Treatment for Individuals With Severe Mental Illness Who Use Illicit Drugs While Maintained on Methadone: Mindfulness and Modification Therapy.

Substantial research has noted the serious consequences of 1) co-occurring severe mental illness (SMI) and substance use disorders, and 2) use of illicit drugs while maintained on methadone for opioid dependence. However, treatment needs of individuals who meet both of the above criteria remain largely unmet. This pilot study investigated the feasibility and acceptability of a 12-week, transdiagnostic group therapy (mindfulness and modification therapy [MMT]) tailored for opioid-dependent individuals (N = 6) with SMI and illicit drug use. Retention was 83%. At posttreatment and 2-month follow-up, participants rated the treatment as highly helpful (9 of 10; 8.67 of 10, respectively), reported routinely practicing the guided-mindfulness exercises, and reported high confidence that they would continue to practice. Assessments revealed clinically meaningful decreases in reported days of illicit drug use at posttreatment and follow-up, with large effect sizes. Preliminary evidence suggests that MMT may be a feasible and acceptable therapy that may improve treatment engagement in this underserved population.

The Emotion Mapping Activity: Preliminary evaluation of a mindfulness-informed exercise to improve emotion labeling in alexithymic persons.

Alexithymia is a psychoemotional trait associated with many treatment-resistant psychological and social difficulties. Research suggests that these difficulties stem primarily from an inability to appropriately apply linguistic labels to emotional experiences and content. The present research introduces and preliminarily evaluates a novel mindfulness-informed exercise to improve emotion-labeling ability in alexithymic persons. Based in culturally universal patterns of somatic experience, the Emotion Mapping Activity (EMA) directs alexithymic persons to reflect on their internal, somatic experiences as a source of information for interpreting and labeling emotional experiences. In the present study, 67 alexithymic persons completed a series of emotion-labeling tasks either with or without assistance of the EMA. Results suggest that completion of the EMA may improve ability to label emotions that would be otherwise misinterpreted - without interfering with labeling that is already intact. Though further research is necessary, the present study suggests that the EMA may hold the potential to be incorporated into psychotherapy protocols as an exercise for improving emotion-labeling ability in alexithymic clients.

Substance-Treatment Professionals' Perceived Barriers to Incorporating Mindfulness Into Treatment.

BACKGROUND: Despite scientific favor, psychological interventions supported by research are often underutilized by practitioners due to perceived obstacles in implementation. Increased transparency between researchers and practitioners throughout treatment development and dissemination is therefore necessary. The rising popularity of mindfulness-based approaches in the treatment of substance-use disorders suggests such transparency is necessary in further developing, disseminating, and implementing such approaches within the context of substance treatment. OBJECTIVES: The present study aimed to increase transparency by surveying substance-treatment professionals regarding their perceptions of barriers to adopting mindfulness in the treatment of substance use. METHODS: Substance-treatment professionals throughout the United States (N = 103) completed an online survey about their perceptions of potential barriers to implementing mindfulness into substance treatment. RESULTS: Overall, professionals were moderately familiar with mindfulness as a treatment for substance use. Approximately one-third reported providing mindfulness in substance treatment; however, only 7% reported providing mindfulness using a research-supported treatment manual. Across professionals of various backgrounds, the need for further training was rated as the greatest barrier to implementation. CONCLUSIONS/IMPORTANCE: Results suggest that practitioners are generally familiar with and willing to implement mindfulness in the treatment of substance use. Future research and implementation efforts should focus on methods of increasing training availability, accessibility, and relevance to address the needs and expectations of substance-treatment professionals.

Self-compassion and emotional invalidation mediate the effects of parental indifference on psychopathology.

This study investigated whether self-compassion and emotional invalidation (perceiving others as indifferent to one's emotions) may explain the relationship of childhood exposure to adverse parenting and adult psychopathology in psychiatric outpatients (N=326). Path analysis was used to investigate associations between exposure to adverse parenting (abuse and indifference), self-compassion, emotional invalidation, and mental health when controlling for gender and age. Self-compassion was strongly inversely associated with emotional invalidation, suggesting that a schema that others will be unsympathetic or indifferent toward one's emotions may affect self-compassion and vice versa. Both self-compassion and emotional invalidation mediated the relationship between parental indifference and mental health outcomes. These preliminary findings suggest the potential utility of self-compassion and emotional schemas as transdiagnostic treatment targets.

Mindfulness and Modification Therapy for Behavioral Dysregulation: A Comparison Trial Focused on Substance Use and Aggression.

OBJECTIVES: Disorders of behavioral dysregulation often involve more than one dsyregulated behavior (e.g., drug abuse and aggression, alcohol abuse and gambling). The high co-occurrence suggests the need of a transdiagnostic treatment that can be customized to target multiple specific behaviors. METHOD: The current pilot study compared a 20-week, individual transdiagnostic therapy (mindfulness and modification therapy [MMT]) versus treatment as usual (TAU) in targeting alcohol problems, drug use, physical aggression, and verbal aggression in self-referred women. Assessments were administered at baseline, post-intervention, and 2-month follow-up. RESULTS: Wilcoxon signed-ranked tests and multilevel modeling showed that MMT (n = 13) displayed (a) significant and large decreases in alcohol/drug use, physical aggression, and verbal aggression; (b) significantly greater decreases in alcohol/drug use and physical aggression than did TAU (n = 8); and (c) minimal-to-no deterioration of effects at follow-up. Both conditions showed significant decreases in verbal aggression, with no statistically significant difference between conditions. MMT also displayed greater improvements in mindfulness. CONCLUSIONS: Preliminary findings support the feasibility and efficacy of MMT in decreasing multiple dysregulated behaviors.

Borderline personality features and harmful dysregulated behavior: the mediational effect of mindfulness.

OBJECTIVES: The current preliminary study investigated whether deficits in mindfulness (awareness, attentiveness, and acceptance of the present experience) may underlie the relationship of borderline personality disorder (BPD) features to self-injury and overall acts of harmful dysregulated behavior. METHOD: Nonparametric bootstrapping procedures were used to examine theoretical relationships among variables in a psychiatric sample of adults (N = 70). Participants were asked to imagine themselves in distress-inducing situations and then write what they would actually do to decrease distress in such situations. RESULTS: As hypothesized, mindfulness statistically mediated the relationship of BPD features to reported acts of (a) self-injury and (b) overall harmful dysregulated behaviors. CONCLUSIONS: Difficulties in the ability to be aware, attentive, and accepting of ongoing experience may play a role in the relationship of BPD features to harmful dysregulated behaviors. Future research should clarify potential reciprocal effects between BPD features and mindfulness with prospective, multioccasion designs.

Is the association between various emotion-regulation skills and mental health mediated by the ability to modify emotions? Results from two cross-sectional studies.

BACKGROUND AND OBJECTIVES: In order to clarify mechanisms underlying the association between emotion regulation and psychopathology, we tested whether the ability to modify negative emotions mediates the associations of other emotion-regulation skills with psychopathological symptoms in two studies. METHODS: The first study included 151 college students; the second included 121 psychiatric inpatients. Bootstrapping-enhanced mediation analyses were utilized to assess associations between self-reports of emotion-regulation skills and psychopathology, as well as potential mediation effects. RESULTS: In both samples, the ability to modify emotions completely mediated the association between symptoms and skills for most skills, but not for the skill of accepting/tolerating negative emotions. LIMITATIONS: Major limitations include the use of a cross-sectional design as well as exclusive use of self-report data. CONCLUSIONS: The ability to modify negative emotions may be the common pathway by which many emotion-regulation skills exert their influence on mental health; however, the skill of accepting/tolerating negative emotions may be beneficial to mental health regardless of whether or not it facilitates modification of emotions.

Emotion regulation and mental health: recent findings, current challenges, and future directions.

PURPOSE OF REVIEW: In recent years, deficits in emotion regulation have been studied as a putative maintaining factor and promising treatment target in a broad range of mental disorders. This article aims to provide an integrative review of the latest theoretical and empirical developments in this rapidly growing field of research. RECENT FINDINGS: Deficits in emotion regulation appear to be relevant to the development, maintenance, and treatment of various forms of psychopathology. Increasing evidence demonstrates that deficits in the ability to adaptively cope with challenging emotions are related to depression, borderline personality disorder, substance-use disorders, eating disorders, somatoform disorders, and a variety of other psychopathological symptoms. Unfortunately, studies differ with regard to the conceptualization and assessment of emotion regulation, thus limiting the ability to compare findings across studies. Future research should systematically work to use comparable methods in order to clarify the following: which individuals have; what kinds of emotion regulation difficulties with; which types of emotions; and what interventions are most effective in alleviating these difficulties. SUMMARY: Despite some yet to be resolved challenges, the concept of emotion regulation has a broad and significant heuristic value for research in mental health.

Mindfulness and modification therapy for behavioral dysregulation: results from a pilot study targeting alcohol use and aggression in women.

OBJECTIVES: Increasing evidence suggests that deficits in mindfulness (awareness, attentiveness, and acceptance of the present moment) play a role in a range of disorders involving behavioral dysregulation. This paper adds to that literature by describing a transdiagnostic psychotherapy (Mindfulness & Modification Therapy; MMT) developed to target behavioral dysregulation. DESIGN: An open-treatment pilot-trial investigated the feasibility, acceptability, and pre-post effects of MMT targeting women (N = 14) court-referred for alcohol abuse/dependence and aggression. RESULTS: Pre-post comparisons revealed significant decreases in alcohol use, drug use, and aggression. In addition, the retention rate was 93%. CONCLUSION: Preliminary evidence suggests that MMT is a feasible and acceptable treatment that decreases dysregulated behaviors such as substance use and aggression, while also potentially increasing retention.

Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence.

OBJECTIVE: As emotion regulation is widely considered to be a primary motive in the misuse of alcohol, our aim in the study was to investigate whether deficits in adaptive emotion-regulation skills maintain alcohol dependence (AD). METHOD: A prospective study investigated whether emotion-regulation skills were associated with AD and whether these skills predicted alcohol use during and after treatment for AD. Participants were 116 individuals treated for AD with cognitive-behavioral therapy. Emotion regulation and severity of AD symptoms were assessed by self-report. Alcohol use during treatment was assessed by Breathalyzer and urine analysis for ethyl glucuronide; alcohol use during the 3-month follow-up interval was assessed by self-report. RESULTS: Pretreatment emotion-regulation skills predicted alcohol use during treatment, and posttreatment emotion-regulation skills predicted alcohol use at follow-up, even when controlling for other predictors potentially related to emotion regulation. Among a broad range of specific emotion-regulation skills, the ability to tolerate negative emotions was the only skill that negatively predicted subsequent alcohol consumption when controlling for the other skills. Individuals in the AD sample reported significantly larger deficits in emotion-regulation skills than did those in a nonclinical control sample but significantly less than did those in a sample of individuals exclusively meeting criteria for major depressive disorder. CONCLUSIONS: Enhancement of general emotion-regulation skills, especially the ability to tolerate negative emotions, appears to be an important target in the treatment of AD.

Enhancing emotion-regulation skills in police officers: results of a pilot controlled study.

Police officers are routinely exposed to situations that elicit intense negative emotions; thus, officers have a particularly strong need for effective methods of regulating such emotions. The main purpose of this study was to investigate whether a manualized emotion-regulation training (Integrative Training of Emotional Competencies; iTEC; Berking, 2010a) can improve the emotion-regulation skills of police officers. First, self-reports of 9 emotion-regulation skills were assessed in a sample of officers (N=31) and compared to those of a matched community-based control group. Then, the effects of the training on the emotion-regulation skills of officers were evaluated in a time-staggered design with a waitlist control condition. Results indicate that, compared to controls, officers have difficulties in accepting and tolerating negative emotions, supporting themselves in distressing situations, and confronting emotionally challenging situations. The training significantly enhanced successful skill application, especially some skills with which officers reported difficulty applying. These findings suggest that a focus on emotion-regulation skills may be an important component for programs aimed at preventing mental-health problems in police officers.

The role of mindfulness in borderline personality disorder features.

This study investigated whether deficits in mindfulness (attention, awareness, and acceptance of the present moment) underlie variability in borderline personality disorder (BPD) features and related impairments in interpersonal functioning, impulsivity, and emotion regulation. A path analytic approach was used to examine the relationships of trait mindfulness with BPD features, interpersonal effectiveness, impulsive and passive emotion-regulation, and neuroticism in a psychiatric sample of adults (N = 70). As hypothesized, mindfulness was associated inversely with BPD features and core areas of dysfunction, and these associations continued when controlling for neuroticism. Furthermore, mindfulness deficits continued to predict BPD features even when interpersonal effectiveness, passive and impulsive emotion-regulation, and neuroticism were controlled. These findings suggest that mindfulness may be a unique predictor for the expression of BPD pathology. An emphasis on mindfulness may thus be crucial in enhancing the formulation and treatment of BPD.

Violence and substance use among female partners of men in treatment for intimate-partner violence.

To improve understanding of the complex dynamics in intimate partner violence (IPV) in heterosexual relationships, we explored violence and substance use among the female partners of men entering treatment for both IPV and substance-related problems. All male participants (n = 75) were alcohol dependent and had at least one domestic-violence arrest. Results showed that female partners were as likely as men to engage in substance use the week before treatment; however, according to reports by the men, the female partners were more likely than men to use substances during the last week of treatment, due to a reported increase in use during the men's treatment. Regarding violence, 59 percent of female IPV victims reported engaging in some form of mild violence against their male partners, and 55 percent reported engaging in some form of severe violence. By contrast, only 23 percent of male batterers reported that their female partners had engaged in mild violence, and only 19 percent reported that their partners had engaged in severe violence. Regardless of whether the violence was defensive in nature, the data suggest that women in relationships involving substance abuse and IPV are in need of treatment. Implications of these findings are discussed.

Do deficits in mindfulness underlie borderline personality features and core difficulties?

The current study investigated whether deficits in mindfulness (the awareness, attention, and acceptance of the present moment) can account for variability in borderline personality (BPD) features and characteristic difficulties in emotion regulation, interpersonal effectiveness, and impulsivity. Structural equation modeling and hierarchical regressions were utilized to examine the associations of trait mindfulness with BPD features, interpersonal problem-solving, impulsive and passive emotion-regulation strategies, and neuroticism in a sample of young adults (N = 342). As hypothesized, mindfulness was related inversely to BPD features and core areas of difficulty, and these associations continued even when controlling for neuroticism. Additionally, mindfulness deficits continued to predict borderline features even when interpersonal effectiveness, passive and impulsive emotion-regulation, and neuroticism were controlled. It is concluded that deficits in mindfulness may be integral to BPD features. Difficulties with attention, awareness, and acceptance of internal and external experience appear to explain borderline pathology even when controlling for problems with negative affectivity, behavioral dyscontrol, and emotional and interpersonal dysfunction--which have been described as definitional of this disorder. Thus, attention to mindfulness deficits may enhance clinical formulation of BPD symptomatology, as well as provide a vital component of effective BPD treatment.

Emotion-regulation skills as a treatment target in psychotherapy.

BACKGROUND: Deficits in emotion-regulation skills have been shown to be integral to the development and maintenance of a wide range of mental disorders. AIM: To evaluate the importance of these skills as a treatment target in psychotherapeutic interventions. METHOD: Nine specific emotion-regulation skills were assessed in a sample of 289 inpatients before and after cognitive-behavioural treatment. Self-reports of success in pretreatment skills application were first compared to those of 246 non-clinical controls. Pretreatment skills application and change in skills application during therapy were then related to a variety of outcome measures. Finally, the effects of integrating a brief training of general emotion-regulation skills into the CBT-based treatment were evaluated in a controlled trial. RESULTS: Uni- and multivariate analyses identified the skills of acceptance, tolerance, and active modification of negative emotions as particularly important for current mental health and treatment outcome. Replacing parts of the standard CBT treatment with the emotion-regulation training enhanced the effects of the CBT treatment on skills application and on other measures of mental health. CONCLUSION: Incorporating interventions that directly target general emotion-regulation skills may improve the effectiveness of psychotherapeutic interventions.

Commentary: implications for assessment and treatment of addictive and mentally disordered offenders entering prisons.

In this commentary, we discuss the main findings of the research study by Gunter et al., "The Frequency of Mental Health and Addictive Disorders Among 320 Men and Women Entering the Iowa Prison System: Use of the MINI-PLUS." This commentary provides an overview on the use of standardized assessments with prison populations; prevalence rates of mental and addictive disorders within prisons; substance use disorders, as opposed to substance-induced psychiatric disorders, among prison populations; and research on diversion treatment programs within the community for nonviolent mentally ill and substance-using offenders.

Neurocognitive performance among alcohol dependent men with and without physical violence toward their partners: a preliminary report.

OBJECTIVE: There are high rates of co-occurring alcohol dependence and intimate partner violence (IPV) among men seeking substance abuse treatment. The authors examined neurocognitive performance among treatment-seeking alcohol dependent men with (IPV+) and without reported physical violence (IPV-). METHOD: Twenty-five subjects participated in this pilot study. All participants underwent a neurocognitive battery including, Continuous Performance Test (CPT), California Verbal Learning Test (CVLT), Digit Span, Iowa Gambling Test (IGT), Wisconsin Card Sort (WCST), Trail Making Test, Parts A & B, a visuospatial memory (VSWM) task and the Stroop Color Word Test (SCWT). RESULT: Alcohol dependent participants with IPV (IPV+; n = 9) had more severe deficits in attention, concentration, cognitive flexibility compared to controls (n = 7). Both the alcohol dependent (IPV-; n = 9) and IPV+ groups had significantly more impairments on tasks of impulsivity than the smoking controls. The IPV- group had significantly more impairments on executive functioning compared to smoking controls, but was not significantly different than the IPV+ group. CONCLUSIONS: Our preliminary results suggests that IPV+ males have more severe neuropsychological impairments compared to the smoking control group than did the IPV - group. The implications of these findings are discussed.

Prospective effects of emotion-regulation skills on emotional adjustment.

Deficits in emotion-regulation skills have widely been shown to be associated with poor emotional adjustment. However, it is still unclear whether these deficits are a cause or a consequence of poor adjustment. The purpose of the present research was to clarify the reciprocal effects between these 2 concepts. In 2 studies (Ns = 446 and 635), self-reports of emotion regulation and emotional adjustment were assessed twice with a 2-week interval. Cross-lagged regression analyses demonstrated that self-reports of emotion regulation predicted subsequent adjustment, over and above the effects of previous adjustment, whereas emotional adjustment did not predict subsequent emotion regulation. Thus, a focus on emotion-regulation skills may be important in the prevention and treatment of affect-related mental health problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Reconstruing the "reconstruction" of psychopathy: a comment on Cooke, Michie, Hart, and Clark.

In this comment we highlight critical problems in the estimation of parameters for their hierarchical three-factor model of psychopathy, as assessed with the Hare Psychopathy Checklist, and their interpretation of these factors as causally related to socially deviant behavior. We argue that there is nothing "causal" about a model in which cross-sectional data are used to assert that antisocial tendencies are consequences of other more fundamental psychopathic traits. We present an equally viable model, based on the PCL-R four-factor solution, in which antisocial tendencies play a fundamental role in the construct of psychopathy, consistent with previous research and clinical tradition.