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Mindfulness as an Adjunct Intervention With Dually Diagnosed Individuals
By Mallory Hanfling, MSW

In the field of clinical social work, evidence-based practice (EBP) is essential in validating the profession within the scientific community. Accordingly, there is an ongoing need to diligently reassess the interventions social workers administer to clients to ensure effective treatment. With the advancement of integrative techniques and holistic approaches to mental health treatment, it is important to research their effectiveness and consequences in therapy. Recently an intervention based on the Buddhist principles of awareness, called mindfulness, has become increasingly prevalent as an adjunct intervention in clinical settings. Mindfulness is a general term for using the “present moment as the core indicator of the appropriateness of particular choices” (Kabat-Zinn, 1996).

“Scientific interest in dual diagnosis is based on observations in clinical samples that patients with both mental and substance disorders are more persistent, severe, and treatment resistant than patients with pure disorders” (Kessler, 2004). This review of the existing literature surrounding mindfulness and dual diagnosis (DD) treatment will help to inform a prospective research study on the extent to which a mindfulness practice intervention, in addition to standard care, is effective in reducing anxiety over the desire to use a substance, and to increase self-control to not use, among dually diagnosed clients.

Dual Diagnosis Treatment
The U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC) found annual prevalence rates of 8.5% of adult Americans met criteria for alcohol abuse and alcoholism and 9.4% for any other substance of abuse in 2001-2002 (Maxmen, Ward, & Kilgus, 2009). Further, the NESARC results indicated an alarming 78% comorbidity rate of psychiatric disorders within the population diagnosed with substance abuse disorders in their lifetime.

Despite the strikingly high DD prevalence, the prognosis for treatment of this population is often poor due to their tendency to be less compliant with treatment, being more likely to drop out of treatment, at a higher risk for suicide, and having less support for sobriety from family and the work environment (Le Fauve, Litten, Randall, Moak, Salloum, & Green, 2004). DD patients present a unique obstacle, in that both the mental illness and the substance abuse/dependence must be addressed and resolved.

According to the DSM-IV-TR (American Psychiatric Association, 2000), the definition of substance dependence is “a maladaptive pattern of substance use, leading to clinically significant impairment or distress…” (p.197). As the Psychodynamic Diagnostic Manual (PDM) (2006) suggests, acute and chronic distress is at the heart of addictive behavior, and addictive vulnerabilities are the result of developmental deficits in ego and self-organization (p.138). So, understandably, the one-third to one-half of psychiatric patients with DD (Carey, K. B., & Carey, M. P., 1990) would naturally have biopsychosocial problems associated with their dual mental illness and substance abuse diagnoses. The PDM (2006) also explains that patients’ substance use is likely a coping mechanism of self-medicating to ameliorate their acute and chronic distress (p.138). As Kessler (2004) mentions, these complicated factors that must all be considered in DD treatment lead to significantly poorer treatment success, but that could be mediated by matching effective treatments with the complex needs of dually diagnosed patients.

Mindfulness helps patients focus on their experience and learn to pause before reacting to a situation (more specifically, not automatically reaching for a substance in an uncomfortable situation), which has likely resulted in heavier usage in the past.

Several studies have been conducted on the efficacy of cognitive-behavioral therapy (CBT) that indicated CBT is effective in managing both depression and alcoholism (Brown, & Ramsey, 2000, Brown et al., 1997 from Le Fauve et al., 2004). Similarly, numerous studies have proven that behavioral interventions, cognitive interventions, structural family therapy, solution-focused therapy, motivational interviewing, and other intervention methods are effective in treatment with substance-disordered patients and with various mental disorders separately (Walsh, 2009).

Because these methods have been proven effective in both populations, some theorize that they will work equally well with dually diagnosed patients and have been widely implemented in the mental health community. Substance abuse treatments often stem from the traditional 12-step program, taking the approach of the “addiction as a disease model” where the addiction is the disease in and of itself and the patient must surrender to a “higher power” in the recovery process. Additionally relapse-prevention models (emphasizing the patient’s coping efforts in stressful situations) and behavioral and cognitive techniques such as contingency management (operant conditioning, using positive reinforcement) have been effective in treating substance-abusing populations (Bornovalova & Daughters, 2007).

Dialectical behavioral therapy (DBT) has recently emerged from these aforementioned interventions as an effective treatment for severe personality disorders, such as borderline personality disorder. DBT emphasizes that the patient’s maladaptive behaviors act as a regulatory function in aversive situations, which reduces the patient’s discomfort and thus negatively reinforces the same maladaptive behaviors in future situations. DBT intends to help the patient acquire, utilize, and generalize adaptive emotion regulation skills and discontinue their maladaptive behavioral reactivity (Bornovalova & Daughters, 2007). Mindfulness is a key component in DBT, theoretically targeting deficits in distress tolerance and learning how to experience and tolerate the distress rather than immediately trying to escape it with substance use or other maladaptive behaviors (Bornovalova & Daughters, 2007).

Mindfulness-Based Intervention Studies
What is meant by mindfulness? Jon Kabat-Zinn’s definition (1994) states, “Mindfulness means paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally” (p. 4). So, in using mindfulness, the clinician is aiming to provide patients with alternative ways to respond to stressful events, allowing them to step out of automatic cognitive reactions that often worsened their stress and interfered with effective problem solving (Segal, Williams, & Teasdale, 2001). Kabat-Zinn (1990) explained the process of mindfulness and the helpful way that “…the simple act of recognizing your thoughts as thoughts can free you from the distorted reality they often create and allow for more clear-sightedness and a greater sense of manageability in your life” (pp. 69-70).

Two important aspects of mindfulness become valuable in the treatment of mental disorders and substance abuse: First, exercises in purposeful awareness can build capacity in dealing with the ruminative thought-affect cycles which tend to exacerbate depression and anxiety for those with mental illness; and second, having the skill to recognize thoughts, feelings, and body sensations through mindfulness may serve as an early warning system of an impending depressive or vulnerable episode (Segal et al., 2001).

Several studies have been conducted to date on the use of mindfulness-based relapse prevention (MBRP) with substance-disordered patients. At the forefront of mindfulness research are Sarah Bowen and Katie Witkiewitz. In a study focused on the use of mindfulness meditation and substance use in an incarcerated population (Bowen, et al., 2006) participants were taught to observe experiences (substance use cravings) as impermanent events not necessarily requiring action (using a substance), allowing the subject to let go of compulsive thought patterns. Thus mindful awareness can help substance users discover alternatives to mindless, compulsive, or impulsive behaviors (from Marlatt, 2002 in Bowen et al., 2006). The results of this study indicated that after release from jail, the participants who received the mindfulness intervention, as compared to the treatment-as-usual control group, showed significant reductions in alcohol, marijuana, and crack cocaine use, as well as decreases in alcohol-related problems and psychiatric symptoms and increases in positive psychosocial outcomes. (Bowen et al., 2006). This study illuminates the potential for decreased anxiety over desire to use a substance and increased perception of self-control over the desire to use in dually diagnosed populations (the dependent variables of the abovementioned research proposal).

Another study conducted by Witkiewitz and Bowen (2010) examined the relationship between depression, craving, and substance use and mindfulness-based relapse prevention in a randomized controlled trial condition. The study provided encouraging support for the use of mindfulness as a skill set with dually diagnosed patients. Individuals with substance abuse histories tend to habitually react to depressive thinking or mood states with relapse-related thoughts or cravings due to past associations of depressive states with craving and relapse. Through increased awareness of these reactive patterns between depressive (or anxious) states and substance craving, and learned alternative responses, mindfulness-based relapse prevention may help dually diagnosed patients break the current habit of using a substance to relieve uncomfortable depressive and anxious episodes. “They learn to investigate the emotional, physical, and cognitive components of experience, rather than to immediately attempt to escape them” (Witkiewitz & Bowen, 2010). MBRP seemed to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in substance use after treatment for the experimental group (Witkiewitz & Bowen, 2010).

Learning How to Change
“The process of change starts with a general, often difficult to articulate feeling that not everything is as it should be; things could be better than they are. From such a feeling may arise a commitment to find a better way of handling things: We start out on a path to find a better way” (Segal et al., 2001). Currently, the field of social work has a variety of cognitive, behavioral, cognitive-behavioral, and psychodynamic interventions that have been empirically supported in the treatment of dually diagnosed patients. However, these interventions are not foolproof, they do have weaknesses, and patients with substance abuse/dependency disorders and co-occurring mental health disorders are still relapsing after completing treatment. It is for this reason that exploring the effectiveness of mindfulness-based interventions is a worthwhile endeavor with encouraging prospects.

Current research showcases mindfulness-based interventions as a fully developed, highly cost-effective, empirically supported treatment program that can easily be utilized with many patients across a vast spectrum of somatic and mental disorders. Further, evidence shows that some form of mindfulness practice can be maintained on a regular basis by a majority of patients for up to three years after completing their initial treatment (Miller, Fletcher, & Kabat-Zinn, 1995). There are a variety of applications of mindfulness as an adjunct to more professionally accepted interventions, however most have their roots in the evidence-based world of cognitive and behavioral approaches to psychotherapy. These mindfulness-based interventions, rooted in BT/CT/CBT, have considerably constituted mindfulness as a legitimized and evidence-based intervention in the eyes of the public and of other professionals (McCown, Riebel, & Micozzi, 2010).

At the risk of presenting as a mindfulness-zealot, we, ourselves as clinicians, can mindfully choose to avoid prematurely dismissing possible revolutionary interventions, which tend to be discounted through our automatic filters and schemas in our perception of the world, and expand our repertoire of clinical skills to encompass a holistic and integrative approach to social work practice. With the complex nature of dual diagnosis, and its poor treatment prognosis, it is important for clinicians to explore alternative interventions and evaluate what combinations of theoretical approaches will best serve our clients. As we say in the profession, we are actively trying to work ourselves out of a job.

— Mallory Hanfling, MSW, is the winner of the Virginia P. Robinson publication prize at the University of Pennsylvania School of Social Policy and Practice.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. Revised 4th ed. Washington, DC: American Psychiatric Association.

Bornovalova, M. A. & Daughters, S. B. (2007). How does dialectical behavioral therapy facilitate treatment retention among individuals with comorbid borderline personality disorder and substance use disorders? Clinical Psychology Review, 27(8), 923-943.

Bowen, S., Witkiewitz, K., Dillworth, T. M., et al. (2006). Mindfulness meditation and substance use in an incarcerated population. Psychology of Addictive Behaviors, 20(3), 343-347.

Carey, K. B., & Carey, M. P. (1990). Social problem-solving in dual diagnosis patients. Journal of Psychopathology and Behavioral Assessment, 23(3). 247-253.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. (pp. 69-70) New York: Dell Publishing.

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. (p. 4) New York: Hyperion.

Kabat-Zinn, J. (1996). Mindfulness meditation: What it is, what it isn’t, and its role in health care and medicine. In Y. Haruki, Y. Ishii, & M. Suzuki (Eds.), Comparative and psychological study on meditation. Netherlands: Eburon.

Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological Psychiatry, 56(10), 730-737.

Le Fauve, C. E., Litten, R. Z., Randall, C. L., Moak, D. H., Salloum, I. M., & Green, A. I. (2004). Pharmacological treatment of alcohol abuse/dependence with psychiatric comorbidity. Alcoholism: Clinical and Experimental Research, 28(2), 302-312.

Maxmen, J. S., Ward, N. G., & Kilgus, M. (2009). Substance-related disorders. Essential psychopathology and its treatment. 3rd ed. New York: W. W. Norton & Company.

McCown, D., Reibel, D., Micozzi, M.S. (2010). Teaching mindfulness: A practical guide for clinicians and educators. New York: Springer.

Miller, J. J., Fletcher, K., & Kabat-Zinn, J., (1995). Three-year follow-up and clinical implications of a mindfulness-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17(3), 192-200.

PDM Task Force. (2006). Psychodynamic Diagnostic Manual: (PDM). (p. 138) Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.

Walsh, J. (2009). Theories for direct social work practice.2nd ed. Belmont, CA: Brooks Cole.

Witkiewitz, K. & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Counseling and Clinical Psychology, 78(3), 362-374.