5/17/2011 1 How Does Relapse Happen? The Cognitive Behavioral Model Effective Increased Decreased High-Risk Situation Effective Coping Response Increased Self-Efficacy Probability of Relapse Decreased Self-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-Risk Situation Self Monitoring, Inventory of Situations Contract to limit use, Reminder Card (what to do if you lapse) Cognitive Restructurin g: Lapse is a Ineffective Coping Response Decreased Self-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 vs Delayed Effects Slides: Bowen et al. 2011
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5/17/2011
1
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
Slides: Bowen et al. 2011
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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)
Slides: Bowen et al. 2011
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
Slides: Bowen et al. 2011
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Enhancing Relapse PreventionEnhancing Relapse Prevention with Mindfulness
Slides: Bowen et al. 2011
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)
Slides: Bowen et al. 2011
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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
Slides: Bowen et al. 2011
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
Slides: Bowen et al. 2011
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Session 1: Automatic Pilot and Relapse
Session 2: Awareness of Triggers and CravingAwareness,
Across 4-month follow-up, significant differencesAcross 4 month follow up, significant differences between groups:
• Mindfulness (awareness) (p =.01)
• AcceptanceAcceptance(p =.045)
Slides: Bowen et al. 2011
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
Slides: Bowen et al. 2011
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)
Slides: Bowen et al. 2011
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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
Slides: Bowen et al. 2011
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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
Slides: Bowen et al. 2011
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
Slides: Bowen et al. 2011
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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
Slides: Bowen et al. 2011
Thank you!
Slides: Bowen et al. 2011
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Mindfulness‐Based Relapse Prevention for Addictive Behaviors: A