Sarah Bowen, PhD Assistant Professor Dept. of Psychiatry and Behavioral Sciences

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

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

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

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

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

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

8. “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)

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 (MBCT; Segal, Williams, & Teasdale 2002) Prevent relapse to major depression • Awareness  Change • Recognize cognitive patterns in mild sadness • Moods 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 Vulnerabilities, Predispositional Factors Temporary alleviation Discomfort, Dissatisfaction Craving Trigger Substance Use Relapse Cycle Shame Fear “Automatic” Guilt Hopelessness “I’m a failure”

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

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

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

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

17. Outcomes 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 Age37 • Nonrandomized • (No BL differences on key demographic or outcome variables) • 3-Month follow-up • Substance Use • Marijuana, Crack cocaine, Alcohol, Negative consequences • Psychosocial Outcomes • Psychiatric symptoms (depression, anxiety, hostility) • Optimism (Bowen et al., 2006; 2007)

18. Mindfulness-Based Relapse Prevention • Strategies and practices from several sources • Integrates mindfulness meditation and cognitive therapy • Clients have completed initial treatment • 8-week outpatient group treatment • 2-hour weekly sessions Relapse Prevention Mindfulness-Based Cognitive Therapy For Depression • EACH SESSION • Formal meditation practice • “Informal” mindfulness practice • Cognitive Behavioral skills 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 Affective discomfort Direct Experience (sensation, thought, feeling tone) pain “I can’t meditate” “I can’t handle this. I need a drink.” (craving) Relationship (Reactions, stories, judgment) suffering

21. Familiarity with Individual Patterns

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

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

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

25. Results: Feasibility • Attendance • 65% of sessions • (M = 5.18, SD= 2.41) • Formal Practice • 4.74 days/week (SD = 4.0) • 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) • Acceptance(p =.05) • Craving(p = .02) • Substance Use at 2 months (p = .02) • Significant mediating effect of craving (Bowen et al., 2009)

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

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

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

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 • MBRP & RP (vs TAU) • Delay to first use • Fewer days of use at 6 months • MBRP (vs RP & TAU) • Day of drug use at 12 months • Likelihood of any heavy drinking

32. Limitations • Attrition • 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 • 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) • 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. Client Experiences “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.” 

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