craving and negative emotion.

But how do mindfulness-based approaches compare to traditional substance abuse treatments? And do mindfulness-based treatments work for everyone? Researchers like Bowen are beginning to answer these questions.

Here is the key to the success of the program: MBRP helps people to relate differently to their thoughts, and use tools to disengage from automatic, addictive behaviors.

The JAMA Psychiatry article describes how effective the Mindfulness-Based Relapse Prevention program is in comparison to a standard relapse-prevention program as well as a conventional 12-step program. Six months following the intervention, the mindfulness-based program and the standard relapse-prevention program were both more successful at reducing relapse than the 12-step program. One year later, the mindfulness-based program proved better than the other two in reducing drinking and drug use.

Bowen says that when people cultivate mindfulness, they’re developing a tool to become aware of that inclination to want only pleasurable things and escape uncomfortable things. Mindfulness also helps people learn to relate to discomfort differently. When an uncomfortable feeling like a craving or anxiety arises, people like Sophia are able to recognize their discomfort, and observe it with presence and compassion, instead of automatically reaching for a drug to make it go away. Bowen says that awareness of our experience and the ability to relate to our experience with compassion gives us more freedom to choose how we respond to discomfort, rather than defaulting to automatic behaviors.

More research is needed to determine why MBRP might be more successful than other programs in reducing substance abuse relapse, but Bowen speculates that MBRP holds an advantage because mindfulness is a tool that can be applied to all aspects of one’s life.

Standard relapse-prevention programs teach tools specific to struggles with substance abuse—for instance, how to deal with cravings or how to say no when someone offers you drugs. A year after completing the program, a person may have a very different set of challenges that the relapse-prevention program did not equip them to deal with.
But because mindfulness is a tool that can be used in every part of a person’s life, practicing moment-to-moment awareness could continue to be an effective coping tool.

James Davis and his colleagues at Duke University are investigating mindfulness training as a way to help people quit smoking. Davis speculates that mindfulness is likely an effective tool in helping people with addiction because it’s a single, simple skill that a person can practice multiple times throughout their day, every day, regardless of the life challenges that arise. With so much opportunity for practice—rather than, say, only practicing when someone offers them a cigarette—people can learn that skill deeply.

Their intervention results showed a significant difference in smoking cessation for people who completed the intervention, as compared to people who were given nicotine patches and counseling from the Tobacco Quit Line.

Both Bowen and Davis emphasize that mindfulness is not a panacea; it doesn’t always work for everyone.

Dr. Zev Schuman-Olivier and his colleagues at the Massachusetts General Hospital Center for Addiction Medicine suggest that the type of therapy a person responds to may have something to do with their disposition. People who had the tendency to treat thoughts and behaviors with non-judgment and acceptance before the intervention began were more likely to be successful in reducing smoking following the mindfulness training. They write that if a person already has the skill to treat the self with non-judgment and acceptance, learning mindfulness practices likely comes easier to them than someone who has not previously practiced this skill.

Ultimately, the type of therapy that works best for a given person will likely capitalize on their pre-disposed strengths.Of course, as Bowen and Davis both note, the skills of mindfulness can be taught to everyone. But Schuman-Olivier’s finding suggests that people who are not oriented toward mindfulness may need a more vigorous or lengthy intervention, in order to more thoroughly learn mindfulness skills. It may be the case that people with less disposition toward mindfulness would fare better with a different therapy.

Another predictor of success in mindfulness-based treatment could be a person’s motivation to engage in the therapy. In Davis’ study, the people that started the intervention with the highest level of nicotine addiction were the most successful in reducing smoking by the end of the treatment. Davis said that this seemingly counterintuitive result likely reflects their motivation to quit; the people that were the most addicted had, at that point, tried everything, and were willing to try their hardest to make this therapy work. Meanwhile, people that were less addicted saw their addiction as less of a problem. They reasoned, “If this doesn’t work, I’ll be ok—something else will work, eventually.” As a result, they were likely less motivated to quit, and less engaged in the therapy.