Mindful Living: A Proposed Relapse Prevention Project

Substance abuse prevention is generally thought to involve primary and secondary prevention strategies which target populations that have either not yet engaged in use of alcohol and drugs (though they may be at risk to do so), or those who are in the very early stages of alcohol and drug use (Wilson & Kolander, 2011). Though efforts to prevent the onset of addiction are important, of equal concern is substance use relapse prevention wherein the stabilization brought about during treatment is preserved, and long-term abstinence is promoted.

Unfortunately, it appears that relapse prevention is often viewed as an afterthought of treatment wherein patients are discharged with little meaningful guidance nor provision of resources to aid them moving forward in recovery (McClellan, Lewis, O’Brien, & Kleber, 2000). As experts in the field continue to acknowledge that addiction is a chronic rather than acute condition, the provision of continuing care for those who have completed treatment must likewise adapt to meet this emerging awareness. To this end, the following substance use relapse prevention project, Mindful Living, is proposed.

Target Population

In the areas of health promotion and disease prevention, best practice requires tailoring of programs to the characteristics, needs, and attitudes of a target population (Wilson & Kolander, 2011). For the purpose of this proposed prevention project, the target population will be individuals diagnosed with substance use disorder in early remission, as defined by the DSM-IV, who have completed residential or intensive outpatient treatment within the two weeks prior to the program start date. This target population has been selected based on evidence and findings which demonstrate that persons in early recovery are at high risk for relapse; and based on the need for continuity of care to prevent relapse and improve short and long-term treatment outcomes. The evidence and findings which support the selection of this target group are set forth as follows:

  • Depending on various factors, between forty (40.0%) percent and sixty (60.0%) percent of persons who undergo treatment for alcohol or other drug dependence will return to active substance use within the year following discharge from treatment (McClellan et al., 2000). Approximately forty (40.0%) percent of persons presenting for substance abuse treatment are those who have undergone prior treatment and subsequently relapsed into addiction (Caravella, 2008). Individuals most often relapse during the first eighteen  months following treatment; and of these early-stage relapses, most occur during the first six months of recovery (Caravella, 2008).
  • Both biological and environmental risk factors contribute to the high rate of relapse. From a biological perspective, relapse is more likely in the first year following treatment due to enduring changes in both the structure and function of the brain brought on by substance abuse (McClellan et al., 2000). While it is well-known that drugs of abuse target the mesolimbic system of the brain and thereby reinforce addictive behavior through the mechanism of reward, studies now indicate that other neural pathways – such as those associated with memory, drive, motivation, saliency and cognitive control – are likewise altered in ways that increase the risk of relapse (Volkow, 2000). Additionally, environmental risk factors such as low socioeconomic status and lack of supportive family/social networks also increase the chance that relapse will occur (McClellan et al., 2000). Taken together, these powerful biological and environmental risk factors conspire with cognitive and behavioral processes to keep substance use remission alarmingly low in both the short-term and the long-term. In longitudinal studies fewer than ten (10.0%) percent of drug users will achieve continuous post-treatment abstinence over any significant period of time (Sellman, 2009).
  • Furthermore, the treatment industry – in both the public and private spheres – must bear some responsibility for the generally poor substance use outcomes. Even though the healthcare mainstream has begun to recognize that addiction is a chronic relapsing condition, addiction has heretofore been seen as an acute condition wherein patients are administered treatment and then abruptly discharged with little to no provision for meaningful aftercare (McClellan et al., 2000). While treatment often does provide short-term biopsychosocial stabilization, patients are often recycled through repeated interventions within a outdated model of acute care that is ill-suited to meet the long-term needs of those who suffer from a chronic condition (“Recovery Advocates,” 2010). The result is that an overburdened system which consistently faces shortfalls in resources is stretched beyond its ability to meet the demand for treatment.

The Institute of Medicine (IOM) has introduced a system of prevention classification which takes into account the purpose of the intervention and the identity of the target population (Wilson & Kolander, 2011). Within this framework, selective strategies are those which target subgroups that are at higher risk for substance abuse than is the general population; while indicated strategies target individuals who are exhibiting early signs of substance abuse (Wilson & Kolander, 2011). While persons in remission from substance abuse represent a selective population within the IOM design, a comprehensive relapse prevention strategy must take into account the fact that addiction is a chronic relapsing condition. Therefore appropriate interventions for those individuals who resume use of alcohol or drugs (or who engage in other high risk behaviors) must be planned. In this respect, relapse prevention must incorporate indicated strategies which are deployed within the selective population as the need inevitably arises.

The Determinants of Relapse

In order to devise an effective relapse prevention program, it is first necessary to understand the relapse process so that program strategies properly address specific risk and protective factors. G. Alan Marlatt is credited with having developed the first cognitive-behavioral model of relapse more than thirty years ago – a model which remains widely accepted to this day (Marlatt & Donovan, 2005). Marlatt (2005) identified a taxonomy of intrapersonal and interpersonal determinants of relapse which are described as follows:

  • Self-efficacy.  Bandura defined self-efficacy “as the degree to which an individual feels confident and capable of performing a certain behavior in a specific situational context” (as cited in Marlatt & Donovan, 2005, p. 8). Self-efficacy has been shown to relate positively to the number of days abstinent, and it is predictive of the time to relapse in the first twelve (12) months following treatment (Marlatt & Donovan, 2005).
  • Outcome expectancies. Outcome expectancies are the effects that one anticipates experiencing following consumption of alcohol or drugs (Marlatt & Donovan, 2005). Studies have shown negative correlations between outcome expectancies and treatment outcomes (Marlatt & Donovan, 2005).
  • Motivation. Motivation is defined in the Oxford Dictionary as “the conscious or unconscious stimulus for action towards a desired goal provided by psychological or social factors; that which gives purpose or direction to behavior” (as cited by Marlatt & Donovan, 2005, p. 11). Motivation is influenced by both self-efficacy (e.g., “I would like to stop using drugs, but I do not think I can”) and outcome expectancies (e.g., “I would like to stop drinking, but if I did I would not be able to relieve my stress”) (Marlatt & Donovan, 2005). The resolution of this sort of motivational ambivalence in favor of abstinence is crucial in preventing relapse (Marlatt & Donovan, 2005).
  • Coping. Marlatt believed that the most critical predictor of relapse is whether or not an individual engages effective coping strategies in high-risk situations (Marlatt & Donovan, 2005). In the context of addiction, an individual may engage in either “stress coping” (during which one seeks to diminish the impact of stressors) or “temptation coping” (during which one resists the temptation to use drugs notwithstanding stress) (Marlatt & Donovan, 2005). Stress coping and temptation coping occur on both cognitive and behavioral levels (Marlatt & Donovan, 2005).
  • Emotional states. Numerous studies have demonstrated a strong correlation between negative affect and relapse (Marlatt & Donovan, 2005). Often times, addicted persons use alcohol and drugs as self-prescribed medication for emotional discomfort (Marlatt & Donovan, 2005). In fact, cocaine users reported feeling lonely, depressed, tense, and/or angry on the day of relapse (Marlatt & Donovan, 2005). However, in the same study, cocaine users (albeit a significantly smaller percentage) reported feeling “extremely good” and “extremely excited” (Marlatt & Donovan, 2005). The implication here is that while negative emotional states may be the most reliable predictor of relapse, any extreme emotion – whether positive or negative – could be a warning sign of impending relapse.
  • Craving.  Craving is defined as the “subjective desire to experience an addictive substance . . . ‘craving’ is a cognitive response with stimulus properties” (Witkiewitz, Marlatt, & Walker, 2005, p. 216). It has been suggested that craving occurs in response to a number of triggers including non-automatic processes, environmental cues, withdrawal, negative affect, expectancies, perceived availability of the substance, and/or neuroadaptations (Witkiewitz et al., 2005). Substance use cravings are often experienced as intrusive thoughts, impulsive drives, or even as physical sensations which arise from biological, cognitive, and emotional processes (Witkiewitz, Bowen, Douglas, & Hsu, in press).
  • Social support. Negative social support, such as interpersonal conflict or social pressure to use substances, increases the chances of relapse (Marlatt & Donovan, 2005). Social pressure may arise directly such as when peers promote the use of drugs, or indirectly through modeling or cue exposure (Marlatt & Donovan, 2005).

The interactions between the intrapersonal and interpersonal determinants of relapse are complex, multidimensional, and dynamic – a fact recognized by Marlatt in his re-conceptualization of the original linear model of relapse (Marlatt & Donovan, 2005). The current model allows for several different configurations and reciprocal causation between the determinants (Marlatt & Donovan, 2005). For example, an episode of interpersonal conflict might result in a negative emotional state, which in turn yields positive outcome expectancy for drug use, which leads to craving, which results in ambivalence towards remaining abstinent and lowered self-efficacy. In every situation, the individual is challenged with balancing multiple cues and consequences which arise from distal risk factors (e.g., family history, years of dependence, social support, and comorbid psychopathology), cognitive and affective processes, and cognitive-behavioral coping skills. Further complicating matters is the lead-up to a relapse, during which the individual often makes a series of inconsequential and covert decisions which set up high risk situations (Larimer, Palmer, & Marlatt, 1999). These so-called “apparently irrelevant decisions” (AIDs) are particularly dangerous forms of denial and rationalization because they are, by their nature, rarely recognized in advance as moving the individual closer to relapse (Larimer et al., 1999). The following statement is an example of a typical AID: “I am not going to use drugs, but I am going to sell them to help pay the bills.”

Relapse Prevention

The Cognitive-Behavioral Approach

In general, relapse prevention is a tertiary prevention strategy with two major goals: 1) lapse prevention and maintenance of abstinence (or, in some cases, harm reduction goals); and 2) when lapse occurs, providing lapse management to prevent relapse (Marlatt & Donovan, 2005). Though individual and situational variables will determine whether or not the prevention strategy should aim for abstinence or harm reduction, moderation research supports the general idea that abstinence is an important treatment objective (Sellman, 2009). Research has shown that those with abstinence goals have significantly reduced rates of relapse than do those with the goal of non-problem use (Mertens, Kline-Simon, Delucchi, & Moore, 2012). In the medical model wherein addiction is described as a disease process, abstinence is the only effective means of addiction management (Caravella, 2006). However, as is often the case when individuals attempt to change any problematic behavior, lapses will likely occur. As such, Marlatt recognized the distinction between a lapse (an instance of behavior) and a relapse (a return to a pattern of behavior) (Marlatt & Donovan, 2005). When a lapse occurs, providers should anticipate what Marlatt referred to as the “abstinence violation effect” (AVE) – a condition wherein individuals who have lapsed in the face of abstinence goals experience guilt, shame, remorse, loss of perceived control and diminished self-efficacy (Marlatt & Donovan, 2005). Left unrecognized, these highly negative cognitive and affective responses to lapse increase the chance than an individual will progress into relapse (Marlatt & Donovoan, 2005).

The cognitive-behavioral model for relapse prevention (RP) was originally developed for individuals with alcohol-related disorders, but has since been incorporated into prevention efforts addressing several types of addictive behaviors (Marlatt & Donovan, 2005). According to Marlatt, the cognitive-behavioral model relies

on the initial assessment of potentially high-risk situations for relapse (e.g., environmental stressors, personality characteristics). Once situations are identified, the therapist works with the client to monitor the individual’s coping skills, self-efficacy, and lifestyle factors (e.g., lifestyle imbalance), which may increase the probability of an individual being in a high risk situation. (Marlatt & Donovan, 2005, p. 4)

The purpose of identifying potential high risk situations and relapse triggers is to allow for the implementation of counteracting cognitive-behavioral strategies (Marlatt & Donovan, 2005). These strategies, which are taught in a psychoeducational context, include learning effective coping, enhancing self-efficacy, and encouraging mastery over successful outcomes (Marlatt & Donovan, 2005). In addition to strategies for particular high risk situations, the cognitive-behavioral approach also incorporates global lifestyle self-management strategies such as promoting lifestyle balance, stress reduction, and encouraging engagement in “healthy addictions” such as exercise and meditation (Marlatt & Donovan, 2005). The clinical and cost-effectiveness of the cognitive-behavioral approach to relapse prevention has been demonstrated in numerous studies (Witkiewitz, 2005).

Mindfulness-Based Relapse Prevention

Mindfulness is “a mental state, characterized by concentrated awareness of one’s thoughts, actions or motivations” (Appel & Kim-Appel, 2009, p. 507). According to Kabat-Zinn, in the pursuit of mindfulness, one seeks to “[pay] attention, in a particular way: on purpose, in the present moment, and non-judgmentally” (as cited in Bowen et al., 2009, p. 296). Mindfulness is a concept which is derived from the spiritual practices and philosophies of the Far East and specifically finds roots in the Buddhist traditions (Appel & Kim-Appel, 2009). Mindfulness techniques, which often include training in meditation exercises, have been incorporated into treatment of a variety of behavioral disorders including borderline personality disorder, anxiety, and depression (Marlatt & Donovan, 2005). Several therapeutic models such as Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Mindfulness-Based Stress Reduction (MBSR), and Mindfulness-Based Cognitive Therapy (MBCT) have all incorporated mindfulness techniques as an intervention strategy with successful results (Appel & Kim-Appel, 2009; Bowen et al., 2009; Witkiewitz & Bowen, 2010).

Research in the use of mindfulness-based intervention for substance use disorders began in studies of prison populations. Therein, it was found that transcendental meditation (a form of concentration meditation) positively correlated with reduced recidivism (Bowen et al., 2006). In a study of prisons in India, Vipassana mediation (VM) has been shown to contribute to reduced recidivism, anxiety, depression, and hostility; and to increased cooperation with prison workers (Bowen et al., 2006). Vipassana mediation teaches “mindfulness through objective, detached self-observation without reaction . . . acceptance of thoughts and sensations as independent, impermanent events and not as direct reflections of the self” (Bowen et al., 2006, p. 343). In North American prison populations, it was found that participation in VM resulted in significant reductions in post-incarceration use of alcohol, marijuana, and crack cocaine; and in significantly fewer alcohol-related negative consequences (Bowen et al., 2006). Participants also reported fewer psychiatric symptoms, greater locus of control, and higher levels of optimism (Bowen et al., 2006).

Building on both the success in the use of mindfulness techniques to treat other behavioral disorders and the promising results from the prison studies, Mindfulness-Based Relapse Prevention (MBRP) was developed (Witkiewitz & Bowen, 2010). MBRP combines the cognitive-behavioral elements of Marlatt’s relapse prevention program (RP) with mindfulness practice in a structure similar to MBCT (Witkiewitz & Bowen, 2010). Participants are trained in both cognitive-behavioral relapse prevention skills (such as identifying high risk situations, and coping strategies) and mindfulness meditation. Though meditation practice merges nicely with cognitive-behavioral approaches because it too involves elements of cognition and behavior, meditation is best described as “metacognitive” in that it “induces a state of detached awareness which changes a person’s relationship to their thoughts” (Witkiewitz et al., 2005, p. 219). This stands in contrast to the goal of cognitive restructuring wherein one seeks to change the content of maladaptive thoughts; whereas in mindfulness meditation, one seeks to change only the attitude towards those thoughts, feelings, and sensations (Witkiewitz et al., 2005).

Incorporation of mindfulness techniques into relapse prevention mitigates the influence of risk factors in several important ways, including:

  • Mindfulness meditation has been shown to reduce activity in the regions of the brain associated with craving response (Witkiewitz & Bowen, 2012).
  • Practice in mindfulness meditation aids in the development of coping skills. A mechanism known as “skillful means”, as it relates to addiction, involves the principle of inaction wherein cravings and urges are observed and accepted in the present moment without shame or self-judgment (Witkiewitz et al., 2005). Over time, this practice weakens the habituated craving response which in turn strengthens acceptance and self-efficacy (Witkiewitz et al., 2005).
  • Mindfulness meditation has been shown to result in neurological changes that are associated with increased alertness, relaxation, attention control, and reduced readiness for action; all of which work as powerful forces of counterconditioning against impulsive addictive behavior (Witkiewitz et al, 2005).
  • Mindfulness-based practices help attenuate the linkage between negative affective states (such as depression), craving, and self-medicating through increased awareness of emotional patterns and learned alternative responses (Witkiewitz & Bowen, 2012).
  • The tendency of the human mind is to multi-task but when several different areas of the brain are tapped simultaneously, the result is lowered efficiency of thought and reduced response time (Appel & Kim-Appel, 2009). On the other hand, mindfulness training teaches a more directed and powerful use of the brain (Appel & Kim-Appel, 2009).
  • Mindfulness meditation has been shown to activate areas of the brain which figure into self-referential processing and perspective-taking (Appel & Kim-Appel, 2009). The significance here is that self-obsession is linked to greater degrees of psychological suffering. Mindfulness meditation appears to address this problem by cultivating increased empathy, imparting a better sense of self, and diminishing self-obsession (Appel & Kim-Appel, 2009).
  • Mindfulness training aids in the prevention of individual relapse by “revitalizing their capacity for healthy adaptation, by easing the navigation of drug cravings and cues, by reducing emotional reactivity and cue salience, and by facilitating cue extinction through dampening the affective and semantic cascade associated with drug-related cues” (Dakwar, Mariani, & Levin, 2011, p. 168).
  • Mindfulness meditation serves as a gratifying alternative behavior, or alternative “healthy addiction” in its own right (Witkiewitz et al., 2005).

Furthermore, preliminary findings indicate that that the merger of cognitive-behavioral approaches with mindfulness-based techniques is an effective relapse prevention strategy. In a pilot study, participants in MBRP demonstrated significant improvements in days of substance use, craving, awareness, and acceptance over the TAU control group (Bowen et al., 2009).

Mindfulness-based relapse prevention also provides a tenable alternative to those who seek spiritual growth as a component of addiction recovery, but for whom traditional Western theism is not well suited. In the Buddhist tradition from which mindfulness springs, the cause of all human suffering is identified as “desire”. In terms of addiction and recovery, the parallel source of suffering is craving. As observed by Witkiewitz et al. (in press)

From a Buddhist perspective, craving is considered a core component of human existence, and craving and attachment are viewed as the root cause of human suffering. From a mindfulness perspective, we might view addiction as either an effort to hold on to or avoid cognitive, affective, or physical experiences. In an effort to avoid suffering, an individual either clings onto positive states (e.g., craving the next high) or avoids negative states (e.g., seeking an escape from sadness).

Noticing this craving and the attendant suffering in a gentle, non-judgmental way is at the very heart of mindfulness practice. The individual learns to bring awareness to the craving which springs from the cognitive, emotional, and physical cues with knowledge and acceptance that these states are impermanent (Witkiewitz et al., in press). In so doing, automatic responses may be interrupted and relapse avoided. In Marlatt’s dynamic model of relapse, each success builds upon the other wherein the individual gains self-efficacy and future cravings are dampened (Marlatt & Donovan, 2005). Mindfulness training provides the individual greater opportunity to experience these sorts of successes and, therefore a better chance to remain abstinent in the long-term.

Mindful Living: A Proposed Substance Use Relapse Prevention Project

    Based on the foregoing, the following relapse prevention project is proposed:

Project name. The proposed name of the relapse prevention project is “Mindful Living”.

Participant selection. The prevention program will seek to partner with providers of intensive outpatient and inpatient substance abuse treatment in Hopkins and the surrounding counties in Western Kentucky. Partners will refer clients to the program who meet the target criteria of having been diagnosed with substance use disorder in early remission, as defined by the DSM-IV; and who have completed residential or intensive outpatient treatment within the two weeks prior to the date of the program launch. Offers to participate will be extended by random selection until up to fifty (50) participant slots are filled. Individuals who accept the offer to participate in the program must have been medically cleared and will be assessed for program eligibility via telephone using a structured interview. Participants will be randomly assigned to groups consisting of six (6) to ten (10) participants.

Venue. Program partners will provide access to meeting space within the service area at locations which ensure that participants face minimal transportation barriers to and from group sessions. Meeting space shall be conducive to the nature of the mindfulness practice which will be undertaken.

Time frame and program content. Participants will be administered MBRP in eight weekly group sessions of two hours each. As set forth by Bowen et al. (2009), the program content shall include: a central theme at each groups session with meditation practices and related relapse prevention (RP) discussion and exercises (e.g., “automatic pilot” in relation to relapse, recognizing thoughts and emotions in relation to triggers, integrating mindfulness practice into daily life, mindfulness in high risk situations, acceptance and skillful action; seeing thoughts as thoughts, self-care and lifestyle balance, and social support and continuing practice); twenty to thirty minutes of guided meditation each session; a variety of experiential exercises interspersed with discussion of the role of mindfulness in relapse prevention; and review of homework assignments. Participants will also be assigned daily exercises and provided audio recordings of guided meditation for practice outside of the group sessions (Bowen et al, 2009; Bowen, Chawla & Marlatt, 2011).

In addition, at the conclusion of the group sessions, participants shall attend a two day meditation retreat to be held at a centralized location in the service area. Thereafter, participants will be offered bi-weekly mindfulness meditation sittings of thirty to forty-five minutes each which they may attend on a voluntary basis. These meditation sittings shall be offered within the service area for at least one year following the final group session. These offerings (the two day retreat and continuing meditation) are made in addition to standard MBRP protocols in an effort to solidify mindfulness practices in the lives of the participants.

CSAP strategies. The United States Department for Health and Human Services (DHHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) established the Center for Substance Abuse Prevention (CSAP) “to provide national leadership in the Federal effort to prevent alcohol, tobacco, and drug problems” (Substance Use and Mental Health Services Administration, 2012). In furtherance of this leadership objective, CSAP has outlined six substance abuse prevention strategies (Hogan, Gabriesen, Luna, & Grauthaus, 2003). The CSAP strategies to be utilized by the proposed prevention project in order of prevalence are a) prevention education; b) alternative activities; and c) problem identification and referral.

Prevention education. This CSAP strategy involves two-way communication between the educator and the participants (Hogan et al., 2003). In the proposed prevention project, participants will be taught cognitive-behavioral skills and mindfulness techniques in small group settings. The education component will also include instructions on how to manage the “abstinence violation effect” (AVE) if a lapse does occur. In the group context, participants will be encouraged to engage in mutual discussions in an atmosphere that is open and accepting.

Alternative Activities. The purpose of this strategy is to encourage participation in activities which are alcohol and drug free (Hogan et al., 2003). According to CSAP, engaging in “constructive and healthy activities offsets the attraction to drugs, or otherwise meets the needs usually filled by drugs” (as cited in Hogan et al., 2003, p. 30). Program participants will be encouraged to utilize mindfulness meditation and other techniques as healthy alternatives to the usual high risk behaviors. Not only are the MBRP activities which are taught rewarding in their own right, but meditation leads to improved overall subjective well-being (Bowen et al., 2006).

Problem Identification and Referral. Recognizing that addiction is a chronic relapsing condition, project staff members will very likely encounter participants who have experienced a lapse. When this occurs, participants will be referred back to partners who will assess whether additional treatment is necessary, or whether continued program participation is indicated.

Materials. The following materials will be procured prior to the program start date:

  • Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician’s Guide (contains instructions for the facilitation of each group session and master copies of all necessary handouts);
  • Bell and timer.
  • White board and accessories.
  • Guided meditation audio recordings (CDs).
  • Meditation cushions, meditation benches, and/or other appropriate seating.

Staffing. As set forth by Bowen et al. (2011), group facilitators should have experience in substance abuse treatment and moderating group sessions. However, the most important characteristic is that facilitators be familiar with and have developed their own mindfulness practice (Bowen et al., 2011). It is recommended that prior to the program launch date, facilitators will have participated in a three day workshop which includes presentations of MBRP theory and rationale, as well as practice in conducting all eight of the groups sessions (Bowen et al., 2011). More intensive and in-depth retreat-style MBRP workshops are also available (Bowen et al., 2011). Project managers will work with partners to determine the minimum professional credentials for group facilitators and assign administrative tasks as necessary. The professional services of a consulting psychologist qualified to administer and analyze self-report measures will be enlisted for program evaluation purposes.

Limitations. MBRP is a cost-effective relapse prevention approach with very few limitations. However, there are some issues which are unique to MBRP which should be considered in advance. These include:

Legal Issues. MBRP is conducted in an atmosphere of openness and honesty which encourages participants to discuss both past and present substance use without fear of judgment. Individuals who are facing legal problems as a result of substance use present with mixed motivations and are often hesitant to disclose lapses or relapses for fear of facing serious personal consequences (Bowen et al., 2011). This sort of inhibition leaves these individuals at risk of missing the full benefits of the mindfulness-based, non-judgmental approach.

Religion. Though some individuals will see MBRP as a welcome alternative to traditional Western spiritual practices, others may be averse to participation in MBRP for fear of indoctrination into a non-theistic religion. Even though mindfulness practices are rooted in the Buddhist tradition, one need not become a Buddhist to incorporate meditation and other mindfulness practices into daily living. Indeed, the mindfulness practices of MBRP have been translated into and are presented in a non-religious Western context (Appel & Kim-Appel, 2009). For those who are concerned, it should be pointed out that MBRP is an approach that tolerates all religious beliefs (and non-belief) and which allows for individualized, flexible goals (Bowen et al., 2006).

Staffing. To be most effective, the program should be staffed with facilitators who bring to the group an established mindfulness practice of their own (Bowen et al., 2011). The above-described availability of training and workshops is meant to supplement personal experience rather than to provide facilitators with initial exposure to mindfulness techniques. Given the demographics of the service area, finding qualified facilitators who are engaged in mindfulness practices of their own may prove difficult.

Home practice. A major component of MBRP involves home practice wherein participants are asked to engage in mindfulness activities and meditation in their daily lives. Assuming that participants will be willing to take up home practice, many of them nevertheless face difficult living conditions that interfere with their ability to practice mindfulness techniques (Bowen et al., 2011). Some participants may have difficulty finding time and space to engage in meditation, while others may not have access to suitable playback equipment (Bowen et al., 2011). Because of the importance of home practice as a means to incorporate mindfulness into daily living, clients should be encouraged to “think outside the box” if they are faced with difficult living situations (such as mindfulness practice while engaging in a routine activity or finding quiet areas such as libraries, green spaces or their own parked car) (Bowen et al., 2011).

Evaluation. Program evaluation will take place according to the following logic model:

Logic Model – Mindful Living Pilot Program

  Logic Model Evaluation Questions Design & Methods
A. Goals Through program participation, clients will learn coping strategies for situations which present a high-risk for relapse, and will utilize mindfulness techniques to reduce cravings. What coping strategies did participants use when faced with situations which are high-risk for relapse? Did participants’ level of mindfulness increase? Did participants experience reduced cravings? Upon program completion and in follow-up intervals, participants will self-report coping strategies utilized when presented with high risk situations for relapse; they will self-report mindfulness using the Five Factor Factor Mindfulness Questionnaire (FFMQ); and they will report level of cravings using the Penn Alcohol Craving Scale (PACS) adapted for alcohol and drugs.
B. Strategies Participants will be administered Mindfulness-Based Relapse Prevention (MBRP) over a period of 8 weeks with 2 hour groups sessions of 6 to 10 participants in each group. Participants will also be assigned daily meditation exercises and provided audio-recorded instructions for this purpose for guidance. Participants will attend a meditation retreat at the conclusion of the group sessions. Participants will be offered bi-weekly guided meditation sittings of 30-45 minutes each which they may attend on a voluntary basis upon completion of the group sessions. How many groups were offered? How long was each group session? What were the exercises/topics at each group session? How many enrollees attended each group session? Did attendees participate in group discussions? Did attendees complete daily meditation assignments outside of group context? How many persons attended the meditation retreat? How many persons attended the bi-weekly meditation sessions? Group facilitators will keep running logs which document the following: the date, time, location, session length, description of exercises/topics, name of persons attending session, level of participation of each attendee (scored using a Likert scale). Clients will self-report daily meditation activity onto logs which are provided to them. The facilitator of the retreat will document the date, time, location, retreat length, description of exercises/topics, names of persons attending session, level of participation of each attendee (scored using a Likert scale). Facilitators of bi-weekly meditation sessions will document the date, time, location, session length, description of exercises/topics, names of persons attending session, level of participation of each attendee (scored using a Likert scale).
C. Target Group Persons diagnosed with substance use disorder in early remission who have, within the previous two (2) weeks, completed intensive outpatient or inpatient treatment. This is a tertiary prevention strategy which targets a selective population. Participants will be recruited from a local treatment center and other local mental health service providers in the Western Kentucky area. How many persons per week, on average within the past 3 months, completed inpatient substance treatment or intensive outpatient treatment through a program administered by the service providers? How many active clients of the service providers currently meet the target criteria? How many active clients do the service providers anticipate will meet the target criteria within the next 30 days? Data regarding number of persons per week, on average, within the last 3 months who have completed inpatient substance treatment or intensive outpatient treatment; number of active clients who currently meet target criteria; and number of active clients who will meet target criteria in the next 30 days (prior to program launching) will be provided by the service providers. This data will be used to determine the number of eligible clients.
D. If-Then Statement If persons in early remission from substance use disorder are offered post-treatment aftercare, then they will attend the sessions. If these persons attend the sessions, then they will be taught cognitive-behavioral and mindfulness techniques. If they are taught cognitive-behavioral and mindfulness techniques which they put into practice, then they will better cope when exposed to high-risk situations for relapse and experience reduced cravings. If they are better able to cope when exposed to high-risk situations and/or experience reduced cravings, then they will be less likely to relapse. How many persons were offered admission to the program? How many of those persons were offered and accepted into the program? How many persons attended each of the sessions? Who were the group leaders and what were their qualifications? What topics were covered at each group session? Were participants better able to cope in situations which are high-risk for relapse? Did participants experience reduced cravings? How many of the program participants experienced a relapse after enrolling into the program? Program administrators will document the number of offers of entry and the number of acceptances, refusals, and disqualifications to calculate an admission rate. Group leaders will document the number of attendees at each group session. Group leaders will be credentialed professionals trained in cognitive-behavioral strategies and mindfulness techniques. Participants will self-report at 6 month and 1 year follow-up on exposure to high-risk situations and coping strategies employed. On follow-up, participants will self-report cravings using the Penn Alcohol Craving Scale (PACS) adapted for drug and alcohol use. On follow-up, participants will self-report use of alcohol and drugs using Timeline Followback (TLFB). Analysis will consist of, inter alia, determination of correlations between program participation, self-report measures, and relapse rates.
E. Short-term outcomes Participants will experience increased mindfulness, reduced cravings, increased acceptance, and increased impulse control at the conclusion of program participation. Participants will integrate mindfulness practices into their daily lives. Have the participants experienced increased mindfulness, reduced cravings, increased acceptance, and increased impulse control? Have the participants integrated mindfulness practices (such as meditation) into their daily lives? Participants will be administered the following self-report measures before entering the program, and upon completion: The Five Factor Mindfulness Questionnaire (FFMQ); The Penn Alcohol Craving Scale (PACS) adapted for drug and alcohol use; The Acceptance and Action Questionnaire (AAQ); and The Short Inventory of Problems (SIP). At a 6 month follow-up, clients will report the number of days per week they engage in mindfulness practices such as meditation.
F. Long-term impacts The rate of substance use relapse among program participants will be reduced to below fifty percent at one year follow-up. What is the rate of substance use relapse among program participants? Use of alcohol and drugs will be measured using Timeline Followback (TLFB).


Appel, J., & Kim-Appel, D. (2009). Mindfulness: Implications for substance use and addiction. International Journal of Mental Health and Addiction, 7, 506-512.

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Author’s Note:
The foregoing research article was written by the Site Administrator for a university assignment in November, 2012.

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