1. MBCT and Addiction :Developing Compassionate Mind Amanda Burden. In loving memory of Professor Alan Marlatt 1941-2011 A Gentle Warrior. Amanda Burden. In loving memory of Professor Alan Marlatt 1941-2011 A Gentle Warrior.

2. Background to study First UK study to adapt MBCT within substance dependency and negative affect based at Nelson trusts Gloucestershire : Duration :3Years,including pilot study USA :Mindfulness based relapse prevention (MBRP) was being developed. Began to establish professional links with Professor Marlatt team USA Returned to UCSD for MBRP professional training. First UK study to adapt MBCT within substance dependency and negative affect based at Nelson trusts Gloucestershire : Duration :3Years,including pilot study USA :Mindfulness based relapse prevention (MBRP) was being developed. Began to establish professional links with Professor Marlatt team USA Returned to UCSD for MBRP professional training.

3. Two research questions 1. Could MBCT support clients in remaining experientially present to high risks situations both interpersonal and intrapersonal How could we help ?By developing greater self- efficacy and self compassion for depression and anxiety symptomology 2 If approaches do show affect what can be understood about the mechanisms by which they work ? and the role of self -compassion ? 1. Could MBCT support clients in remaining experientially present to high risks situations both interpersonal and intrapersonal How could we help ?By developing greater self- efficacy and self compassion for depression and anxiety symptomology 2 If approaches do show affect what can be understood about the mechanisms by which they work ? and the role of self -compassion ?

4. Causation ? Research evidence: Negative affect identified as a primary predictor of relapse (Wikiewitz & Marlatt 2004; Shiffman et al 1996 ) The inner critic and shame self to self relating are high with substance misuses’ (Bien,2006) Emotional deregulation is the core underlying pathology and is seen Co morbid with substance abuse (Linehan,1993) Research evidence: Negative affect identified as a primary predictor of relapse (Wikiewitz & Marlatt 2004; Shiffman et al 1996 ) The inner critic and shame self to self relating are high with substance misuses’ (Bien,2006) Emotional deregulation is the core underlying pathology and is seen Co morbid with substance abuse (Linehan,1993)

5. Two camps in addiction. Treatment Gap ? Camps “ its part of the addiction process only natural they will feel depressed anxious “ “ not enough being done to combat underlying pathology to much focus on the substance dependency” Regardless of causation Negative affect is accepted but no specific treatments to support reduction and management of symptomology Problem: not uncommon at the end of treatment that clients are still presenting with high symptoms of depression and anxiety. (Dodge,2005) Camps “ its part of the addiction process only natural they will feel depressed anxious “ “ not enough being done to combat underlying pathology to much focus on the substance dependency” Regardless of causation Negative affect is accepted but no specific treatments to support reduction and management of symptomology Problem: not uncommon at the end of treatment that clients are still presenting with high symptoms of depression and anxiety. (Dodge,2005)

6. Maladaptive Coping Mechanisms Between childhood neglect and substance dependency : Mediated by emotional dysregulation and the inability to self sooth. Loving versus abusive environments. Validates childhood experience and offers optimum support in develop internal self soothing skills to regulate emotion. Contrast External ways of dealing with emotion(drink, drugs, self harm behavioural impulsivity) (Maguire 2009) Between childhood neglect and substance dependency : Mediated by emotional dysregulation and the inability to self sooth. Loving versus abusive environments. Validates childhood experience and offers optimum support in develop internal self soothing skills to regulate emotion. Contrast External ways of dealing with emotion(drink, drugs, self harm behavioural impulsivity) (Maguire 2009)

7. Trying to think/drink our way out of affective states Judging our experience: inner critic Constant comparison across states and time Automatic habitual “Well worn records” Leads to problem solving thinking about feelings “Why do I feel sad today” Rumination leads to conditioned response of craving and cues i.e. high risk situations Judging our experience: inner critic Constant comparison across states and time Automatic habitual “Well worn records” Leads to problem solving thinking about feelings “Why do I feel sad today” Rumination leads to conditioned response of craving and cues i.e. high risk situations

8. Mindfulness in action (MIA) and how does it work approaching negative affect (NA)? Sensory cues Memory Cognitive cues Affective interlock situation NA Substance use to alleviate negative affective state Can lead to Conditioned response : Craving Rumination Story MIA

9. What we did Model in practice Meets: 2 hours for 8 week plus a retreat day Working with high risk situations i.e. interpersonal, anxiety, low mood which may lead to relapse “how do they relate to the situation/ feeling Changing the relationship to the thought Decentering cultivating self soothing emotional regulation and self- efficacy ability to approach negative affect. Mechanisms by which Mindfulness may work mediated by Augmented Self-Compassion Kuyken 2009, Burden 2010 Meets: 2 hours for 8 week plus a retreat day Working with high risk situations i.e. interpersonal, anxiety, low mood which may lead to relapse “how do they relate to the situation/ feeling Changing the relationship to the thought Decentering cultivating self soothing emotional regulation and self- efficacy ability to approach negative affect. Mechanisms by which Mindfulness may work mediated by Augmented Self-Compassion Kuyken 2009, Burden 2010

10. Results What we found n= 74 n=56 completed. No significant difference between alcohol and poly substance use or on gender. However, drop outs pre scores were lower for symptoms of anxiety depression. Results Decrease in depression anxiety symptomology Increase in self- efficacy, mindfulness and self- compassion N=56, Predictor variables (MAAS) mindfulness attention awareness Scale: (HADS) Hospital Anxiety Depression Scale: (AASE ) Alcohol Abstinence Self Efficacy (SCS) Self compassion scale all ANOVAs significant at p<0.001 n= 74 n=56 completed. No significant difference between alcohol and poly substance use or on gender. However, drop outs pre scores were lower for symptoms of anxiety depression. Results Decrease in depression anxiety symptomology Increase in self- efficacy, mindfulness and self- compassion N=56, Predictor variables (MAAS) mindfulness attention awareness Scale: (HADS) Hospital Anxiety Depression Scale: (AASE ) Alcohol Abstinence Self Efficacy (SCS) Self compassion scale all ANOVAs significant at p<0.001

11. Results Mechanisms behind how it works Four stages of mediation Model : Augmented Self Compassion. HADS, AASE Stage 1. Mindfulness is predictive of Anxiety Stage 2.Self-Compassion is predictive of Anxiety. Stage 3. Mindfulness is predictive of self-compassion Stage 4. Mindfulness is not significantly related to Anxiety in the presence of self-compassion, but Self compassion remains predictive. Four stages of mediation Model : Augmented Self Compassion. HADS, AASE Stage 1. Mindfulness is predictive of Anxiety Stage 2.Self-Compassion is predictive of Anxiety. Stage 3. Mindfulness is predictive of self-compassion Stage 4. Mindfulness is not significantly related to Anxiety in the presence of self-compassion, but Self compassion remains predictive.

12. New frontiers in research Augmented self- compassion SC: full mediation for Alcohol abstinence self efficacy SC: Partial mediation for Anxiety. No mediation for depression. Possible reasons Depression pre scores lower Anxiety seemed more problematic. Augmented self-compassion is an important process mechanisms behind how mindfulness may work : results support Kuykens findings: SC: full mediation for Alcohol abstinence self efficacy SC: Partial mediation for Anxiety. No mediation for depression. Possible reasons Depression pre scores lower Anxiety seemed more problematic. Augmented self-compassion is an important process mechanisms behind how mindfulness may work : results support Kuykens findings:

13. Voices from the course “First time ever being able to distinguish my emotions and thoughts. More mindful how I interact with others, I often tell myself that thoughts are not facts”. “Three minute breathing space has stopped me reacting and acting on impulses giving me time to step away and be kind to myself, without big stick “. “Not so hard on me. Not so frightened of unpleasant feelings, I can manage feelings of cravings and reminded of the words that this too shall pass “ “First time ever being able to distinguish my emotions and thoughts. More mindful how I interact with others, I often tell myself that thoughts are not facts”. “Three minute breathing space has stopped me reacting and acting on impulses giving me time to step away and be kind to myself, without big stick “. “Not so hard on me. Not so frightened of unpleasant feelings, I can manage feelings of cravings and reminded of the words that this too shall pass “

14. Where are we now This study adds value and support for mindfulness and addiction as a valuable clinical intervention. New model to the UK Mindfulness based relapse prevention (Bowen Chawla Marlatt 2010) New training possibilities for 2011 Funding for RCT being investigated. This study adds value and support for mindfulness and addiction as a valuable clinical intervention. New model to the UK Mindfulness based relapse prevention (Bowen Chawla Marlatt 2010) New training possibilities for 2011 Funding for RCT being investigated.

15. Self-compassion therapeutic relationship Mindful therapy is a therapy in which the therapists produces true presence and deep listening. “It is not technique driven”. It begins with ones own self – compassion ( Bien 2006 ) Mindful therapy is a therapy in which the therapists produces true presence and deep listening. “It is not technique driven”. It begins with ones own self – compassion ( Bien 2006 )