Mindfulness-Based Relapse Prevention Program for Treatment of Addictions

TABLE OF CONTENTS

ABSTRACT

ACKNOWLEDGEMENTS

DEDICATION

TABLE OF CONTENTS

LIST OF SYMBOLS, ABBREVIATIONS AND NOMENCLATURE

PART I: MINDFULNESS AND ADDICTIONS

PART II - PARTICIPANT’S MANUAL

REFERENCES 190

ABSTRACT

The construct of mindfulness has become a very strong influence in current changes to interventions in the area of stress reduction, depression relapse and is now seen as relevant to addiction relapse prevention. This paper explores some of the background materials pertinent to the construct and inclusion of mindfulness in treatment. Models of addiction and addiction relapse prevention are then explored leading to the current dynamic modelling. Finally the model of Mindfulness Based Relapse Prevention, which has been proposed by a number of authors, is explored. A proposed manual to integrate the previous work in relapse prevention while supporting it with a current model of mindfulness, will give shape to this emerging reality building on existing relapse prevention programs and mindfulness-based therapy.

ACKNOWLEDGEMENTS

I would like to acknowledge the work of all those involved in the line of research on mindfulness from Jon Kabat-Zinn to the inclusion of this research in the development of a relapse prevention program for depression by Segal, Williams and Teasdale. I would also like to acknowledge the work of Marlatt and colleagues for their early recognition of the impact that the inclusion of meditation and mindfulness would have on treatment programs for relapse prevention in addictions as well as their current research of these programs. Without their hard work I would not have been able to write this paper. I would like to acknowledge Maureen Angen for her work in the application of mindfulness to support survivors of cancer in learning to live life more fully again. The manual from the Tom Baker Cancer Clinic is an excellent example of the integration of mindfulness-based intervention into treatment.

DEDICATION

The paper is dedicated to the support that my wife, Holly, and my children, Kayla and Ethan, have given me in the completion of this master’s program. Their patience and understanding are deeply appreciated. It is also dedicated to the many individuals who have given their time to the development of an online campus at the Campus Alberta Applied Psychology program, which allowed this to happen. Finally I wish to dedicate this also to the first full group of students to enter the program in January 2003. It is the spirit of curiosity, adventurousness, patience and generosity that allowed this cohort to survive the trials and tribulations inherent in the start-up of such an innovative program.

LIST OF SYMBOLS, ABBREVIATIONS AND NOMENCLATURE

Abbildung in dieser Leseprobe nicht enthalten

PART I: MINDFULNESS AND ADDICTIONS

Chapter I: The Background

Introduction

Bringing the new field of Mindfulness into play as an intervention for addictions is the overarching goal of this project. In order to do this, two areas of study will intersect in this paper. First the study of “mindfulness” and the use of “mindfulness-based” therapy in the development of treatment programs for a variety of disorders will be delineated. Secondly the study of addiction and recovery will be considered. There are also three themes that are interwoven into the discussion of these two areas. One of these is neurology; studies of neurological changes from mindfulness, addiction and treatments for mental health and addictions will be considered. The second theme is the relapse process and relapse prevention programs. This is discussed within the mindfulness-based therapies primarily as relapse prevention in the mental health disorders, but also with some applications to addictions in the form of the development of mindfulness-based relapse prevention. The third theme is spiritual awareness and meaning.

To begin with in order to keep the discussion of mindfulness-based treatment in context, the background section of this paper will start with a brief examination of the use of Complimentary and Alternative Medicines (CAM) in therapy with a focus on mind- body therapies and addiction. Then there is a discussion of spirituality with its evolving role in therapy. Spirituality has been a part of informal and formal treatment, particularly with addictions but until recently spirituality has not been extensively recognized or studied. A construct of spirituality will be discussed, which leads into alternative types of treatment and some current trends integrating this component into treatment models.

In Chapter II the use of mindfulness in treatment programs will look at where the practice comes from within Buddhist psychology and how it is described as a construct within western psychology. Next, how mindfulness has been incorporated into a Mindfulness-Based Stress Reduction (MBSR) program and Mindfulness-Based Cognitive Therapy (MBCT) will be explored. The variety of mindfulness-based interventions will be outlined and a focus on Kabat-Zinn’s (1990) and Segal, Williams and Teasdale’s (2002) programs will be taken. This leads into the discussion of the research into mindfulness-based treatments and the ingredients common to mindfulness-based treatments. This section closes with the discussion of the research on the neurology of mindfulness.

In Chapter III the literature of addictions will be discussed including the scope of the problem, a brief review of the areas of neurology of addiction, methamphetamines as an example, the development of addictions treatments with a focus on the Matrix program, and the Transtheoretical Model (TTM) as a model of readiness to change. In Chapter IV relapse in the addictions field will be discussed and the currently accepted models for relapse prevention. The precipitants of relapse and the ingredients that are used in relapse prevention treatment will be examined and proposals of a dynamic model of addictions and recovery will be discussed. In conclusion a growing number of addiction researchers are working on the inclusion of mindfulness in relapse prevention. The theory and research behind Relapse Prevention (RP) and mindfulness in the identified existing programs will be examined and used to produce a facilitator and participant’s manual for a Mindfulness Based Relapse Prevention (MBRP) program. The development of a MBRP program works towards bringing the areas of mindfulness and addictions and the three themes of neurology, relapse prevention and spiritual awareness together in the translation of theory and research to fieldwork.

Complimentary and Alternative Medicine in Therapy

Complementary and alternative medicines (CAM) are medical practices not in conformity with the standards of the medical community, which most patients use along with, not in replacement of, traditional medical care. CAM’s recognizes the link between a person’s body, mind, and spirit in creating a more holistic approach to patient care. Mind-body therapies are coming to have a special importance and popularity as informed consumers take control of their health. This movement is paving the way for interventions using meditation. In a study of psychotherapy clients, the degree that clients seek help through CAM’s was found to be of increasing importance to our understanding of clients. Elkins, Marcus, Rajab, and Durgam (2005) studied a group of two hundred and sixty two clients of a mental health clinic. The authors found the clients used CAM’s, including such treatments as acupuncture, herbal supplements and meditation in the treatment of a variety of mental health problems. They found the use of mindfulness meditation was common in clients dealing with stress, anxiety and depression. Of the clients surveyed 64% had used at least one CAM therapy in the last six months, 44% being mind-body therapies. “Relaxation and mental imagery were the most frequently cited mind-body therapies for anxiety (47%) and depression (29%)” (p. 233).

In a study of the use of CAM’s by intravenous drug users (IDU) Manheimer, Anderson and Stein (2003) found that the top three therapies were in the “mind-body” domain. About 45% of the IDUs engaged in some form of CAM with the highest rate (20%) using religious healing (prayer and spirituality), 18.9% used relaxation techniques and 14.5% used meditation. The study participants who used CAM therapies rated them 4.1 out of 5 for effectiveness. Out of the total sample, the IDU’s were more likely to be using a CAM therapy if they had a higher education or reported a lower health related quality of life. The authors postulated that persons with lower educations could have lower usage because of the reduced access to information about CAM therapies. The authors conclude by stating:

If these therapies are truly effective for health promotion and for managing chronic illness, they may have a particular relevance for a marginalized population such as IDUs, who as a group have a heavy disease burden and at the same time are underserved by conventional medicine... a significant number of them are now turning to CAM, perceiving benefit from CAM use, and using it for reasons specifically related to their addiction. (p. 411)

This study indicates an acceptance, applicability and possible efficacy of mind-body techniques in the treatment of addictions. Specifically it speaks to the use of spirituality in change and maintenance and the possibility of meditation as an avenue of service delivery. The highest proportion of respondents identified religious healing as a CAM they have chosen. Further evidence of the acceptance of spiritually based services by IDUs comes from a study by Arnold, Avants, Margolin, and Marcotte (2002) that found: Participants thought that addressing spirituality in addiction treatment would be helpful in their recovery, for reducing craving, for reducing HIV risk behavior, for following medical recommendations, and particularly for increasing hopefulness. The vast majority expressed an interest in receiving a spirituality-focused intervention. (p. 324)

These studies show the importance in understanding spirituality in treatment.

Spirituality in Treatment

In the study of addiction, spirituality is important in the context of this paper for a number of reasons. “Twelve Step” groups have long linked recovery from addictions to spiritual development in a general sense. In the Alcoholics Anonymous (AA) “Big Book” (Alcoholics Anonymous World Services, 2001) the terms “spiritual experience” and “spiritual awakening” are used many times when discussing a “power greater than ourselves” as the essence of spiritual experience. In the “AA Big Book” that power greater than ourselves is described as “Creative Intelligence, a Spirit of the Universe underlying the totality of all things” (p. 46). In chapter four the authors describe in some detail their beliefs and reasons for these beliefs about spirituality and these are the basis for the 12-Step program. Similar to AA, authors DiLorenzo, Johnson and Bussey (2001) talk about spirituality in addictions recovery. They believe a “significant difference exists between religion (a discreet value system and set of traditions) and spirituality” (p. 259). They relate to spirit as “our ability to contemplate the purpose of our existence, ways to better ourselves, to delay our gratification and to think about the long-term consequences of our actions” (p. 259). In describing addictive behaviour they believe it “can be understood within the context of this detachment from spiritual self and from the wider social community” (p. 260). Their discussion contains a number of ingredients identified in the definition earlier. This detachment leads to an inability to love and trust, which affects parental bonding and can have dramatic generational consequences.

Miller (1998) proposed that the study of spirituality in the treatment of addictions should include a study of the role of spiritual variables; “(1) as risk or protective factors for substance use and problems; (2) as elements of the course of addiction disorders; (3) as dependent variables influenced by alcohol/drug use; and (4) as components of the recovery process” (p. 981). Poage, Ketzenberger, and Olson (2004) completed a study of 53 AA members (35 male, 18 female) and found that years of sobriety “was significantly positively correlated with scores on the SAS (Spirituality Assessment Scale) (r = .527, P < .001), indicating that people with more years of sobriety felt more spiritual than those with fewer years” (p. 1859). A study of 22 randomly selected individuals who had completed a 28-day Minnesota Model treatment program (based on the first steps of AA) indicated through self and family questionnaires that the use of prayer or meditation is positively correlated with abstinence (Johnsen, 1993). In a five year follow-up on 708 cocaine dependent individuals, where 235 werejudged to be in recovery by no drugs detected in urine or hair specimens, no self-reported use of any drugs, less than daily alcohol use, and no illegal activity or arrests during the past year, Flynn, Joe, Broome, Simpson, and Brown (2003) found:

Besides motivation and drug treatment experiences, individuals in recovery credited religious/spiritual life and the support of family as key factors. Although the patient’s spiritual life has been generally neglected by researchers in their attempts to understand the recovery process, a link has been identified between spirituality and both positive life orientation and level of social support among recovering individuals. In the current study, attributions of the importance of spirituality to recovery provide additional support for this element in the recovery process. For many patients, spirituality may offer a source of support that can be targeted through strategies including, but perhaps not restricted to, the use of twelve-step groups, (p. 407)

The authors argue that this spiritual life factor has long been considered important to the long-term stability of the recovery process. Research supports the need for attention to spirituality as an aspect of the treatment of clients for addictions; an ongoing problem is defining spirituality.

Through a “MEDLINE” and “PsychlNFO” search for all articles on addictions and spirituality prior to 2002, Cook (2004) identified 265 articles using a range of components to define spirituality. Cook found: “The ‘relatedness’ and ‘transcendence’ components appear to be the most important. ‘Core/force/soul’ and ‘meaning/purpose’ were the next most commonly encountered, albeit three to four times less frequently” (p. 547). Using this information the author came up with the following comprehensive definition:

Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions. It may be experienced as relationship with that which is intimately ‘inner’, immanent and personal, within the self and others, and/or as relationship with that which is wholly ‘other’, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values. (p. 548-549)

This definition of spirituality is a step towards identifying and clarifying the complexity of a concept that is often expressed in the literature and gives more structure than has previously been available. This structure includes a number of factors: the inner awareness and insight, outer experience of relatedness or connectedness, felt relationship to something greater than the individual, and the individual meaning of this inner experience and sense of purpose. These factors are also found in the discussions of experience of the metacognitive and mindfulness. When we are looking at insight meditation and mindfulness remembering this definition will help in the discussion of its nature especially in the Buddhist beliefs about how one ought to think and act.

An ongoing issue is the spiritual beliefs of facilitators and how those interact with the spirituality of clients. Gilbert (2000) found that group facilitators were including spiritual content in the group planning and validating the appropriateness of spiritual content in the group participation because of the belief system of the clients. The facilitators had not received training but over time had moved towards an inclusion of spirituality in an attempt to work in a holistic and culturally relevant manner. The author contends that spirituality is something that needs to be considered when working with clients. This leads to some implications for practice such as the appropriate assessment of the spiritual issues for the client, assessment by the practitioner of their own spiritual beliefs and beliefs about other’s spirituality, maintaining a balanced respectful attitude within the group because of the differences of individual attitudes that may emerge, the issue of transference and counter transference, and “the need for techniques of intervention that enhance spirituality as a support and prevent its misuse” (p. 81). The author concludes that:

Professional social workers cannot continue to exclude a significant, sometimes central, dimension of an individual’s identity in social work group practice and education. Spiritual values, beliefs, and practices are not only keys to culturally competent assessment, but sources of resources for many clients who cope with the challenges of living, (p. 82)

The author points out that the inclusion of spirituality is important but it also has to be done with awareness by the therapist of the possible barriers to its effective use. This indicates just how seriously training in the use of spirituality needs to be taken.

D’Souza and Rodrigo (2004) have developed a new model of therapy called Spiritually Augmented Cognitive Behaviour Therapy (SACBT), which focuses on meaning, purpose and connectedness in the context of the client’s belief system with particular focus on acceptance, hope, achieving meaning and purpose, and forgiveness. The behavioural focus is on relaxation, meditation and prayer/ritual exercises. These foci are very similar to the mindfulness therapies we will discuss later. SACBT has been developed into a 16 session semi-structured manualized format. In the study:

Randomized controlled trials comparing SACBT and supportive therapy in patients with depression and demoralization found significant improvement in treatment groups over controls in the second to third week. Another randomized controlled trial... found significant benefits over controls in improving treatment adherence and reducing hopelessness and despair. The results of the trials have not only shown SACBT’s benefits .but, importantly, significantly better treatment adherence, lower adverse effects of treatment and lower relapse compared to controls at 12 month follow up. (p. 151)

SACBT is an example of an emerging trend toward integrating mind-body and spiritual ingredients into a new model in order to increase effectiveness in addictions therapy.

The research is supportive in linking spirituality to the activity of treatment and recovery and should not be ignored. The evidence supports the inclusion of spirituality in addictions treatment to move the individual toward a state of ongoing recovery. The addition of spirituality to the biopsychosocial model provides us with a holistic version of addictions interventions. The exploration of how spirituality fits into recovery and treatment will continue to be an important thread in this paper as we move on to look at the construct of Mindfulness.

Chapter II: Mindfulness

Introduction

This chapter explores mindfulness and its applications. The Buddhist psychology, with its focus on the particular practice of Vipassana meditation and the more recent developments of this practice, will give the background elements that become a part of the proposed treatment model. Buddhist psychology is discussed as the ground of mindfulness meditation and its’ delineation of change through discussion of the “middle way” is described. The two major types of meditation that have been introduced in the west, Transcendental Meditation (TM) and Mindfulness Meditation (MM) are explored. The discussion supports the decision to use MM in the development of a treatment manual.

Next the definitions of mindfulness in western psychology are explored through some of the disagreements. The main focus of this section is to represent the diversity of western positions on what mindfulness is, through two major conflicting positions. From that diversity the mindfulness-based therapeutic model with its central component of MM is chosen and the reasons are given. This leads into the discussion of two examples of the application of Mindfulness-Based therapy (MBSR and MBCT) with the main focus to document the development and central features of the two mindfulness based treatment programs and a narrower focus on MBCT because of its use as relapse prevention. The Interacting Cognitive Subsystems (ICS) model, which forms a western look at what is happening and why it is effective, is used to describe how mindfulness works.

The research section looks at why MBSR and MBCT have credibility in the development of a relapse prevention program. The research evidence for both of these treatment models is given and then the ingredients of the two models are explored. Then the main ingredients of MBSR and MBCT that will be incorporated into the manual are discussed and summarized, as well as the cognitive components of MBCT. Finally the chapter will finish with some of the neurological research on MM. This will be an ingredient in the manual to support understanding how the brain adapts based on the activity it does. The goal of this section is to explore how the activity of the neurons that takes place during mindfulness changes the structure of the neurons through neurological adaptation. This same process of adaptation will apply when looking at AOD usage. Buddhist Psychology

Mindfulness is in its infancy in the West and yet has a history that goes back 2500 years in the east. Siddhartha Gautama lived sometime between 600 and 400 BC and taught the original teachings on mindfulness. He taught a system of thinking that put human awareness at the centre of our understanding of reality. Ajahn Sumedho (2002) states Siddhartha’s four noble truths, the most fundamental principles of Buddhist psychology, as: first, “There is suffering” and “Suffering can be understood”; second, “there is desire” and “desire can be let go”; third, “all that is subject to arising is subject to ceasing” (all mental events); fourth, “there is a way out of suffering and it can be developed”. The fourth principle is represented in Buddhism as the “middle way”, elaborated by the “eight-fold path”, which delineates the way to end human suffering. It is achieved in the “eightfold path” by developing true wisdom in steps one and two through right understanding and intention, true moral commitment in steps three to five through right speech, action and livelihood, and true emotional balance in steps six to eight through right effort, mindfulness and concentration. The eight-fold path is not to be taken as a linear process because the eight parts are interdependent and interrelated. Each step supports the others as a group and all steps have different levels of insight. Mindfulness meditation is expanded upon specifically in steps six through eight of the path. The path explains how we should meditate and places meditation at the centre of mindfulness practice. It is required from a Buddhist psychological perspective that all teachers of mindfulness have a person practice of mindfulness.

An addictions researcher, Marlatt (2002) reviewed Buddhist psychology and the application to addiction treatment and relapse prevention. This author has used the Buddhist model of addictions and addictions treatment for a number of decades and included it in the “lifestyle balance intervention” based in part on Vipassana meditation and the “middle way” taught by Siddhartha. The Buddhist psychological view, that our mental states create much of the suffering that we experience, that we can think differently and that we can find a way out of suffering is similar to the fundamental principles of post-modern Western counselling psychologies (Marlatt, 2002). A difference between the two is that “as a means of directly observing the ‘behavior of the mind,’ meditation (offers) many advantages as a technique for self-monitoring thoughts and feelings in an atmosphere of acceptance and (non-judgemental) objectivity” (p. 45). In Buddhism the outcome that comes with the practice of mindfulness meditation is a state of being aware and observing the activities of the mind withoutjudgement or attempting to control those activities. In contrast most Western psychology is based on the individual learning to control and change their thoughts and therefore to control and change their emotional responses. Buddhism considers this judgement of the mental states and view of certain thoughts as unacceptable as the basis of an unhelpful internal conflict.

What is described in Buddhist psychology as the “art of living” or how one “ought to” do things in the world or the “right way” provides a direction for change in the individual’s life. This adds to treatment the process of disconfirming previously established ways of thinking. Buddhism states that attachment or craving is suffering and this is the way out of suffering. Siddhartha taught that four mental qualities of loving­kindness, compassion, altruistic joy and equanimity are important to cultivate. They can transform our lives and the world giving beauty, joy, and meaning. These qualities are based in an attitude of unconditional acceptance and are cultivated toward all living beings. The Buddhist way of being in the world is based on these qualities. The Dalai Lama, current leader of Tibetan Buddhism, is described by Time Magazine (August 23­30, 1999) as a living icon of what he calls "our common human religion of kindness”.

Meditation has been used across many centuries in many cultures. There are a wide variety of types of meditation. Germer, Siegel, and Fulton (2005) describe the two most researched forms of meditation; concentration and mindfulness: the former is often represented in the West by Transcendental Meditation (TM) and the latter by Vipassana Insight or Mindfulness Meditation (MM). Each of these will be considered in turn. Transcendental Meditation

As the most common form of concentration meditation in the West, TM has practitioners repeat a silent word or phrase (a mantra) with the goal of quieting (and ultimately transcending) the ordinary stream of conscious thoughts. TM has commonly been represented in the West by Maharishi Mahesh Yogi (1966) and has had a considerable history of research. Aron and Aron (1980) summarized a number of studies investigating the use of TM in the treatment of addictions that showed promising results and they felt that TM had considerable potential in the treatment of addictions that warranted more research. On the other hand Canter and Ernst (2004) felt that the research has important methodological weaknesses and that “It is important that any future research in this area be carried out by fully independent researchers without any affiliation to, or involvement with, institutions of the TM organization” (p. 2053). The position taken by its’ leader, the Maharishi Mahesh Yogi, and the TM movement is that their paid trainers are the only individuals who can teach TM. This concern over inherent bias is a considerable weakness that weighs against the inclusion of TM as an ingredient in treatment.

Mindfulness or Insight Meditation

The second type of meditation, MM, may be described as a form in which practitioners simply observe or attend to thoughts, emotions, sensations, perceptions, and other mental activity (withoutjudgment and with total acceptance) as they arise moment by moment in the field of awareness. This second form may also be referred to as Vipassana or Insight meditation. S.N. Goenka, an influential teacher ofVipassana meditation, started Vipassana centers around the world and used MM to form the basis of treatment withinjails and for addictions. MM has become the basis of a variety of mindfulness-based therapies in the West starting with the work of individuals like Kabat- Zinn (1990) to the present.

One of the underlying beliefs of mindfulness practice in all its permutations is that mindfulness meditation helps to alleviate psychological suffering (Germer, et al., 2005). These applications could generally be seen as treatment to reduce relapse from a variety of mind-body problems. In “The Essentials of Insight Meditation” the Venerable Sujiva (2000) states: “The main aim of Buddhist Meditation is to purify the mind of all negative tendencies - such as greed, anger and delusion, through mind control. When all negative tendencies are removed, the mind will be freed from suffering.” (p. 9). This state of “right mindfulness” cultivated through meditation is highly relevant to the treatment of addictions. The cultivation of mindfulness traits such as forgiveness, acceptance and loving-kindness can heal the shame and guilt that build up during the addiction process. Right mindfulness also involves clear, alert and calm awareness that promotes truthfulness or accurate assessment of the events in the mind, which helps the individual to be truthful to them-selves. The Venerable Sujiva describes addictions in this way:

A good picture of craving can be seen in one who is suffering from addiction. If you are a drug addict or are addicted to cigarettes but your drug or cigarette is not available, when you look at the state of mind you can see how terrible it is. When craving arises in the same way, you look at the nature of craving. ft is a state of wanting, clinging, and so on. This craving and anger arises very often. ff you can catch it every time and nip it in the bud, then it will not disturb you (p. 65).. .Once you have started getting hold of intentions, you find that the mind actually has a life of its own. You think you are controlling the mind but the mind is controlling you more than you are controlling it. ff a person is not mindful, he acts largely on impulses. He is not aware of his actions. That is why things like addictions arise (p. 69).

This discussion of addictions from a Buddhist psychology perspective is a good example of the application generally of mindfulness to the elements of cravings and triggers. Buddhism is psycho-educational in that it sees addiction as the lack of awareness or ignorance of how suffering is created by the craving or desire and treatment involves learning to develop insight and awareness. Buddhist psychology recommends and invites the practice of mindfulness in the events of everyday life (informal) and in mindfulness meditation (formal) practice. Mindfulness is a mental state of non-doing that changes the mind’s relationship in an experiential way to mental and environmental events. This is practiced through formal meditation and it is applied in the process of experiencing daily life (Kabat-Zinn, 1990).

Defining Mindfulness in Western Psychology

There has been considerable controversy in the west over the use of mindfulness in therapy. One reason is two very distinct models that have been called mindfulness therapies. The first includes therapies based on behavioural therapy: Acceptance and Commitment Therapy (ACT), Dialectic Behaviour Therapy (DBT), as well as the work of Langer (Hayes, Follette, & Linehan, 2004), and the second includes therapies based on Mindfulness Meditation: Mindfulness-Based Stress Reduction (Kabat-Zinn, 1990), Mindfulness-Based Cognitive Therapy (Segal, et al., 2002), and Mindfulness-Based Relapse Prevention (Witkiewitz, Marlatt, & Walker, 2005). It is important to identify these alternative models in order to understand the differences in the research and why the therapies supporting mindfulness meditation will be the focus of this paper. The following is a brief summary of how these therapies have defined mindfulness.

Radical behaviourism models: Hayes and Wilson (2003) worry that other therapies based on mindfulness meditation signify “a new package that validates and dignifies the importance of human thoughts and feelings and their role in human suffering” (p. 165). They state from the ACT perspective: “the problem is not the presence of particular thoughts, emotions, sensations, or urges: It is the constriction of a human life. The solution is not removal of difficult private events: It is living a valued life” (p. 165).

Hayes and Shenk (2004) argue that mindfulness should not be linked to a particular technique such as meditation as it has been in MBSR, MBCT or MBRP. Within a model of radical behaviourism, functional contextualism, and relational frame theory, Hayes, Luoma, Bond, Masuda, and Lillis (2006) discuss mindfulness and acceptance in ACT as a functional process defined through observable behaviour involving: “acceptance, defusion, contact with the present moment, and self as context” (p. 9). Hayes and Shenk (2004) argue that this does not have to be defined by reference to internal states nor involve the practice of mindfulness meditation because it can be produced by a number of techniques or exercises, which are proposed in ACT and other acceptance therapies.

In another behavioural model, Dialectic Behaviour Therapy (DBT), McMain, Korman and Dimeff (2001) define mindfulness through skill development in non- judgmentally observing and bring one’s full attention to current experience. In DBT the dialectic is between change during therapy and acceptance of how things are and thereby “according to Linehan (1993), increasing mindfulness of current emotional experience functions as an informal exposure to negative emotions, which over time helps to extinguish maladaptive avoidance responses” (p. 189).

DBT and ACT have a goal of cognitive flexibility through acceptance and change that is, Hayes, et al. (2004) state: “Similar to Langer’s (1989) analysis of mindfulness, flexibility seems to be a process goal of almost all these new methods” (p. 24). Langer’s definition of mindfulness is in juxtaposition to mindlessness or a state of mind that is overly reliant on past learning and cannot distinguish novelty in situations. Langer and

Moldovan (2000) defined the term mindfulness as cognitive flexibility where:

Mindfulness can best be understood as the process of drawing novel distinctions (that) can lead to a number of diverse consequences, including (1) a greater sensitivity to ones environment, (2) more openness to new information, (3) the creation of new categories for structuring information, and (4) enhanced awareness of multiple perspectives in problem solving, (p. 1-2)

As Hayes and Shenk (2004) state this idea of mindfulness is radically different then how mental events are treated within the Buddhist and cognitive models of MBSR or MBCT.

The mindfulness meditation model: The radical behavioural analysis tradition does not capture the understanding or central nature of mindfulness meditation practice in cognitive or Buddhist psychology. Within the therapies based on mindfulness meditation, Kabat-Zinn (1994) defines mindfulness as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (p. 4). Teasdale, Segal and Williams (1995) in their early work used the Attentional Control Training model, which defined mindfulness as defusion and attentional control but this changed. In the final development of MBCT the researchers defined mindfulness awareness as a newly identified mode of mind or the “being mode”. They identified mindfulness as metacognitive awareness or insight that is developed by the experience of mindfulness meditation and mindfulness practice (Teasdale, et al., 2002). Similarly Marlatt and Kristeller (1999) define mindfulness as: “to be aware of the full range of experiences that exist in the here and now. It is bringing one’s complete attention to the present experience on a moment to moment basis” (p. 68).

The construct of mindfulness: Given this variety of definitions of mindfulness, Bishop (2002) pointed out the need for an accepted definition of the construct of mindfulness. Bishop combined with a group of ten other colleagues (Bishop, et al., 2004) to develop a construct for research of mindfulness and defined mindfulness as follows:

We propose a two-component model of mindfulness. The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment. The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance.. .The notion of mindfulness as a metacognitive process is implicit in the operational definition that we are proposing since its evocation would require both control of cognitive processes (i.e., attention self regulation) and monitoring the stream of consciousness.. .we see mindfulness as a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiosity, experiential openness, and acceptance. We further see mindfulness as a process of gaining insight into the nature of one’s mind and the adoption of a de-centered perspective (Safran & Segal, 1990) on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence). (p. 232-234) Bishop et al.’s construct supports a better understanding of mindfulness within western psychology. Although ACT, DBT and Langer’s research have similarities to the above definition of mindfulness, they do not use the mindfulness component independently of the behaviour change strategies in the definition of mindfulness (Baer, 2002). The use of the term mindfulness in Buddhist psychology and researched as MBSR, MBCT and MBRP is based on both the formal and informal practice of mindfulness. This model accepts that the investigation of internal mental events and metacognitive awareness or insight is central to metacognitive insight training in the form of mindfulness meditation. To keep a consistent theoretical basis in the manual, it will be based on the Bishop et al., Kabat-Zinn’s MBSR, Segal, et al.’s MBCT and Marlatt’s MBRP. This fits cognitive and Buddhist psychology, has developed credibility through research (Baer, 2003), and has been implemented successfully in a variety of sites (Germer, et al., 2005). Mindfulness-Based Stress Reduction

Kabat-Zinn (1990) started a Stress Reduction Clinic based on mindfulness meditation at the University of Massachusetts Medical Center in 1979. Kabat-Zinn (1994) describes the practice of mindfulness as “simply a practical way to be more in touch with the fullness of your being through a systematic process of self-observation, self-inquiry, and mindful action” (p. 6). A central feature of Kabat-Zinn (1990) eight-week treatment program is the seven identified Attitudinal Foundations of Mindfulness: non-judging of internal and external experience -“assuming a stance of an impartial witness to our own experience” (p.33); patience - to “understand and accept the fact that sometimes things must unfold in their own time” (p. 34); beginners mind - “to see the richness of the present moment.. .willing to see everything as if for the first time” (p. 35); trust - “developing a basic trust of yourself and your feelings” (p. 36); non-striving - developing a stance of “non-doing”, of not being absorbed in “what has been or will be”, as a counter balance to the world of “doing” (p. 37); acceptance - “seeing things as they actually are in the present” (p. 38); and, letting go - non-attachment to the thoughts, feelings or other mental events, which “the mind wants to hold on to” (p. 39). These attitudes form the backbone of the treatment program that the author describes.

Kabat-Zinn gives instruction for the formal practice of MM, informal mindfulness practice and as the mindfulness attitudes are developed how to apply them to the events of the mind and activities of life. One of the main differences between this program and traditional cognitive behaviour therapy is that the individual is supported in relating to thoughts, beliefs and feelings from a state of awareness or being that is not attached to or dependent on any of these mind states. Kabat-Zinn’s (1990) book is a seminal work in the development of mindfulness-based therapy.

Mindfulness-Based Cognitive Therapy

Segal, et al. (2002) developed a new treatment for depression relapse based on the work of Kabat-Zinn. I will give some detail as I feel their experience speaks to the type of cognitive shift that is necessary for understanding the application of a similar MM model to relapse prevention for addictions. The authors were all cognitive behavioural therapists and firmly believed that they could find a more effective cognitive behavioural therapy to treat depression relapse. In the early stages of this process the authors were looking specifically at how the individual processes information. The components that they had identified as having a longer-term impact on reduction of depression were the development of defusion, attentional control and metacognition. This led to looking at the mental modes involved in depression (e.g. Metacognitive processing) in an effort to find a maintenance version of cognitive therapy that would prevent relapse. The authors explored the idea of “stepping back” from the thoughts which they identified as decentering. They found that it was similar to the “mindfulness” awareness that Kabat-

Zinn had described and after attending one session of the MBSR program decided to include MM as a decentering technique with the regular cognitive therapy components they had been using. They were told that they would need to start to practice mindfulness meditation themselves in order to work with the treatment group using it but they did not considered this as a requirement. The authors’ state:

We now had a theoretical model that emphasized the importance of changing patient’s relationships to their negative thoughts and feelings. We had moved away from thinking the key ingredient in cognitive therapy (the reason why it had such long lasting effects) was that it changed the person’s degree of belief in his or her thoughts and attitudes. Instead, we believe that the key was whether people could learn a decentered perspective on their patterns of thinking. (p. 45)

They developed Attentional Control Therapy and started to pilot it. When the participants came back and started to talk about the experience of MM the instructors could not answer their questions adequately. The authors then went back and studied the whole 8- week MBSR program. They realized that they had only applied it to the thoughts as that was the main target of cognitive therapy but MBSR expanded their understanding of this “relationship not only to thoughts but also to feelings and bodily sensations” (p. 58). They also realized that it was not a state of stepping back from the mental experience but rather one of neither identifying with the experience or pushing it away. The authors state, “The mode of mind one brings to decentering is critical. The stance of the mindfulness approach is one of welcoming and allowing” (p. 58). The changing of modes of thought from one centered in the experience of the thought to a mental mode of “thoughts as just thoughts” supports the interruption of the depression cycle. The authors add: “the key idea is that patients make radical changes in the underlying views, or mental models, that shape their relationship to negative thoughts and feelings” (p. 65). They state, “we need to provide new experiences for the mind and body, over and over again, that will accumulate to create an alternative view” (p. 67). They came to realize the central nature of formal and informal mindfulness practice to the treatment. They also realized the importance of the clinician practicing mindfulness as this allows the facilitator to answer questions from the point of view of having experienced it and to model it when interacting with the participants in the group. The authors decided “after seeing for ourselves the difference between using MBCT with or without the personal experience of using mindfulness practice, that it is unwise for instructors to embark on teaching this material before having extensive personal experience with its use” (p. 84). The manual proposed in this paper follows the example of MBSR and MBCT, which have been built on the daily practice of mindfulness meditation and where the facilitators also practice mindfulness meditation daily.

A theoretical cognitive model for mindfulness: Teasdale (1999) provides a model of Interacting Cognitive Subsystems (ICS) to support how MBCT works. This in turn provides a model for understanding mindfulness, how it supports the reduction of depression relapse and is valuable in understanding how mindfulness might help prevent addictions relapse. The ICS model describes three different levels of processing that we apply when problem-solving, the first level is the incoming information about the world, the first step back from objects in the world is the propositional relationship and the next step back is about the rules that are applied to propositional relationships or metacognitive knowledge. These three cognitive subsystems are the most commonly understood when looking at how humans deal with the world and were central to understanding Cognitive Therapy. Within the emotional area there is also a process of knowing emotions and meaning or “implicational code” based on past experience that we add to new experience. The next step back Írom the direct emotional experience is a generalized level of emotions, which has at times been identified as intuitive thought or a “generic implicational” level of meaning.

Teasdale (1999) explains that mindfulness “does not seem to map neatly onto the contrasts that are currently made within research on metacognition” (p. 147) because neither metacognitive knowledge nor generic implicational code really captures the metacognitive yet experiential emotive nature of mindfulness. The author identifies mindfulness as the next step back from generic implicational meaning. Mindfulness is metacognitive insight and metacognitive awareness, which are a similar level of mental mode in the affective realm to metacognitive knowledge in the reasoning realm. Metacognitive insight refers to actually experiencing thoughts as thoughts as they arise (Teasdale, et al., 2002). Metacognitive insight is an experiential form of mental mode, which is the practice of not pushing away any mental event or pulling it towards you; the practice of non-doing rather than desire or aversion to any mental event; a state of awareness of objective curiosity, of invitation, acceptance and welcoming of experience. Metacognitive awareness is a form of metacognitive insight, where negative thoughts and feelings are seen as passing events in the mind rather than as inherent aspects of self or as necessarily valid reflections of reality. Increasing metacognitive awareness involves a change in relationship to thoughts and feelings (Teasdale, et al.).

Change comes about through metacognitive awareness of the other modes of thought and insight into this awareness. If there is going to be change in this level of emotional experience then it has to happen through learning in which the components are actually experienced in new patterns. Mindfulness practice especially daily formal practice (MM) supports the strengthening of this metacognitive insight and metacognitive awareness while experiencing mental events, physiological events in the body and experiencing sensory input from the environment. MM training promotes daily practice for the change process to work in a more structured experiential way.

The ICS model and the process of change through the practice of MM describe why the experiential nature of metacognitive insight supports change of the depressed person’s dominant implicational code that triggers depression. The explanation of why depression is triggered after periods of remission is the trigger’s meaning, emotional content and the generic implicational level of meaning which makes it the target of treatment. Teasdale (1999) links the development of metacognitive insight to changing “Depressive interlock: a self-perpetuating processing configuration that can establish/ maintain the depressed state” (p. 151) and to reduce the risk of relapse through “shifting the processing configuration” (p. 153) by focusing on process rather than content. Taking this practice from the internal to the external during MM supports the individual in dealing with mental triggers (desires or aversions) wherever and whenever they happen. The repeated experiential component along with the metacognitive insight of non-doing and knowing that evolves in the treatment process supports the effectiveness of the individual change of belief systems required to reduce relapse. This model will be used to understand the processes that maintain addictions as well as indicate how to support the individual in recovery to prevent relapse in the proposed manual.

What are the Ingredients of MBCT: “MBCT is a manualized group skills-training program (Segal et al., 2002) based on an integration of aspects of CBT for depression (Beck et al., 1979) with components of the MBSR program developed by Kabat-Zinn (1990)” (Ma & Teasdale, 2004). The key steps of the mindfulness intervention are; the rationale, instructing the client on the attitudinal foundations for mindfulness practice, instruction about commitment and preparation, learning the body scan to relax muscles, breathing instructions, instructions on the wandering mind and how to sit quietly, close the eyes, focus on breathing and be present in the moment. These steps are joined with the steps for Cognitive Behaviour Therapy of identification of problem thoughts and the schemas at their foundation, the link between the event, the thought and the emotion or vice versa, the development of alternative ways of thinking about that event (alternative hypotheses) and finally the use of positive thoughts to replace the distorted thought. In the case of MBCT the metacognitive insight of thoughts as thoughts and the attitudes of mindfulness are the alternative mental experiences. A major ingredient is the use of psycho-educational materials related to depression and mindfulness to support metacognitive insights. A specific cognitive ingredient is teaching participants to become aware of automatic thinking. The program teaches skills that allow individuals to disengage from habitual (“automatic”) dysfunctional cognitive routines, in particular depression related ruminative thought patterns, as a way to reduce future risk of relapse and recurrence of depression (Ma & Teasdale). This is done within a group milieu to provide greater service to a greater number of participants and to provide supportive interaction. The overall effects of the group intervention including the mindfulness, cognitive work, group support, therapeutic alliance or other ingredients are all contributory to the relapse prevention. (It is recommended that interested readers read Segal, et al. (2002) for the full account of the MBCT program including a weekly program.)

Research Evidence for the Use of Mindfulness Treatment

Bogart, in 1991, gave a review of the literature on meditation and its use in psychotherapy. The conclusion was that it held promise because:

First, meditation is associated with states of physiological relaxation that can be utilized to alleviate stress, anxiety, and other physical symptoms. Secondly, meditation brings about cognitive shifts that can be applied to behavioural self­observation and management, and to understanding limited or self-destructive cognitive patterns.. .meditative techniques like Vipassana focus attention on the manner in which unconscious conflicts are being processed and recreated in the mind on a moment-to-moment basis. Thus, Vipassana offers the possibility of not just understanding such conflicts conceptually, but actually penetrating and gradually dismantling them through meditative insight. (p. 406-407)

Since his review in 1991, MBSR has been applied to a wide variety of health problems including chronic pain, anxiety, panic, depression, binge eating, psoriasis and fibromyalgia (Baer, 2003). Baer in a review of MM research states, “all of the treatment programs reviewed here include acceptance of pain, thoughts, feelings, urges, or other bodily, cognitive, and emotional phenomena, without trying to change, escape, or avoid them” (p. 130). The author gives a review of this line of research that started with a search of the PsychINFO and Medline databases as well as the reference lists from the studies. Studies by Langer and on Transcendental Meditation were excluded based on difference of definition and methodological reasons. No studies of DBT and ACT were included, because none were found that examined the mindfulness component independently of the behaviour change strategies also included in these treatment approaches. All the studies that met the criteria were based on MBSR and MBCT. In 21 studies that met the criteria Baer (2003) found at least a medium effect size with some effect sizes in the large range. Baer stated that MBSR meets the criteria of “probably efficacious” and MBCT is approaching this designation and suggested that if there were one more methodologically sound study, which confirm Segal, et al. ’s (2002) findings, then MBCT would qualify for a “well established” designation. Baer (2003) reported a mean effect size of 0.59 or moderate range for the studies overall.

Grossman, Niemann, Schmidt, and Walach (2004) completed a meta-analysis as well of the research findings in 20 studies with 10 of them controlled. They found a medium effect size across controlled studies of .54 and the observational studies were also reported as having a medium effect size. The authors concluded:

Our findings suggest the usefulness of MBSR as an intervention for a broad range of chronic disorders and problems. In fact, the consistent and relatively strong level of effect sizes across very different types of samples indicates that mindfulness training might enhance general features of coping with distress and disability in everyday life, as well as under more extraordinary conditions of serious disorder or stress. (p. 39)

The studies included treatment of the following diagnoses: fibromyalgia, stress due to chronic illness, coronary artery diseases, depression, chronic pain, anxiety and panic disorders, psoriasis, addictions, obesity and binge eating disorder, and psychiatric patients. There is now extensive literature for the use of mindfulness as a component of treatment programs for a variety of issues (Germer, et al., 2005).

More specifically in the study for MBCT discussed above, Segal, et al. (2002) researched MBCT’s effectiveness against Treatment As Usual (TAU) in a large multi-site research project on participants who were stabilized from previous depressive relapses and taken off medications. One effect they found was that participants who had three or more relapses had a significant response effect. They found that in the TAU group 23% had not relapsed after sixty weeks. In the treatment group of those who had three or more relapses 77% had not relapsed after sixty weeks. This finding makes this model very interesting in the search for effective treatment options for relapse. Though the researchers applied it to depression relapse as stated earlier it has become of interest to Witkiewitz and Marlatt (2004) and Witkiewitz, et al. (2005) in their work with addictions relapse.

Mindfulness and Neurology

From a western perspective mindfulness has been the subject of study in the area of neurology as well. These findings are preliminary but could have a significant impact on the area of addictions due to the neurological nature of the use of addictive substances. Lazar (2005) gives a summary of the current neurological research on meditation states. The author discusses the use of positron emission topography (PET), functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG) to research different areas of the brain and their activity levels during meditative states. The type of meditation used and the length of time meditation has been practiced complicate this research, as does the process of relying on matching the subjective reports with the data from the instrumentation. Though in a preliminary state, the results do indicated that different parts of the brain and different neurotransmitters are being used during different types of meditation and as compared to non-meditative states. There is also a difference based on the length of time the individual has been meditating. Lazar, et al. (2000) studied a group of five subjects who had practiced Kundalini meditation for a least four years. They used an fMRI and physiological tests to measure levels of activity during control and meditation periods. They found that the two periods were significantly different with greater activation of specific neural structures involved in attention and arousal/ autonomic control as well as memory. In a second study, Lazar, et al., (2005) found that the cortical thickness in the areas that had been identified as activated is significantly thicker in a group of regular meditators than a matched control group. The authors state, “These data provide the first structural evidence for experience-dependent cortical plasticity associated with meditation practice” (p. 1893). The authors concluded that: “meditation may be associated with structural changes in areas of the brain that are important for sensory, cognitive and emotional processing. The data further suggest that meditation may impact age related declines in cortical structure” (p. 1896).

Neurology researcher R.J. Davidson teamed up with J. Kabat-Zinn to study how mindfulness meditation training changes brain activity. They used a randomized control group and an eight-week treatment group to measure brain activity by EEG before and after the treatment and in a four-month follow-up. The authors state, “The findings from this study are the first to suggest that meditation can produce increases in relative left­sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect” (p. 569)

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