Mindfulness-Based Relapse Prevention for Addiction (Jennifer Kim Penberthy)

Mindfulness-Based Relapse Prevention for Addiction (Jennifer Kim Penberthy)


JOHN SCHORLING: … an associate professor in the Department
of Psychiatry and Neurobehavioral Sciences here at UVa, and, as many people do in the
health center, she has many roles. She does a lot of research in addiction. She
teaches in the medical school and in the psychiatry residency program. She is a clinical psychologist and therapist,
so she has her own private practice, and she also practices and teaches a number of mindfulness
based interventions, as I mentioned before, including Mindfulness Based Relapse Prevention
and Mindfulness Based Cognitive Therapy. She’s a member of the directorate of the Contemplative
Sciences Center. And I have to say I have been very fortunate
enough, over the past three, four, five years, number of years that we’ve working together
very closely on a number of issues. So, Kim will be talking about Mindfulness
based relapse prevention for addiction. J. KIM PEMBERTHY: Thank you John, that was excellent. I really
appreciate that. I appreciate being invited here today, and
your attention. I know it’s right before lunch, so bear with
me. I don’t like getting that spot sometimes,
but that’s okay. No it’s fine. People don’t look too hungry, they had snacks,
so that’s good. Yes. I am a clinical psychologist, so what
I’m going to talk to you about today is some of the research, but also some of the clinical
work that I do, primarily with addictions. And a lot of this will compliment, very nicely,
Dr. Schorling’s presentation. And hopefully augment that with the specifics, or focus,
on this population. I love this quote, I won’t read it for you,
you can read it yourself. It has a lot of meaning to me. Especially with the population
I work with. The people I see are typically people with
pretty severe addictions and a lot of comorbidities, which means other psychological disorders. Many of them come to our clinic and are almost
in tears because this is one of the first places they’ve been treated, as they say,
like a human being. So, I think it’s very important to remember,
even some of these people that the rest of society has given up on, we can help. I’m used to making the disclosure for my medical
presentation, so I’m accustomed to putting this in there, but I have no financial gain
from giving you this presentation. So the work that I’m going to be talking about
is conducted, primarily, in locations around the country that I’m going to report from
about other people, and then at the CARE clinic where we do our
research on addictions. This is a picture of it. It’s a unique combination – I feel very fortunate
because I get to work with geneticists – my direct division chief is a geneticist, and we look at genotypes, phenotypes, and
collaborate in a really interdisciplinary way. What I’m going to be talking about, primarily,
as you’ve been introduced, is the mindfulness based approach for addictions. As John said, this sort of grows off of the
Mindfulness Based Stress Reduction, but really targets a specific population. To talk really intelligently about this I
feel like it’s necessary to give a little bit of background on the way we conceptualize
addiction. And it is a little bit different than some
of the work done on stress reduction, pain, depression, that sort of thing. So, addiction, the way we would conceptualize
it in a medical setting, as a psychologist especially, it is based on a lot of different
components. So there’s typically conceptualized, a genetic
component- this is why we have a geneticist involved, learned behaviors – part of the
reason I’m involved, because I’m a learning specialist as well,
as in learning theory- and physiological changes, over time, with the exposure to addictions. So it’s a little bit different than some of
the other issues that you involve yourself in in other kinds of mindfulness based interventions. So we have to consider all of that when we
are looking at an approach to treat it. The way the process is laid out here, is a
learning theory basis for addiction that talks about how you may have a genetic proclivity, but often learned experience is the way people
begin an addiction. So, this is an example from a real person with some, also, some comorbid
social anxiety. Going to a party, he has some thoughts, that’s
it’s going to be uncomfortable, he therefore then develops and emotion that comes around
the time of the same thoughts. He stumbles upon the ability to drink and
this makes him feel a lot better. He’s less anxious – this is the reward – this is learning
right here. This is the brain soaking up and learning
I found something that works really well fo rmy anxiety. What happens over time then is
this can get connected to a craving. And you see here, it can be through – you
can have neutral cues. You get in your car, that’s sort of neutral,
but if it’s connected with, in your mind, driving by the store to get some beer, it
can produce a craving. Positive cues as well as negative cues can
induce these cravings that either come directly as a craving to the person, or generally some
sort of affect. Negative affect, I’m lonely, so now I want
to drink. Or, I’m happy so let’s go celebrate and have a drink. So you’ve got it from all
angles here. These are conceptualized as producing cravings.
We can see cravings in the brain. We can measure them physiologically, we can measure them
on paper and pencil. These typically are what lead most quickly
to drug use. With drug use, alcohol use, any other kind
of drug use, you then have some sort of augmentation, or decrease, in the affect that sort of moved
you towards that movement. So you feel better, or you feel less pain.
And of course, because we are human, – I feel like I’m coming in and out with this,
but I’m trying to stay steady – because we are human, we then attach thoughts
to it as well and we remember. So, this sort of augments it all. This just talks about the same sort of thing
but what happens is also that there are changes molecularly, on a cellular level, in the brain
– just like John talked about – that we see with the acquisition of drug dependence
and chronic drug use and then with abstinence. What I’m going to focus on is more of this
abstinence component, because we are talking about treatment for preventing relapse. So we’ve got some therapies that are pretty
adequate, not great, but they can certainly help achieve remission of addiction and abstinence. But, the typical problem with treating addiction,
in today’s world, is that, inevitably, most people relapse. So, one of the reasons we are working on these
developments for relapse prevention is to help decrease those numbers, so that once we get people to a point where
they are abstinent we can maintain them there. That means, changing a lot of things. It means
sustaining the behavioral changes. It means resisting the temptations that are
provided with the craving, and it means – as John indicated – changing the brain again. It’s changed once with the addiction process
and we need to sort of reverse those changes. What we know from the literature, that is
the primary cause of relapse, – and this shows it here up at the top – the negative emotional states are the primary
reason that people report relapsing. So that gives us some clue of what we might
need to do to prevent relapse. What has traditionally been done, with cognitive therapy – in my
very complicated drawing here – is the cognitive therapies that we use now,
or the medications, typically target the craving. So the medications target the craving more
neurobiologically, through use of medications like ondansetron and topiramate that have
shown to provide neurochemical changes that are associated with the patient reporting
that they feel reduced craving. Now this only works for some people. What we’re finding
is that it really seems to be based on genetics. I’m not going to go into all of that, but
there seem to be genotypes who respond to anticraving medications very well, almost
100 percent rates, and then genotypes who respond not at all. So it’s not really going to be a consistent
sort of method to treat these cravings. The other thing that we see – there’s research
coming out, this is only in rats right now – but it seems to differ depending on where
you are in your stage of addiction process. So different anti-craving medications work
better early on in the process while you’re still becoming addicted. Sort of early phases,
maybe when you’re binge drinking. And some medications seem to work better later
on once you are dependant, because they are sort of physiologically different. But, with respect to therapy, basically the
cognitive behavioral therapy approach has been to behavioral strategies like avoid the
cues. Don’t drive by the store that you typically
get your beer, or do substitute behaviors. This is doing things like chewing gum, drinking
coffee instead of smoking, that sort of thing. And there are cognitive components as well
that talk about belief systems and changing some of your automatic thoughts. But, by and large, these are only moderately
effective and we still have a long way to go with respect to treatments. So, with respect to relapse prevention, what
it appears from some of the literature I just showed you, and the thinking in the field, is that what we need to do is exactly what
John described earlier. This is to think about ways to uncouple these linkages here. How can we uncouple the craving feeling from
the drug use? Perhaps even, how can we reduce the stress
or the craving to begin with? And if we could figure out ways to do this,
then not only might we reduce the likelihood of drug use, but prevent relapse to full blown
dependance again. So, this was the idea that Alan Marlatt had
back in the early 80’s. He’s a clinical psychologist who is unfortunately now deceased. But he was out in Washington and was a practitioner,
a meditator himself, a practitioner of meditation, and he decided to use Vipassana meditation
with a population of heavy alcohol and drug users to see if it might help uncouple some
of this stuff. So, what he worked with was – he had this
sort of a captive audience to at least do this initial study. It wasn’t a great study, but he had these
incarcerated people who were readily available and they came in – and he recorded their use
before coming to jail – he had a mixture, because it was a convenience
sample. So he had a mixture of people smoking crack, and using marijuana, and alcohol dependant. But, what he found was after eight weeks of
teaching them this meditation – and they actually did meditate, and they meditated in jail – once they were released he went and recorded
different changes and they did demonstrate different changes in their psychiatric problems,
their intake of substances, and their optimism. So, he found a lot of these sort of similar
factors that John, Dr. Schorling, was talking about, were improved in these folks once they
were released. They weren’t really maintained over time,
and most likely that may be because the folks didn’t continue to meditate once they were
released. So, what he did then was he said, well, how
can we put this in sort of a more secular way. Again, the struggle was with pulling
it out of context and recontextualizing it in another setting. He decided to sort of approach it – this was
after Jon Kabat-Zinn had sort of come about with his Mindfulness Based Stress Reduction
– and after the folks, Teasdale and others,
had put together Mindfulness Based Cognitive Therapy, which was for relapse prevention
in depression – Marlatt worked with his team to include mindfulness,
described here, into an approach to combine with his relapse prevention therapy – which
is primarily cognitive behavioral – and has now published a manual on this and
done some preliminary research. Of course, unfortunately, he died midway through
a lot of this, but he’s got some graduate students who are carrying it on. So, I’ve already talked about this a little
bit here but Mindfulness Based Relapse Prevention really falls in this rubric here with a lot
of other different therapies that are coming about now in psychology, including Dialectical Behavioral
Therapy, Acceptance and Commitment Therapy. A lot of these therapies that we’ve been doing
in psychology and offering to people and researching for about 20 years or so. Another therapy I do, which is for chronically
depressed patients, is CBASP here, which was designed really with more of a focus on interpersonal
mindfulness, for folks with chronic depression, which is a whole other topic. I’m not really going to focus a lot on the
neuroscience of it, but I think it is important for you to note – just like John was talking
about – all of these studies, because they have been typically researched
in medical settings, have component of, usually brain imaging, or at least EEG’s, or fMRI’s
that are helping us document that there are significant changes functionally, and structurally
as well, in these people. As a psychologist that’s very interesting
to me but it’s even more powerful for me to see actual behavioral changes and changes
in quality of life for these folks. So the reason mindfulness is very helpful
in substance use, if anyone has ever suffered from substance use disorders, or had a loved
one who did – and that’s probably most of you in here,
if you’re like the majority of people in the United States – you probably can intuitively understand why
the concept of mindfulness may be helpful for folks. Paying attention really helps focus people
on this awareness of their triggers and responses and can interrupt this sort of automatic reflexive
behavior that’s conceptualized as learned. In the present moment, this is about the acceptance. Rather than using substances to avoid this
emotion or then to judge yourself, you’re using a sort of focus on acceptance of the
present and all that includes, including emotions. And non-judgemental, so detaching from attributions
and automatic thoughts that can lead to relapse. These are the really powerful and helpful
components of mindfulness that are used in the treatment. So it’s patterns very much like MBSR, as we
talk about, this is the focus I had just mentioned. We talk a lot in psychology about the relationship
– it makes me think of our presentations from earlier this morning – the doctor patient relationship is really
important in the mindfulness based approaches. And it’s really sort of a Rogerian – Carl
Rogers was the proponent of person centered therapy- where there is this sort of acceptance of
non- judgemental-ness. And that we feel is very important for the physician to have those
kinds of relationships. I suspect this is why most of the providers
– if you read MBSR, or MBCT, manuals most of them are recommending that the providers
have their own practice. And you might think, well why is that necessary,
but what it really helps to do is promote this in the provider, this person centered
approach. This sort of motivational interviewing style,
if anyone is familiar with that – that’s sort of a style of gentle curiosity, non-judgemental,
not pushing, but just sort of standing with the patient. So, this sort of authenticity, unconditional
acceptance, are all hallmarks of a Rogerian therapy and motivational interviewing, and
really are necessary if you’re going to successfully do this treatment with folks. Some of the formal practices that are technically
done in the Mindfulness Based Relapse Prevention are included here. Very similar to things in MBSR, the body scan,
the sitting meditation, walking meditation, and mountain mediation, andd these are more
formal in that they’re done in the group setting when you meet with the patients and you ask
them to do this on their own. There are some things that we do in MBSR that
are a little bit different. One of them is what we call the SOBER breathing space. Because our folks are going to be going out
into the world and encountering triggers and cravings constantly, this is one of the things
they can do. You can see here it’s a wonderful exercise
for anybody, even if you’re tempted to eat cake, or too much of anything. Stop, pause what you’re doing. Observe what is happening in your mind and
body. – so many people don’t do this- Breathe – that’s bringing focus to the breath
as an anchor to stay present. Expand awareness to you whole body and surroundings Respond mindfully We also talk to people about urge surfing.
This is a component, not just for mindfulness but from relapse prevention also. The idea is really – getting back again to
that craving – the idea that a craving will come and rise like a wave, many people on that wave, on the rise up have
a sense, a thought, a cognition, this will never end. It will get worse and worse and
worse. And we help them understand that if they are
given time, this wave is sort of reflective, not just of the craving, but of your sympathetic
nervous system which cannot sustain activation forever. It will crest and it will fall. Part of the
urge surfing is really just being with that, monitoring it in a gentle curious way, and
watching it pass. Very mindful. Very meditative. Something that most of these people never
do on their own. So this really helps disengage a little bit. These are sort of the session themes, which
you can see, generally break down into some awareness, present centered awareness, the mindfulness and relapse prevention sort
of components and then creating a balanced life. Like I said at the beginning, these folks
are typically – their lives are chaotic by the time we see them – their lives are out
of balance. They have beaten up on themselves more than
even the people around them, who have beaten up on them pretty well too. So, the bigger picture of creating a balanced
life. Being kind, compassionate to themselves, is really really important. What we find, typically, in the results are
what you might expect – that John’s already talked about – the same thing that many other
folks find. Improvements physically, settling this sort
of sympathetic nervous system response, more control of attention and dampening reactivity
to stress, increase in positive emotions – which we know if they go on to do any other
psychological work is really important. For too long psychology focused on reducing
negative, but we are finding more and more, and even in our own research, that it’s much more effective if you reduce
negative affect and increase positive affect. Combined they work much better. And really importantly for the people with
addictions, what we find is it really helps dampen this sort of automatic reflexive response. And we find evidence of this in the brain,
which I won’t go into, on imaging studies, but also in their responses. So one of the first trials – surprisingly
there’s some literature out there, but really not a great deal. Like I said we had a great setback with Alan
Marlatt dying, but people are still trying to move forward. But a lot of the studies that are under way
just haven’t produced any papers yet. So we’re still looking at pretty old data. One of the first studies included about 295,
this is after the folks he had in the prison system. Again though, this is a mixture. They just sort of took a bunch of different
people with different addictions and looked at them. Now, you might look at this and say,
well, this is not really all that impressive. This is reduction in substance use. In the
substance abuse world, believe it or not, this is impressive. So what we find here is, this is treatment
as usual, which is typically something like AA or some sort of support group. Again, these
are people with mixtures of different addictions. So you see, from baseline, they are sort of
the same as far as any drug use or alcohol use. And a dramatic decrease in substance
use for both, and this is actually common. There’s a very large, sort of nonspecific
effect of any kind of treatment in addiction. Which makes it – this is why addiction research
is so difficult. For many people with addiction, you do anything
and they get better, initially, but then it doesn’t last. And this is what we’re finding
here. So, post test. Immediately post test and two month the MBSR
were significantly better than the treatment as usual. But then at four months out, they
don’t seem to have any sort of difference. They’re both still better, which is good.
What we’re working on now, in our lab, in many labs across the country, are really tailored
treatments, to look at who. If everyone gets better with some treatments,
well, who do we really need to focus treatment on to maintain it long term. If we can do a little something for most people
and they get somewhat better, that’s great, but how do we really target who we need to
work more with, who we can do less with. That hasn’t been done, it’s just started. These are some more results from that same
study. What they find is that there are, increases, significant increases in acting with awareness
and acceptance. Cravings are where we are targeting from – remember
what we started talking about are cravings so, looking at cravings the MBRP group did
have significantly fewer cravings that they reported throughout, which is important and
we’ll come back to that. It’s important because what they found in
this study were this mediator effect. This means that changes in craving actually mediated
the difference in substance use. So, the people with reductions in craving
are the ones who really reported decreases in substance use, and there is a connection
there. So, decreased cravings led to decreased substance
use, which, you know, you say, well, yeah, that makes sense, but we didn’t have any evidence
that that was really the case. I’m going to show you some – I’m going to
skip this, because I want to get to the good stuff. So, we’ll talk more about cravings and the
role there, but in this study it looks like the Mindfulness Based Relapse prevention helped
decrease cravings, which then led to substance use decrease as
well. Alright, so we’ll file that away. That’s what we sort of hoped and thought we would
see. We saw decreases in the substance use, increased
mindfulness. We always get measures of mindfulness, and those increased over time, and reduced
craving. So that’s all well and great. Now I want to introduce you to some of the
smoking literature. This literature is a little bit different
because many of the smoking cessation studies have populations that are typically a little
higher functioning. So, often you can have people addicted to
nicotine who don’t have a lot of other comorbidities. A lot of people with comorbidities are addicted
to nicotine, but it doesn’t work both ways. So, these are some research by Judson Brewer
at Yale, just recently, where he compared Mindfulness Based Smoking
Cessation – and again, these are people actively smoking – with a Freedom From Smoking. This is sort of the American Lung Association’s
approach. Sort of a mixture of supportive and cognitive based therapy. What he found is that there were significantly
more reductions in the mindfulness based approach than in the Freedom From Smoking. What he noticed in his data is that – he measured
mindfulness – the mindfulness, as mindfulness increased the smoking decreased, but craving – even when craving was high,
if there was high mindfulness the smoking would decrease. So, what he proposes is this
is a true uncoupling. That even while you are craving and wanting
a cigarette, the mindfulness, there’s something about the mindfulness that is keeping you
from responding to that. So he followed up with some neuroimaging studies
and that’s indeed what he found, is that the area – and I won’t get into all that since I’m
not going to show the pretty pictures like John did – but, that the areas that, as John said, it’s
a whole region that is reactive in craving and then the behavior and the use. So, these
areas became, sort of, uncoupled. So that even though I have craving and in
that area in my brain lights up, it doesn’t automatically lead to the behavior of abusing,
which is huge. Because, we know from research, we’re not
going to get everybody to diminish their cravings. It’s a very difficult thing to do. So with this sort of decoupling, the craving
is still moderating, or mediating, in some ways but it’s a little more nuanced than we
see in some of the other addiction research. He has adapted this to a mobile device application,
which needs to be pilot tested, but is another interesting development that we’re seeing
which will certainly help disseminate some of this because that’s our other big problem. A lot of people can’t access this kind of
treatment and if it’s as promising as it’s sort of beginning to look like, we certainly
have a moral imperative to provide this for folks. So to wrap up with future directions, there
still needs to be some information that we find on what, especially in MBSR, what is
the effect of the mindfulness and what is the effect of the relapse branch and the sort
of cognitive component. Can they be untangled? There are many things
that overlap in these two approaches. What are the unique mediators and moderators? Can we- we need to also modify it to really
continue this and get some long-term data. As John mentioned, we still need studies that
look at comparing it to other really effective treatments. We haven’t compared this to an
anti-craving medication, head to head. We haven’t compared this to acupuncture or
some other strategies that sort of have a rationale that demonstrate that they may reduce
cravings as well. We haven’t really looked completely at the
role of stress. How are stress and craving related? They’re similar, but they’re not
exactly the same. We are looking at some of these in a current
study that we have. It’s looking at MBRP versus treatment as usual,
but we’re focusing more on this link between stress and craving and so we’re specifically
targeting stress reduction in people with addiction – and no other study has done this – where we induce a craving and it’s very stressful
and we’re measuring heart rate variability as well as craving response as well as a behavior. So, we’re hoping to see sort of explore more
this complicated relationship between craving, stress response, and behavior, and also look
at the side effects. So far we’ve been fortunate. We haven’t had
any, but many of these people come from very traumatic backgrounds. Like I said, they’ve got other complications
in their lives and it’s completely likely that we will have some issues. People with
abuse that comes to the surface, memories. So, we really need to look at that. If anyone
saw Willoughby Britton when she was here a couple weeks ago, she mentioned this as well. This is something that no one is really looking
at, but there are negative, or adverse, events that we need to keep track of. So, the future- also we have, maybe, looking
at prevention in general. Can we catch these people? I have young people here. This is my daughter’s Mindfulness Based Research
Retreat that she hosted with her friends. I think this is where the future is. Can we
get these people early? And we have a mandate to do education. Can
we train them early how to do these healthy things for themselves? How to not act impulsively, or out of this
sort of automatic learned behavior and maybe inoculate them this way, not with a shot,
but with mindfulness. Again, really important to me, how do we disseminate
this? This shouldn’t be for just wealthy people who can go to yoga and meditation. We need to get it out to everybody and really
make it accessible to those who need it. So I’ll finish with that and I thank you very
sincerely for your time.

6 thoughts on “Mindfulness-Based Relapse Prevention for Addiction (Jennifer Kim Penberthy)

  1. I am 18 months clean, from opiates. I’m starting to understand my triggers, but i live sucha stressful life. I’m very concerned that I am setting myself up, for a relapse. Any help or ideas about this, would be greatly appreciated!♥️

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