Mindfulness Based Addiction Recovery (MBAR)

Mindfulness Based Addiction Recovery (MBAR) and Mindfulness Based Cognitive Therapy for Addiction Recovery (MBCT-AR): Coining the Terms

There has been a burgeoning resurgence in innovations in mindfulness based cognitive behavioral therapies and treatments over the past decade.  These treatments and approaches have become extremely popular among therapists, treatment professionals, and individuals seeking greater awareness of themselves, reduced stress and a more genuine way of being. All with good reason. Mindfulness Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) has been shown to be effective in the management of depressive symptoms, anxiety disorders, stress and pain in hundreds of studies worldwide.

More recently, researchers and clinicians have honed their focus on the issue of mindfulness based strategies and their application to the substance use disorders. Mindfulness Based Addiction Recovery (MBAR) is an umbrella term used here to describe several approaches and techniques to treat the substance use disorders with mindfulness based practices. Far and away, the best, most evidence based and well regarded MBAR approach is Mindfulness Based Relapse Prevention (MBRP). Mindfulness Based Relapse Prevention is predicated on principles of Mindfulness Based Cognitive Behavior Therapy for Depression, Relapse Prevention and MBSR and has been shown to be effective in reducing cravings and relapse rates in several outcome studies.

In a guide created to teach these practices, Mindfulness-Based Relapse Prevention for Addictive Behaviors, authors Sarah Bowen, Neha Chawla and Alan Marlatt (who died in 2011), carefully describe how mindfulness techniques can bring to bare one’s internal coping resources in a given moment in time and how a greater ability to experience the here-and-now in a non-critical way can be highly effective at helping patients cope with cravings and internal distress that so often accompany habitual substance use abuse and dependence.

Mindfulness Based Relapse Prevention, can be described as a combination of standard cognitive-behavioral-based relapse prevention treatment and mindfulness meditation techniques. MBRP is designed to have patients and facilitators identify personal triggers and situations where individuals are especially susceptible to relapse and to encourage patients to allow themselves to tolerate their feelings, thoughts and sensations in the body that can occur during cravings specifically and throughout one’s daily routine when challenges and stresses affect us.

Patients taught these techniques can then develop practical skills to use during stressful situations.  Along with these skills, patients learn mindfulness practices that help them develop a sharper awareness of and shift in their interactions with their own internal personal experience  The focus of mindfulness in general can be directed towards what professionals call the “triangle of awareness.” This refers to thoughts, feelings and sensations in the body. Moreover, the triangle of awareness includes awareness of 1) the brain, mind, thoughts, 2) awareness of the heart, affect or emotions and 3) awareness of sensations in the body such as pain, tension, pressure and other physical experiences etc.. 

MBRP  is directly derived from Mindfulness Based Cognitive Therapy (MBCT) which is essentially cognitive therapy with a mindfulness approach (Segal, Williams, & Teasdale, 2002), and Daley and Marlatt’s, (2006) Relapse Prevention protocol.  (http://mbct.com/) MBSR was developed by Jon Kabat Zinn and presented in his book, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness (1990, 2013) Bantam Books Trade Paperbacks, New York. The curriculum at the University of Pennsylvania’s Penn Program for Mindfulness offers this instruction as the bedrock of their training.  MBRP also combines a body of research by Marlatt and Judith Gordon at the University of Washington whose ground breaking book, Relapse Prevention, changed the substance abuse field for ever by thoroughly combining the principles of Cognitive Behavioral Therapy with the more classical methods of drug and alcohol treatment. Those methods, by and large, are derived from the grass roots development of the twelve-step approach following the principles of Alcoholics Anonymous.

We suggest that the term, “Mindfulness Based Addiction Recovery (MBAR),” should be an umbrella name encompassing all the various mindfulness-based addiction recovery approaches used to date, given that there are so many variations of treatment approaches using mindfulness-based practices for addiction. In other words, MBAR uses mindfulness-based practices like MBCT and MBRP and other approaches, cognitive or not, to help people to reduce the stress that can contribute to relapse through teaching people to be more mindful and aware. Mindfulness Based Cognitive Therapy for Addiction Recovery (MBCT-AR) is a smaller, more narrow category of MBAR and is essentially the application of cognitive behavioral therapy approaches in mindfulness to addiction recovery. MBCT-AR is just one specific branch within an overall MBAR approach where the focus is on strong or more strict CBT ideology and practice. In actuality, when most addiction treatment providers use CBT approaches they tend to be more lax and use “whatever works.” It is the more structured programs with research protocols and university affiliated treatment associations that tend to adhere most rigidly to CBT styled treatment.  

Therapists practicing MBAR and MBCT-AR can help patients see the transient and sometimes random nature of thoughts and cognitions. It can be empowering to see that thoughts are not so much accurate truths to be believed as they are neurological events which happen in the brain.  MBAR and MBCT-AR can help patients understand that our minds wander; that is what minds do. It is part of the human condition. When we can accept that our minds work similarly to other people’s minds, and that  many of the experiences that seem unpleasant personally are actually commonplace or universal we can feel more connected to others and less alone.  Alcoholics Anonymous does this well through the cognitive behavioral concept of “stinking thinking.” This can help people in AA accept that their best thinking is sometimes distorted and that it’s OK and quite normal. The idea of “stinking thinking” parallels the cognitive behavioral concepts of “mis-beliefs,” “cognitive distortions,” and “primary vs. secondary appraisal.” Whereas in CBT approaches we might challenge our thinking, in MBCT-AR we might just become curious about it. We might pay attention to it and just notice it.  When our minds wander we can just take notice of it, not fight it or attempt to change it and bring ourselves back to our current moment.  This might allow us to more fully engage in the here and now and become more present in our daily living.  The result seems to be that people report having less of a feeling that “something is wrong” or that “these thoughts and feelings won’t go away” and this helps them develop deeper compassion for themselves.

A Mindfulness Based Addiction Recovery aphorism, probably borrowed from Alcoholics Anonymous and other recovery circles gets at the crux of mindfulness and cravings: “You have to get comfortable being uncomfortable.” MBAR encourages therapists to help patients accept their feelings and thoughts and become curious about their experience despite how uncomfortable that experience is. In fact, whether you believe addiction is a disease or not, many people refer to the word, “disease” as “dis-ease.” In other words, “not at ease,” or “out of ease.” These are uncomfortable feeling states that those struggling with addiction often report. These feelings can be the basis for triggers and cues to use drugs and alcohol.

It is people’s reactions to these feeling states or “dis-ease,” that seem to get people in trouble. It is the belief that we are not supposed to be uncomfortable that might make someone want to use drugs or alcohol. The expectation that we are supposed to be comfortable all the time or always supposed to have fun or find life and social interaction easy can cause cravings to be intolerable. If patients can learn to tolerate their feelings, thoughts and sensations in their body MBAR can enable them to use cognitive strategies like these to pause and stop the behavioral chain that leads to relapse.

While learning to develop a personal MBAR practice it is essential to practice daily or at least several times a week.  However it is also important to find a balance between encouraging participants to practice and emphasizing the importance of practice but without provoking guilt or judgment if participants aren’t able to meet their practice goals. This parallels other MBAR approaches and substance recovery approaches in general where “prescribing” a recovery treatment plan is often met with resistance. Motivational Interviewing and Harm Reduction techniques have long appreciated the importance of individual responsibility and self-determination in defining one’s individualized recovery plan. Even folks in Alcoholics Anonymous know that the “AA or the highway” approach is better replaced with the actual principle and tradition of “attraction rather than promotion.”

Research into mindfulness and addiction recovery has yielded very promising results. An investigation into MBRP specifically at the University of Washington’s Addictive Behaviors Research Center conducted a randomized controlled pilot trial to compare an 8-week MBRP program with the standard aftercare groups at a local community treatment agency (Bowen et al., 2009).  After the completion of an eight-week program results suggested that MBRP participants displayed significantly greater decreases in craving compared with those in the standard aftercare group. They also reported greater increases in acceptance as well as the tendency to act with awareness. Participants in both groups showed an overall reduction in days of alcohol and other drug use but days of substance use were decreased to a significantly greater extent among those in the MBRP group. Participants in the treatment group also reported that they were more likely to continue both formal and informal meditation practices. Formal practices include body scan meditations, sitting, and yoga. Informal practices included an urge surfing meditation and breathing exercises. 

In another study in the Journal of the American Medical Association of Psychiatry (2013) patients in an MBRP program were compared to a more traditional 12-step facilitation approach and those who relapsed in the MBRP condition reported fewer days of drug and alcohol use at half year and one full year follow up intervals.

Research into Mindfulness Based Addiction Recovery (MBAR) and Mindfulness Based Cognitive Therapy for Addiction Recovery (MBCT-AR) is virtually non existent due to MBAR being an all-encompassing descriptive category and MBCT-AR being a relatively new concept with little to no standardization or operational definition at this time. Further research into these areas is clearly warranted but to be sure, therapists are practicing these techniques and their own versions of mindfulness, cognitive behavioral therapies and addiction recovery treatment in various combinations.  While standardization is necessary for us to better understand the exact nature of what is curative about these practices we are a long way from there being ample treatment providers available with knowledge and experience in all of these methods. In the meanwhile, it seems that any addiction treatment provider and individual seeking treatment for the substance use disorders should familiarize themselves with this body of work and seriously consider exploring a personal practice combining tenants from each of these areas.

About the author:

Jeremy Frank PhD CADC uses Mindfulness Based Addiction Recovery practices at Jeremy Frank Associates in Philadelphia, an evidence based addiction treatment center offering a wide range of addiction services to individuals seeking to stop or control their use of substances.

References

Bowen  S, Chawla  N, Marlatt  GA. Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician’s Guide. New York, NY: Guilford Press; 2010

Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, Carroll HA, Harrop E, Collins SE, Lustyk MK, Larimer ME. Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders. A Randomized Clinical Trial. JAMA Psychiatry.2014;71(5):547-556. doi:10.1001/jamapsychiatry.2013.4546

Daley  DC, Marlatt  GA. Overcoming Your Alcohol or Drug Problem: Effective Recovery Strategies: Therapist Guide.2nd ed. New York, NY: Oxford University Press; 2006.

Kabat-Zinn  J, Massion  AO, Kristeller  JL,  et al.  Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry. 1992;149(7):936-943

Marlatt  GA, Gordon  JR. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, NY: Guilford Press; 1985

Segal  ZV, Williams  JMG, Teasdale  JD. Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York, NY: Guilford Press; 2002.

Witkiewitz  K, Bowen  S.  Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. J Consult Clin Psychol. 2010;78(3):362-374