Addictions Advisor: Mindfulness-Based Relapse Prevention — A Middle-Ground Approach
By Kimberley L. Berlin, LCSW, CSAC, MAC, SAP
Social Work Today
Vol. 19 No. 6 P. 10

The National Institute on Drug Abuse (2018) cites relapse rates for substance use disorders (SUDs) as being between 40% and 60% nationwide; other sources place the figure as high as 75%. What is unclear are the metrics used for relapse rates; studies vary in their definitions, cohorts, and outcomes. What is clear, however, is that the percentage of relapse has remained static for decades, regardless of the metric. Why has this number not changed, and what options are available for relapse prevention that might be considered?

The management of SUDs is riddled with relapse potential and causes are important to understand. Kadam and colleagues (2017) report that the most often-cited reasons for a relapse is the desire for a “positive mood state.” The American Society of Addiction Medicine (2011) cites a lack of connection to self and others, while the National Institute on Drug Abuse (2018) cites the primary reason for relapse as a lack of coping skills for stress.

Posttreatment for SUDs has floundered; completion rates hover at 20% to 40%, depending on which treatment facility is reporting them, and which metric they are using (30, 60, or 90 days; intensive outpatient programs vs. 12 Step; combinations; or none). While it is unrealistic to argue for a one-size-fits-all approach, it would seem that what we are doing is simply not working. With that in mind, why have we not found a middle ground?

Mindfulness
The “mindfulness” movement developed by Jon Kabat-Zinn, PhD, is based on the “Mahayana” model of Buddhist meditation known as “The Middle Way.” Mindfulness-based stress reduction (MBSR), which was officially launched in 1979, proved to be successful for patients at the University of Massachusetts Medical Center who were recovering from a broad range of ailments ranging from heart surgery to rheumatoid arthritis.

What began as a fringe interest in a seemingly foreign idea soon became infused into our culture as a normative practice for health and well-being. Research has consistently shown the advantages to the approach of mindfulness-based interventions, whether in scholarly articles or books.

Early findings in mindfulness-based research triggered an enormous amount of enthusiasm for meditation; by the year 2000 researchers were engaged in rigorous inquiry on the topic. Between 2000 and 2010 the number of research endeavors on mindfulness jumped from 12 per year to 203 per year. In 2018, 842 academic journal studies were published on mindfulness (Black, 2016).

MBSR and subsequent offshoots are Buddhist-inspired collections of practices aimed at helping us cultivate a moment-to-moment awareness of ourselves, and our place in the world around us. This skill affords us the opportunity to have a more acute understanding of a situation as it arises and to be able to refrain from reactive responses. The outcome is an ability to witness events from a more objective point of view.

A New Approach to Relapse Prevention
Research expanded to mental health and substance abuse treatment, giving rise to a body of work known as mindfulness-based relapse prevention (MBRP). Developed by G. Alan Marlatt, PhD, and coauthors Sarah Bowen, PhD, and Neha Chawla, PhD, the benchmark clinical manual on this subject was published in 2010.

Integrating cognitive behavior therapy techniques with the protocols of MBSR, Marlatt and his team engaged in multiple clinical trials over the course of two decades, resulting in the proposal of a new approach to relapse prevention. Marlatt coauthored a seminal 2005 paper published in the Journal of Cognitive Psychotherapy that put forth a comprehensive and compelling argument in favor of this robust and durable treatment approach to relapse prevention.

Framed as an eight-week program consisting of two-hour structured sessions, MBRP is facilitated by trained therapists or clinicians. The sessions focus on basic awareness, understanding the nature of reactivity involved in cravings, accepting situations as they arise without adding a storyline, seeing thoughts as “just thoughts,” and honing the skills of self-care with an ongoing practice of daily meditation. Alternative methods of coping with relapse triggers include “urge-surfing” involving cognitive imagery work, and relaxation strategies that diminish the negative impact of life stressors.

Bowen, an associate professor at Oregon’s Pacific University and a clinical psychologist, is working with the University of South Carolina on a grant from the National Institutes of Health to explore the use of MBRP to treat women with PTSD who have also developed SUDs. She is also in the process of writing the second edition of the clinician’s guide to MBRP.

Bowen explains that since 2011 the field has become “more sophisticated in our thinking about treatment for SUD, working with more diverse populations that include incarcerated individuals, cultures, and those with co-occurring disorders. At the same time, she points out that “what we might be up against in our views of the relapse rate in this country is the need to reconceptualize relapse and treatment in general.”

Positing “negative mood or affect as the number one precipitant of a relapse,” Bowen asserts that it becomes more apparent that what a recovering individual might struggle with are internal states over which they believe they have no control. “We behave in certain ways for a reason because there are causes and conditions for everything we do,” she says. “We engage in false refuge by reaching for something to make us feel better. We reach for the thing that will take away the pain but, in the end, brings the worst of pain.”

Societal issues impact these states by advertising an insistence that we are “supposed to be happy all the time” and “feel pleasure but never pain” Bowen says. This expectation of perfection becomes unrealistic both at the individual and collective levels. “It becomes a cruel threat that the promise of an advertised substance will make you feel better, only to then take everything away from you,” she adds.

Abstinent Violation Effects
Bowen says, “We need to start treating addiction as a chronically relapsing condition. Many programs don’t talk about this and the message in some treatment centers may be the underlying causing of relapse problems including abstinent violation effects.”

The abstinent violation effect occurs when an individual has a single event of use, defined as a lapse. However, an individual may experience such deeply felt shame and guilt over a single use that it drives them to spiral into a return of prolonged and compulsive behaviors.

Bowen adds, “If an individual has one drink but the next day returns to abstinence, is that a relapse? Some will see it as a return to the baseline of use, but many do not see it that way. Does one sip of alcohol mean failure?” It is unclear whether the statistics used are strictly relapses or include lapses. If the latter, the percentage might be significantly different, owing to the various definitions used.

Bowen believes that a lapse can be dangerous: “Any substance can cause extreme harm, even death. So, let’s do everything we can so that the individual doesn’t slip. However, if they do slip, let’s frame it so that it is not the end, but rather, another step in the journey.”

MBRP teaches an individual to observe instances of craving experience from the micro to the macro. When an urge to use substances arises, MBRP techniques guide the individual to ask themselves, “Where is this coming from?”

According to Bowen, the inquiry into examining one’s own behavior offers the opportunity to view the “relapse chain” of events by asking a series of questions: “What am I thinking? What am I feeling? And now what’s happening? And now what?”

While the idea of a lapse is the antithesis of belief from a 12 Step standpoint, Bowen says, “I want to be very clear that MBRP is not ‘instead of’ or pushing away other approaches. This can work beautifully with the 12 Step method as it supports the contemplative and meditative aspects of the program.”

The second edition of the clinician’s guide to MBRP will reflect more of this broader approach to thinking with an eye to making it available to as many people as possible. “It has taken time to evolve. Today’s generation is savvier and influencing our previous notions of the norms,” Bowen says. In addition, years of research data have added a layer of serious credibility to the use of ancient Buddhist practices.

In lieu of an either-or, black-and-white view of the recovering process, MBRP may afford the field of SUD treatment a middle ground that has perhaps been absent from existing treatment models over the course of the 20th and 21st centuries. Incorporating social work values that support the strengths of clients, MBRP offers an opportunity to view the moment-by-moment processes of our minds and train clients in being stronger allies to themselves. This may mean the difference between a lapse or relapse, and in the long run, may alter the perceptions of persons in recovery, from both themselves and society at large.

— Kimberley L. Berlin, LCSW, CSAC, MAC, SAP, is an integrated addiction specialist. Her private practice, Compassionate Beginnings, LLC, is located in Leesburg, VA.

References
American Society of Addiction Medicine. (2011). Definition of addiction. Retrieved from https://www.asam.org/resources/definition-of-addiction.

Black, D. (2016). Mindfulness Journal Publications by Year, 1980-2015. American Mindfulness Research Association. Retrieved from www.goAMRA.org.

Kadam, M., Sinha, A., Nimkar, S., & Matcheswalla, Y. (2017). A comparative study of factors associated with relapse in alcohol dependence and opioid dependence. Indian Journal of Psychological Medicine, 39(5), 627-633.

National Institute on Drug Abuse. (2018). Drugs, brains, and behavior: the science of addiction. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery.