Transcript Title for the slide

Meditation and
Mindfulness-Based
Treatment Approaches
Sarah Bowen, PhD
Assistant Professor
Dept. of Psychiatry and Behavioral Sciences
University of Washington
[email protected]
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)
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)
Mindfulness and Relapse Prevention
Attention,
Present,
Nonjudging
Direct
Experience
(sensation, thought,
“feeling tone”)
pain
Relationship
(Reactions, stories, judgment)
suffering
“Automatic”
Past/Future
Judgment/Nonacceptance
Practicing Mindfulness
(Present
Moment)
(Attention)
Mind on
chosen target
Attention
(Nonjudgment)
Wanders
Notice wandering,
begin again
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
“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)
–
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–
–
–
–
–
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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)
“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)
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)
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
“… 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.
Behavioral Model of Relapse
Vulnerabilities,
Predispositional
Factors
Trigger
Discomfort,
Dissatisfaction
Temporary alleviation
Craving
Relapse Cycle
Substance
Use
Mindfulness and Substance Use
Attention:
Present moment:
Direct observation of the mind
Acknowledge/attend to
present experience
Awareness of triggers
and responses
Interrupt previously
automatic behavior
Acceptance and Nonjudgment:
Accept the unchangeable; “defuse” from attributions and
thoughts that often lead to relapse
Dismantling and Bringing Curiosity
Craving
Sensation
Thought
Emotion
CRAVING
Urge to
React
Underlying
Needs
Curiosity
Use
“Urge Surfing”
Intensity
Time
Staying with discomfort as it grows,
Using breath to stay steady,
Trusting it will naturally subside
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
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 Age 37
• 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)
Mindfulness-Based Relapse Prevention
Relapse
Prevention
Mindfulness-Based
Cognitive Therapy
For Depression
• 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
Mindfulness-Based
Stress Reduction
EACH SESSION
• Formal meditation practice
• “Informal” mindfulness practice
• Cognitive Behavioral skills
Eating a Raisin: Shifting out of “Autopilot”
Routine Activities: Continuous attention, natural
reinforcement
Body Scan: Body awareness, Flexibility of Attention
Breath, Thought, Emotion Meditation
Awareness of processes
Urge Surfing: Relating to Discomfort
Kindness, Forgiveness: Shame, Self-Efficacy
Inquiry: Practice through Dialogue
PainAffective
in left knee,
Restlessness
discomfort
Direct
Experience
(sensation, thought,
feeling tone)
pain
Relationship
(Reactions, stories,
judgment)
suffering
“I can’t handle this.
“II can’t
need meditate”
a drink.”
(craving)
Familiarity with Individual Patterns
Progressive Awareness Training
Compassionate and
skillful responding Awareness
Thoughts,
emotions, and
their nature
and freedom
Pause in midst of
difficulty, curiosity,
what is really needed?
External,
tangible
Body
sensations
MBRP Pilot Study
N = 168
Completed
Inpatient or
Intensive
Outpatient
MBRP
Baseline
8 weeks
TAU
Post
Course
2 mos.
4 mos
(12-step, Psychoeducation,
Process/Support)
Funded by National Institute on Drug Abuse Grant R21 DAO 10562-01A1; PI: Marlatt
Participants
• Age 41; 64% male
•
•
•
•
•
•
•
•
•
50% Caucasian
28% African American
15% Multiracial
7% Native American
45%
36%
14%
7%
72% completed high-school
5%
41% unemployed
2%
33% public assistance
62% less than $4,999 / year
Homeless/unstably housed
alcohol
cocaine/crack
methamphetamines
opiates/heroin
marijuana
other
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)
Results: Main Effects
Across 4-month follow-up, significant differences
between groups:
• Mindful awareness
• Acceptance (p =.05)
(p =.01)
• Craving (p = .02)
• Substance Use at 2 months (p = .02)
• Significant mediating effect of craving
(Bowen et al., 2009)
Results: Depression and Craving
Craving
Total sample
Substance
Use
Depression
Significant mediating effect of craving
Craving
MBRP
Substance
Use
Depression
Non- Significant
(Witkiewitz & Bowen, 2010)
Randomized Trial
For whom?
How?
N = 286
MBRP
Baseline
RP
Post
2m
4m
6m
TAU
8 weeks
(12-step, Psychoeducation,
Process/Support)
Funded by National Institute on Drug Abuse Grant
12m
Participants
• Age 40.6 (11.69)
• 75% male
•
•
•
•
•
65% Caucasian
31% African American
10% Latino/a
15% Multiracial
2% Native American
Primary Substance
Other
10%
Meth
10%
Alcohol
46%
Heroin
12%
Marijuana
11%
• 92% high-school or GED
Crack
11%
• 71% unemployed
• 59% less than $4,999 / year
82% polysubstance
(Bowen et al., in press)
Days of Use over Time
(Bowen et al., in press)
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
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
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
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.”
Acknowledgments
University of
Washington
Investigators:
G. Alan Marlatt
Katie Witkiewitz
Mary Larimer
Seema Clifasefi
Consultants:
Zindel Segal
Jon Kabat-Zinn
Research Team:
Neha Chawla
Joel Grow
Sharon Hsu
Susan Collins
Erin Harrop
Haley Douglas
Kathy Lustyk
Sara Hoang