1. Sarah Bowen, PhD Assistant Professor Dept. of Psychiatry and Behavioral Sciences University of Washington swbowen@uw.edu Meditation and Mindfulness-Based Treatment Approaches Meditation and Mindfulness-Based Treatment Approaches

2. A systematic development of attention to present moment experience with an attitude of acceptance and nonjudging (Bishop et al., 2004; Kabat- Zinn, 1994) (Bishop et al., 2004; Kabat- Zinn, 1994) What is Mindfulness?

3. A systematic development of attention to present moment experience with an attitude of acceptance and nonjudging (Bishop et al., 2004; Kabat- Zinn, 1994) (Bishop et al., 2004; Kabat- Zinn, 1994) What is Mindfulness?

4. Mindfulness and Relapse Prevention Relationship (Reactions, stories, judgment) Attention, Present, Nonjudging “Automatic”Past/FutureJudgment/Nonacceptance suffering pain Direct Experience (sensation, thought, “feeling tone”)

5. Practicing Mindfulness Notice wandering, begin again Attention Wanders Mind on chosen target (Attention) (Present Moment) (Nonjudgment)

6. 1960s – 70s “Vipassana” popularized by psychotherapists and Western teachers (Goldstein 1976; Goldstein and Kornfield, 1987) Mindfulness: Modern History 500 B.C. Spanned countries / cultures for thousands of years (Hinduism, Christianity, Islam, Buddhism) 19 th century Came to the West via practitioners immigrating to U.S. from Asia 1990s – present “Third wave” integrates mindfulness into CBT

7. “Mindfulness-Based” Treatment  Psychological and medical benefits –Depression (Teasdale et al., 1995 Ma & Teasdale, 2004; Bondolfi et al., 2010; Kuyken et al., 2008; Segal et al., 2010) –Anxiety (Koszycki et al., 2007) –Fibromyalgia (Sephton et al., 2007) –Cancer (Monti et al., 2006; Hebert et al., xx; Speca et al., 2000; Foley et al, 2010) –HIV (Creswell et al, 2009) –Back pain (Morone et al., 2008) –Rheumatoid arthritis (Pradhan et al., 2007) –Multiple sclerosis (Grossman et al, 2004; 2010) –Med and premed student stress (Shapiro et al., 1998) –Binge eating (Kristeller & Hallet, 1999) –Addiction (Brewer et al., 2009; Bowen et al., 2006; 2009; 2010; Zgierska et al., 2009; Vieten et al., 2009)  Psychological and medical benefits –Depression (Teasdale et al., 1995 Ma & Teasdale, 2004; Bondolfi et al., 2010; Kuyken et al., 2008; Segal et al., 2010) –Anxiety (Koszycki et al., 2007) –Fibromyalgia (Sephton et al., 2007) –Cancer (Monti et al., 2006; Hebert et al., xx; Speca et al., 2000; Foley et al, 2010) –HIV (Creswell et al, 2009) –Back pain (Morone et al., 2008) –Rheumatoid arthritis (Pradhan et al., 2007) –Multiple sclerosis (Grossman et al, 2004; 2010) –Med and premed student stress (Shapiro et al., 1998) –Binge eating (Kristeller & Hallet, 1999) –Addiction (Brewer et al., 2009; Bowen et al., 2006; 2009; 2010; Zgierska et al., 2009; Vieten et al., 2009)

8. “Mindfulness-Based” Interventions “Mindfulness-Based” Interventions  Formal Meditation Practice  “Home practice” –6 out of 7 days, 30-50 minutes  Interventions Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1986; 1992) Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Teasdale & Williams, 2000) Mindfulness-Based Relapse Prevention (MBRP) (Bowen, Chawla, & Marlatt, 2009)  Formal Meditation Practice  “Home practice” –6 out of 7 days, 30-50 minutes  Interventions Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1986; 1992) Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Teasdale & Williams, 2000) Mindfulness-Based Relapse Prevention (MBRP) (Bowen, Chawla, & Marlatt, 2009)

9. Mindfulness-Based Stress Reduction (MBSR) Developed for management of chronic pain and illness Jon Kabat-Zinn, Ph.D. and colleagues, 1979 64 studies: Significant effects in chronic pain, stress, cancer, psoriasis, anxiety and depression (Grossman, Niemann, Schmidt & Walach, 2003)

10. Mindfulness-Based Cognitive Therapy Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale 2002) Prevent relapse to major depression Awareness  Change Recognize cognitive patterns in mild sadnessRecognize cognitive patterns in mild sadness Moods remain mild and transient vs. escalate to severe affective statesMoods remain mild and transient vs. escalate to severe affective states

11. “… essential to understanding how the mind behaves and how thoughts and expectations can either facilitate or reduce the occurrence of addictive behavior.” Marlatt, G. A. (2002). Cognitive and Behavioral Practice, 9(1), pp. 44-49.

12. Behavioral Model of Relapse Fear Guilt Shame Temporary alleviation Relapse Cycle Hopelessness “I’m a failure” “Automatic” Trigger Substance Use Craving Discomfort, Dissatisfaction Vulnerabilities, Predispositional Factors

13. Attention:Present moment: Acceptance and Nonjudgment: Mindfulness and Substance Use Direct observation of the mind Awareness of triggers and responses and responses Interrupt previously automatic behavior Acknowledge/attend to present experience Accept the unchangeable; “defuse” from attributions and thoughts that often lead to relapse

14. Dismantling and Bringing Curiosity Thought Emotion Urge to React CRAVING Underlying Needs Craving Use Curiosity Curiosity Sensation

15. “Urge Surfing” Staying with discomfort as it grows, Using breath to stay steady, Trusting it will naturally subside Trusting it will naturally subside Time Intensity

16. Meditation in Jail Funded by National Institute of Alcohol and Alcoholism; PI: G. Alan Marlatt Minimum security jailMinimum security jail Substance use chargesSubstance use charges 10-day Vipassana (“Insight”) meditation10-day Vipassana (“Insight”) meditation Led by appointed teachersLed by appointed teachers “Noble Silence”“Noble Silence” ~ 10 hours per day of practice~ 10 hours per day of practice Focus on “attachment” vs. substance useFocus on “attachment” vs. substance use

17. Outcomes Nonrandomized Nonrandomized (No BL differences on key demographic or outcome variables) 3-Month follow-up 3-Month follow-up Substance Use Substance Use Marijuana, Crack cocaine, Alcohol, Negative consequences Marijuana, Crack cocaine, Alcohol, Negative consequences Psychosocial OutcomesPsychosocial Outcomes Psychiatric symptoms (depression, anxiety, hostility) Psychiatric symptoms (depression, anxiety, hostility) Optimism Optimism (Bowen et al., 2006; 2007) 61% Caucasian 13% African American 8% Latino/a 8% Native American 3% Alaskan Native 2% Asian/PI 5% multiethnic or other N = 173 79% men Age 37 N = 173 79% men Age 37

18. Mindfulness-Based Relapse Prevention Strategies and practices from several sourcesStrategies and practices from several sources Integrates mindfulness meditation and cognitive therapyIntegrates mindfulness meditation and cognitive therapy Clients have completed initial treatmentClients have completed initial treatment 8-week outpatient group treatment 8-week outpatient group treatment 2-hour weekly sessions 2-hour weekly sessions EACH SESSION Formal meditation practice Formal meditation practice “Informal” mindfulness practice “Informal” mindfulness practice Cognitive Behavioral skills Cognitive Behavioral skills Relapse Prevention Mindfulness-Based Cognitive Therapy For Depression Mindfulness-Based Stress Reduction

19. Eating a Raisin: Shifting out of “Autopilot” Body Scan: Body awareness, Flexibility of Attention Breath, Thought, Emotion Meditation Awareness of processes Urge Surfing: Relating to Discomfort Kindness, Forgiveness: Shame, Self-Efficacy Routine Activities: Continuous attention, natural reinforcement

20. Inquiry: Practice through Dialogue Pain in left knee, Restlessness “I can’t meditate” Affective discomfort “I can’t handle this. I need a drink.” (craving) Direct Experience (sensation, thought, feeling tone) pain Relationship (Reactions, stories, judgment) suffering

21. Familiarity with Individual Patterns

22. External, tangible Body sensations Thoughts, emotions, and their nature Pause in midst of difficulty, curiosity, what is really needed? Progressive Awareness Training Compassionate and skillful responding Awareness and freedom

23. N = 168 MBRP Pilot Study Completed Inpatient or Intensive Outpatient 8 weeks MBRP TAU Post Course Post Course 2 mos. 4 mos 4 mos Baseline (12-step, Psychoeducation, Process/Support) Funded by National Institute on Drug Abuse Grant R21 DAO 10562-01A1; PI: Marlatt

24. Participants 72% completed high-school 72% completed high-school 41% unemployed 41% unemployed 33% public assistance 33% public assistance 62% less than $4,999 / year 62% less than $4,999 / year Homeless/unstably housed Homeless/unstably housed 50% Caucasian50% Caucasian 28% African American28% African American 15% Multiracial15% Multiracial 7% Native American7% Native American Age 41; 64% male Age 41; 64% male 45% alcohol 36% cocaine/crack 14% methamphetamines 14% methamphetamines 7% opiates/heroin 7% opiates/heroin 5% marijuana 5% marijuana 2% other 2% other

25. Results: Feasibility Attendance Attendance 65% of sessions (M = 5.18, SD = 2.41) (M = 5.18, SD = 2.41) Formal Practice Formal Practice 4.74 days/week (SD = 4.0) 4.74 days/week (SD = 4.0) 29.94 minutes/day (SD =19.5 ) 29.94 minutes/day (SD =19.5 ) (Bowen et al., 2009)

26. Results: Main Effects Across 4-month follow-up, significant differences between groups: Mindful awareness (p =.01)Mindful awareness (p =.01) Acceptance (p =.05)Acceptance (p =.05) Craving (p =.02)Craving (p =.02) Substance Use at 2 months (p =.02)Substance Use at 2 months (p =.02) Significant mediating effect of cravingSignificant mediating effect of craving (Bowen et al., 2009)

27. Total sample Results: Depression and Craving Craving Significant mediating effect of craving Substance Use Depression Substance Use Craving Depression MBRP (Witkiewitz & Bowen, 2010) Non- Significant

28. N = 286 Funded by National Institute on Drug Abuse Grant 8 weeks MBRP TAU Post Baseline RP 6m 12m 4m 2m Randomized Trial For whom? How? (12-step, Psychoeducation, Process/Support)

29. Participants 92% high-school or GED 92% high-school or GED 71% unemployed 71% unemployed 59% less than $4,999 / year 59% less than $4,999 / year 65% Caucasian65% Caucasian 31% African American31% African American 10% Latino/a10% Latino/a 15% Multiracial15% Multiracial 2% Native American2% Native American Age 40.6 (11.69) Age 40.6 (11.69) 75% male 75% male (Bowen et al., in press) Primary Substance

30. Days of Use over Time (Bowen et al., in press)

31. Primary Outcomes Delay to use, Lower likelihood of use, Fewer days of use Delay to use, Lower likelihood of use, Fewer days of use MBRP (vs RP & TAU) MBRP (vs RP & TAU) Day of drug use at 12 months Day of drug use at 12 months Likelihood of any heavy drinking Likelihood of any heavy drinking MBRP & RP (vs TAU) MBRP & RP (vs TAU) Delay to first use Delay to first use Fewer days of use at 6 months Fewer days of use at 6 months

32. Limitations Attrition Attrition Differences between TAU and active treatment groups, (e.g., therapist training, assignment of homework) Differences between TAU and active treatment groups, (e.g., therapist training, assignment of homework) RP and MBRP interventions matched on time, structure and therapist training RP and MBRP interventions matched on time, structure and therapist training Primary treatment outcome measures self-report, with limited urinalysis data Primary treatment outcome measures self-report, with limited urinalysis data Self-reported substance use and urinalysis are often not significantly different (e.g., Jain 2004; Digiusto et al., 1996) Self-reported substance use and urinalysis are often not significantly different (e.g., Jain 2004; Digiusto et al., 1996) Continued aftercare  low base rates of use at follow up Continued aftercare  low base rates of use at follow up

33. Adaptations Adult correctional system with Det. Kim Bogucki Seattle Police Department, WA Seattle Police Foundation, WA Juvenile justice system with Dr. Kevin King Greenhill Juvenile Corrections School, WA University of Washington, Seattle WA Tobacco Cessation with Isabel Weiss, Dr. Elisa Kozasa Universidade Federal de São Paulo, Brazil

34. “I paused and watched my breath … The urges and thoughts would keep poking their heads up, but they got quieter and just weren’t as big of a deal... I sat until I didn’t feel like I had to act on these thoughts and feelings. Finally, I saw the situation clearly; I could make a different choice.” “[I have] more patience with myself, compassion. Ways to get me back into what is happening and get out of my head.” “ I am now able to regularly ‘surf’ those kinds of [triggering] situations, not just with drinking but any other discomfort or unpleasant states.” Client Experiences

35. AcknowledgmentsInvestigators: G. Alan Marlatt Katie Witkiewitz Mary Larimer Seema Clifasefi Consultants: Zindel Segal Jon Kabat-Zinn Research Team: Neha ChawlaErin Harrop Joel GrowHaley Douglas Sharon Hsu Kathy Lustyk Susan Collins Sara Hoang University of Washington