Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial.

IMPORTANCE: Relapse is highly prevalent following substance abuse treatments, highlighting the need for improved aftercare interventions. Mindfulness-based relapse prevention (MBRP), a group-based psychosocial aftercare, integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral relapse prevention (RP) approaches. OBJECTIVE: To evaluate the long-term efficacy of MBRP in reducing relapse compared with RP and treatment as usual (TAU [12-step programming and psychoeducation]) during a 12-month follow-up period. DESIGN, SETTING, AND PARTICIPANTS: Between October 2009 and July 2012, a total of 286 eligible individuals who successfully completed initial treatment for substance use disorders at a private, nonprofit treatment facility were randomized to MBRP, RP, or TAU aftercare and monitored for 12 months. Participants medically cleared for continuing care were aged 18 to 70 years; 71.5% were male and 42.1% were of ethnic/racial minority. INTERVENTIONS: Participants were randomly assigned to 8 weekly group sessions of MBRP, cognitive-behavioral RP, or TAU. MAIN OUTCOMES AND MEASURES: Primary outcomes included relapse to drug use and heavy drinking as well as frequency of substance use in the past 90 days. Variables were assessed at baseline and at 3-, 6-, and 12-month follow-up points. Measures used included self-report of relapse and urinalysis drug and alcohol screenings. RESULTS: Compared with TAU, participants assigned to MBRP and RP reported significantly lower risk of relapse to substance use and heavy drinking and, among those who used substances, significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive-behavioral RP showed an advantage over MBRP in time to first drug use. At the 12-month follow-up, MBRP participants reported significantly fewer days of substance use and significantly decreased heavy drinking compared with RP and TAU. CONCLUSIONS AND RELEVANCE: For individuals in aftercare following initial treatment for substance use disorders, RP and MBRP, compared with TAU, produced significantly reduced relapse risk to drug use and heavy drinking. Relapse prevention delayed time to first drug use at 6-month follow-up, with MBRP and RP participants who used alcohol also reporting significantly fewer heavy drinking days compared with TAU participants. At 12-month follow-up, MBRP offered added benefit over RP and TAU in reducing drug use and heavy drinking. Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01159535

The mindfulness-based relapse prevention adherence and competence scale: development, interrater reliability, and validity.

The present study describes the development of the Mindfulness-Based Relapse Prevention Adherence and Competence Scale (MBRP-AC), a measure of treatment integrity for mindfulness-based relapse prevention (MBRP). MBRP is a newly developed treatment integrating core aspects of relapse prevention with mindfulness practices. The MBRP-AC was developed in the context of a randomized controlled trial (RCT) of MBRP efficacy and consists of two sections: Adherence (adherence to individual components of MBRP and discussion of key concepts) and Competence (ratings of therapist style/approach and performance). Audio recordings from 44 randomly selected group treatment sessions (50%) were rated by independent raters for therapist adherence and competence in the RCT. Findings evinced high interrater reliability for all treatment adherence and competence ratings, and adequate internal consistency for Therapist Style/Approach and Therapist Performance summary scales. Ratings on the MBRP-AC suggested that therapists in the recent RCT adhered to protocol, discussed key concepts in each session, and demonstrated the intended style and competence in treatment delivery. Finally, overall ratings on the Adherence section were positively related to changes in mindfulness over the course of the treatment.

Language-based measures of mindfulness: initial validity and clinical utility.

This study examined relationships among language use, mindfulness, and substance-use treatment outcomes in the context of an efficacy trial of mindfulness-based relapse prevention (MBRP) for adults with alcohol and other drug use (AOD) disorders. An expert panel generated two categories of mindfulness language (ML) describing the mindfulness state and the more encompassing "mindfulness journey," which included words describing challenges of developing a mindfulness practice. MBRP participants (n = 48) completed baseline sociodemographic and AOD measures, and participated in the 8-week MBRP program. AOD data were collected during the 4-month follow-up. A word count program assessed the frequency of ML and other linguistic markers in participants' responses to open-ended questions about their postintervention impressions of mindfulness practice and MBRP. Findings supported concurrent validity of ML categories: ML words appeared more frequently in the MBRP manual compared to the 12-step Big Book. Further, ML categories correlated with other linguistic variables related to the mindfulness construct. Finally, predictive validity was supported: greater use of ML predicted fewer AOD use days during the 4-month follow-up. This study provided initial support for ML as a valid, clinically useful mindfulness measure. If future studies replicate these findings, ML could be used in conjunction with self-report to provide a more complete picture of the mindfulness experience.

Mindfulness meditation for substance use disorders: a systematic review.

Relapse is common in substance use disorders (SUDs), even among treated individuals. The goal of this article was to systematically review the existing evidence on mindfulness meditation-based interventions (MM) for SUDs. The comprehensive search for and review of literature found over 2000 abstracts and resulted in 25 eligible manuscripts (22 published, 3 unpublished: 8 randomized controlled trials, 7 controlled nonrandomized, 6 noncontrolled prospective, and 2 qualitative studies, and 1 case report). When appropriate, methodological quality, absolute risk reduction, number needed to treat, and effect size were assessed. Overall, although preliminary evidence suggests MM efficacy and safety, conclusive data for MM as a treatment of SUDs are lacking. Significant methodological limitations exist in most studies. Further, it is unclear which persons with SUDs might benefit most from MM. Future trials must be of sufficient sample size to answer a specific clinical question and should target both assessment of effect size and mechanisms of action.

Mindfulness-based relapse prevention for substance use disorders: a pilot efficacy trial.

The current study is the first randomized-controlled trial evaluating the feasibility and initial efficacy of an 8-week outpatient Mindfulness-Based Relapse Prevention (MBRP) program as compared to treatment as usual (TAU). Participants were 168 adults with substance use disorders who had recently completed intensive inpatient or outpatient treatment. Assessments were administered pre-intervention, post-intervention, and 2 and 4 months post-intervention. Feasibility of MBRP was demonstrated by consistent homework compliance, attendance, and participant satisfaction. Initial efficacy was supported by significantly lower rates of substance use in those who received MBRP as compared to those in TAU over the 4-month post-intervention period. Additionally, MBRP participants demonstrated greater decreases in craving, and increases in acceptance and acting with awareness as compared to TAU. Results from this initial trial support the feasibility and initial efficacy of MBRP as an aftercare approach for individuals who have recently completed an intensive treatment for substance use disorders.

Perceived approval of friends and parents as mediators of the relationship between self-determination and drinking.

OBJECTIVE: Within the context of self-determination theory, individuals vary in the extent to which they are oriented toward autonomy and control. Previous research on the relationship between motivational orientations and drinking behavior among college students has suggested that students who are more autonomously oriented consume less alcohol whereas those who are more control oriented consume more alcohol. This research evaluated the extent to which these relationships are mediated by the perceived approval of friends and parents, both of which are important sources of potential influence on the behavior of college students. METHOD: First-year students (N = 818, 58% female) who reported one or more heavy drinking episodes in the previous month completed online assessments of their drinking behavior, autonomous and controlled orientations, and perceptions of the approval of drinking (injunctive norms) by important others (friends and parents). RESULTS: The results suggested that controlled orientation was associated with greater alcohol use and that this association was mediated by perceptions of friends being more approving of problematic drinking. In contrast, autonomous orientation was associated with less alcohol use and this association was mediated by perceptions of friends being less supportive of problematic drinking. No support was found for perceptions of parents' approval as a mediator of the associations between either orientation and drinking. CONCLUSIONS: The findings highlight the importance of perceptions of friends' approval or disapproval of problematic drinking in understanding the relationship between self-determination and heavy drinking among college students.

Mindfulness meditation research: issues of participant screening, safety procedures, and researcher training.

Increasing interest in mindfulness meditation (MM) warrants discussion of research safety. Side effects of meditation with possible adverse reactions are reported in the literature. Yet participant screening procedures, research safety guidelines, and standards for researcher training have not been developed and disseminated in the MM field of study. The goal of this paper is to summarize safety concerns of MM practice and offer scholars some practical tools to use in their research. For example, we offer screener schematics aimed at determining the contraindication status of potential research participants. Moreover, we provide information on numerous MM training options. Ours is the first presentation of this type aimed at helping researchers think through the safety and training issues presented herein. Support for our recommendations comes from consulting 17 primary publications and 5 secondary reports/literature reviews of meditation side effects. Mental health consequences were the most frequently reported side effects, followed by physical health then spiritual health consequences. For each of these categories of potential adverse effects, we offer MM researchers methods to assess the relative risks of each as it pertains to their particular research programs.

The relative impact of injunctive norms on college student drinking: the role of reference group.

This research evaluated the importance of reference groups in the relationships between injunctive norms and alcohol consumption for college student drinkers. First-year students (N = 811; 58% women) completed online assessments of their drinking behavior, as well as their perceptions of the approval (injunctive norms) and prevalence (descriptive norms) of drinking by others. Injunctive norms were evaluated with respect to typical students, typical same-sex students, friends, and parents. Descriptive norms were evaluated with respect to typical students and typical same-sex students. Results suggested that for injunctive norms, only perceptions of proximal reference groups (friends and parents) are positively associated with drinking behavior. However, when considered in the context of multiple referents and norms, injunctive norms for more distal groups (typical students/same-sex students) were negatively associated with personal drinking, whereas descriptive norms for distal referents remained positively associated with drinking. Results suggest that injunctive norms are more complex than descriptive norms and these complexities warrant important consideration in the development of intervention strategies.

Posttraumatic stress disorder, alcohol use, and physical health concerns.

PTSD is a risk factor for alcohol problems and both in turn have been independently associated with increased health problems. However, it is unclear whether alcohol use moderates the relationship between PTSD and health. Participants were battered women (N = 336) recruited from local domestic violence shelters and non-shelter victim-assistance agencies. A 2 (PTSD diagnosis) x 3 (abstainer, infrequent/light, regular/heavy drinking) ANCOVA was conducted, with injuries and length of abuse as covariates and health concerns as the dependent variable. Main effects for PTSD and alcohol use were significant but not the interaction. Women with PTSD reported the greatest number of health concerns. Women who abstained from drinking and those who drank regularly/heavily reported more health concerns than the infrequent/light drinkers. Health concerns associated with PTSD do not appear to be due to problem drinking. In addition, infrequent/light drinking, even for women with PTSD, may be associated with fewer health concerns.

Experiential avoidance as a functional dimensional approach to psychopathology: an empirical review.

The construct of experiential avoidance has become more frequently used by clinical researchers. Experiential avoidance involves the unwillingness to remain in contact with private experiences such as painful thoughts and emotions and is often proposed to be critical to the development and maintenance of psychopathology. This review summarizes the empirical studies on experiential avoidance as a factor in the etiology of maladaptive behavior and its relationship to specific diagnostic categories. Although some of the current literature suggests that experiential avoidance may be implicated in various forms of psychopathology, a fundamental limitation of this research is the lack of theoretical integration and refinement with regard to operationalizing and assessing experiential avoidance. Future studies should attempt to understand the core processes involved in experiential avoidance better, and then clearly operationalize the construct and determine its incremental validity relative to other constructs.

Attitudes and perceived approval of drinking as mediators of the relationship between the importance of religion and alcohol use.

OBJECTIVE: Previous research has consistently demonstrated that religiosity and personal importance of religion are associated with lower levels of alcohol use among both adolescents and college students. Although a number of different mechanisms have been proposed to account for this, few studies have empirically examined potential mediators of this relationship. Given the extensive literature on the impact of social norms on the drinking behavior of college students, the present study evaluates the role of perceived drinking norms as a mediator of the relationship between the importance of religion and alcohol use. Specifically, we examined both personal attitudes and perceived injunctive norms with regard to reference groups that vary in their proximity to students (i.e., close friends and typical college students). METHOD: Participants were 1,400 undergraduate students (60.6% women) who were assessed using self-report measures of alcohol consumption, importance of religion, attitudes, and perceived norms. RESULTS: Results indicated that, consistent with the hypotheses, personal attitudes were the strongest mediator of the relationship between importance of religion and alcohol use, followed by the approval of close friends, and, to a lesser extent, the approval of typical college students. CONCLUSIONS: These findings suggest that importance of religion may have an indirect effect on alcohol use via personal attitudes and the perceived approval or disapproval of important others, and this relationship varies as a function of reference group. Implications for interventions that incorporate information on social norms are discussed.

Mindfulness meditation and substance use in an incarcerated population.

Despite the availability of various substance abuse treatments, alcohol and drug misuse and related negative consequences remain prevalent. Vipassana meditation (VM), a Buddhist mindfulness-based practice, provides an alternative for individuals who do not wish to attend or have not succeeded with traditional addiction treatments. In this study, the authors evaluated the effectiveness of a VM course on substance use and psychosocial outcomes in an incarcerated population. Results indicate that after release from jail, participants in the VM course, as compared with those in a treatment-as-usual control condition, showed significant reductions in alcohol, marijuana, and crack cocaine use. VM participants showed decreases in alcohol-related problems and psychiatric symptoms as well as increases in positive psychosocial outcomes. The utility of mindfulness-based treatments for substance use is discussed.

Posttraumatic stress symptoms in parents of children with acute burns.

OBJECTIVE: To develop a model of risk factors for posttraumatic stress disorder (PTSD) symptoms in parents of children with burns. METHODS: Immediately following the burn and 3 months later, parents reported on their children's and their own psychological functioning and traumatic stress responses. RESULTS: Approximately 47% of the parents reported experiencing significant posttraumatic stress symptoms 3 months after the burn. Our model indicates three independent pathways to PTSD symptoms (i.e., parent-child conflict, parents' dissociation, and children's PTSD symptoms). Additionally, parents' anxiety predicted increased parent-child conflict, conflict with extended family and size of the burn predicted parents' dissociation, and size of the burn and children's dissociation predicted children's PTSD symptoms. CONCLUSIONS: This study suggests that many parents of children with burns suffer from posttraumatic stress symptoms. Interventions that target factors such as family conflict, children's symptoms, and parents' acute anxiety and dissociation may diminish the risk for PTSD.

Risk factors for acute stress disorder in children with burns.

The purpose of this study was to (1) estimate the prevalence of acute stress disorder (ASD) in a sample of burned children, and (2) determine risk factors for ASD in these children. Seventy-two children were assessed for acute stress disorder approximately 10 days after being hospitalized for a burn. Variables hypothesized to predict ASD symptoms (i.e., size of the burn, prior behavioral symptoms, body image, parents' symptoms, heart rate) were also assessed. Based on a diagnosis derived from the ASD module of the Diagnostic Interview for Children and Adolescents (DICA), 31% of children met criteria for ASD. Path analyses revealed that the variables of heart rate, body image, and parents' acute stress symptoms were directly related to the development of ASD symptoms and accounted for 41% of its variance. These variables also mediated the relationship between the size of the burn and ASD symptoms. ASD is found in almost one third of children hospitalized for a burn. A high resting heart rate, lowered body image, and parent's acute stress symptoms were found to be significant risk factors for ASD symptoms.

Pathways to PTSD, part I: Children with burns.

OBJECTIVE: The goal of this study was to develop a model of risk factors for posttraumatic stress disorder (PTSD) in a group of acutely burned children. METHOD: Seventy-two children between the ages of 7 and 17 who were admitted to the hospital for an acute burn were eligible for study. Members of families who consented completed the Child PTSD Reaction Index, the Multidimensional Anxiety Scale for Children, and other self-report measures of psychopathology and environmental stress both during the hospitalization and 3 months following the burn. A path analytic strategy was used to build a model of risk factors for PTSD. RESULTS: Two pathways to PTSD were discerned: 1) from the size of the burn and level of pain following the burn to the child's level of acute separation anxiety, and then to PTSD, and 2) from the size of the burn to the child's level of acute dissociation following the burn, and then to PTSD. Together these pathways accounted for almost 60% of the variance in PTSD symptoms and constituted a model with excellent fit indices. CONCLUSIONS: These findings support a model of complex etiology for childhood PTSD in which two independent pathways may be mediated by different biobehavioral systems.

Child Stress Disorders Checklist: a measure of ASD and PTSD in children.

OBJECTIVE: To assess the psychometric properties of the Child Stress Disorders Checklist (CSDC), a 36-item observer-report instrument that measures acute stress and posttraumatic symptoms in children. METHOD: The CSDC was administered to parents of 43 children with acute burns and 41 children who had experienced a traffic crash. This instrument was also administered to the burned children's primary nurse to estimate interrater reliability. The CSDC was completed again by parents of burned children, 2 days and 3 months later. Convergent validity was determined by correlating scores on the CSDC with scores on instruments of known validity for assessing posttraumatic stress disorder (PTSD) in children. Concurrent validity was determined through an examination of the relationship between CSDC scores and an index of trauma severity (percentage of body surface area burned). Discriminant validity was assessed by administering the Child Behavior Checklist (CBCL): it was hypothesized that PTSD symptoms would be more closely related to the PTSD scale of the CBCL than the Thought Problems scale of the CBCL. RESULTS: The CSDC has reliable and valid psychometric properties. CONCLUSIONS: The CSDC, an observer-report instrument of ASD and PTSD in children, has important utility in clinical and research settings.

Self-destructive behavior in patients with dissociative disorders.

Highrates of self-injury have been reported in patients with dissociative disorders, yet no prior study has directly compared these patients with other psychiatric patients. The present study assesses self-destructive behavior in a group of inpatients who have dissociative disorders compared to those who report few dissociative symptoms. These patients more frequently engage in self-destructive behaviors, use more methods of self-injury, and begin to injure themselves at an earlier age then patients who do not dissociate. Results have important implications for understanding the relationship between dissociation, childhood trauma, and self-injury and for assessment and treatment of patients with dissociative disorders.