Mindfulness-Based Relapse Prevention for Alcohol …

1 Journal of Cognitive Psychotherapy: An International QuarterlyVolume 19, Number 3 2005 Mindfulness-Based Relapse Preventionfor Alcohol and Substance Use DisordersKatie Witkiewitz, PhDUniversity of Illinois, ChicagoG. Alan Marlatt, PhDDenise Walker, PhDUniversity of Washington, Seattle, WAGognitive-behavioral approaches to Alcohol and drug use disorders have received considerableempirical support over the past 20 years. One cognitive-behavioral treatment, Relapse preven-tion, was initially designed as an adjunct to existing treatments. It has also been extensivelyused as a stand-alone treatment and serves as the basis for several other cognitive and behav-ioral treatments.

2 After a brief review of Relapse Prevention , as well as the hypothesized mech-anisms of change in cognitive and behavioral treatments, we will describe a "new" approachto Alcohol and drug problems called Mindfulness-Based Relapse Prevention . Preliminary datain support of mindfulness -meditation as a treatment for addictive behavior are provided anddirections for future research are : mindfulness ; meditation; Relapse Prevention ; substance ahuse; substance ahusetreatmentThe excessive use of Alcohol and other suhstances represents a significant puhlic healthproblem worldwide (World Health Organization [WHO], 1999).

3 The United NationsOffice for Drug Control and Crime Prevention (UNODCCP, 2002) recently reported thatapproximately 185 million people worldwide are current drug users, which suggests the demandfor treatment is on the rise. The lack of empirically supported treatments, and the minimal uti-lization of available treatments by those needing services indicates that brief, innovative treat-ments to serve those individuals with Alcohol and drug use disorders are highly desired (Marlatt& Witkiewitz, 2002). Mutual support groups, such as Alcoholics Anonymous (AA) and NarcoticsAnonymous (NA), are the most commonly available treatments in many developed countriesworldwide (Room, 1998).

4 However, these approaches may not he clinically indicated for certaindrug and Alcohol ahusers (Marlatt, 1983; Marlatt & Witkiewitz, 2002). Given the substantial eco-nomic and individual costs of substance abuse worldwide (WHO, 1999), it is critical for cost-effective, empirically supported treatments to he developed, evaluated, and disseminatedinternationally (Marsden, Oghorne, Farrell, & Rush, 2000). Cognitive-behavioral approaches tosubstance use have received considerable attention in the research literature, with many studiesI 2005 Springer Publishing Company 211212 Mindfulness-Based Relapse Preventiondemonstrating the efficacy and effectiveness of cognitive-behavioral treatments for a variety ofaddictive disorders across diverse populations (Carroll, 1996; Kadden, 2001; McCrady &Ziedonis, 2001).

5 In this article we review existing cognitive-behavioral approaches to substanceuse disorders and introduce a novel cognitive-behavioral technique, mindfulness meditation, asan adjunct to existing treatments or as a stand-alone treatment of addictive BEHAVIORAL MODEL OF ADDICTIONB ased on the premise that maladaptive drinking and drug use are learned behaviors, cognitivebehavior therapy (CBT) provides a framework around which interventions attempt to identifysituational, social, affective, and cognitive precipitants of pathological substance use.

6 Once pos-sible causes of maladaptive behavior are identified an individual may decide to reduce the quan-tity or fi-equency of substance use, or may decide to abstain from Alcohol and drugs studies have described the clinical and cost effectiveness of CBT in the promotion ofabstinence rates, reduction of drinking quantity, frequency, and duration (Finney & Monahan,1996; Kadden, 2001; Longabaugh & Morganstern, 1999), and Prevention of Relapse (Carroll,1996; Irvin, Bowers, Dunn, & Wang, 1999).CBT for Alcohol and drug use disorders and the cognitive behavior (CB) model of alcoholand drug Relapse was initially proposed by Marlatt and colleagues (Larimer, Palmer, & Marlatt,1999; Marlatt & Gordon, 1985).

7 As shown in Figure 1, the CB model of Relapse is based on thelinear progression of responses in high-risk situations. According to this model, if an effectivecoping strategy is used, then the individual will likely experience an increase in self-efficacy andis less likely to consume the previously desired substance. However, if an ineffective copingstrategy is used, then self-efficacy may decline and/or outcome expectancies may become morepositive leading to an increased likelihood of consumption. The initial use of a substance (alapse) is then followed by the perceived effects of the substance and the attributions a personmakes following a lapse.

8 For example, if an individual views the lapse as a minor mistake ora learning opportunity, then he or she is more likely to return to the prelapse treatment goal(a prolapse). However, if an individual views the lapse as an uncontrollable, internal indicationof failure, then the individual is more likely to progress to continued use of the substanceEffectivecopingresponseHigh-ris ksituationIIneffectivecopingresponseIncr easedself-efficacyDecreasedself-efficacy +PositiveoutcomeexpectanciesjDecreasedpr obabilityof relapseInitialuse ofsubstanceAbstinenceviolationeffect-1-P erceivedeffects ofsubstanceIncreasedprobabilityof relapseFIGURE 1.

9 Cognitive-behavioral model of et al. 213(a Relapse ). The latter scenario has been described as the "abstinence violation effect" (Marlatt,1985) whereby an individual views the lapse as an irreparable failure, an attitude that may leadto an increase in the undesired variations of CBT have been developed based on the CB model of Relapse . For adetailed overview, Kadden (2001) provides an extensive examination of the most successful cog-nitive and behavioral treatments for substance dependence, including cue exposure, contingencymanagement, community reinforcement approaches, Relapse Prevention , behavioral maritaltherapy, and patient-treatment matching.

10 In the treatment of drug addiction, contingency-management paired with community reinforcement approaches or Relapse preventionapproaches (Budney & Higgins, 1998; Epstein, Hawkins, Covi, Umbricht, & Preston, 2003), andrelapse Prevention combined with pharmacotherapy (Fiore, Smith, Jorenby, & Baker, 1994;Schmitz, Stotts, Rhoades, & Grabowski, 2001), are among the most successful treatments, par-ticularly among individuals with co-occurring disorders. Borrowing the most successful compo-nents from each of these interventions and synthesizing the hypothesized mechanisms of changein CBT-type approaches (coping skills, craving, self-efficacy, motivation, and metacognitiveawareness) we propose a new variation of CBT for Alcohol and drug use disorders, called mind-fulness- based Relapse Prevention (MBRP).