Adaptation of Mindfulness-Based Stress Reduction Program for Addiction Relapse Prevention

Article (PDF Available)inThe Humanistic Psychologist 37(2):192-206 · April 2009with 1,998 Reads
DOI: 10.1080/08873260902892287
Abstract
The Mindfulness-Based Stress Reduction program (MBSR) was offered in a community-based addiction treatment setting to provide skills training for relapse prevention. The population consisted of highly marginalized and poor African American and Latina women with histories of trauma. Through an iterative feedback process, the more systematized MBSR practices were adapted to meet the specific needs of this population. Adaptations focused on the role of stress in relapse prevention and addressed the following common sequelae of addiction and trauma—shortened attention span and sensitivity of particular body areas to revived traumatic memories—as well as low literacy levels of the population served. With appropriate adaptations, MBSR can be implemented successfully for relapse prevention in early recovery. Client ratings indicated high levels of acceptability and satisfaction.
Adaptation of Mindfulness-Based Stress
Reduction Program for Addiction
Relapse Prevention
Zayda Vallejo
Center for Mindfulness in Medicine, Health Care, and Society, University
of Massachusetts Medical School
Hortensia Amaro
Institute on Urban Health Research, Bouve
´College of Health Sciences,
Northeastern University
The Mindfulness-Based Stress Reduction program (MBSR) was offered in a
community-based addiction treatment setting to provide skills training for
relapse prevention. The population consisted of highly marginalized and poor
African American and Latina women with histories of trauma. Through an
iterative feedback process, the more systematized MBSR practices were
adapted to meet the specific needs of this population. Adaptations focused
on the role of stress in relapse prevention and addressed the following common
sequelae of addiction and trauma—shortened attention span and sensitivity of
particular body areas to revived traumatic memories—as well as low literacy
levels of the population served. With appropriate adaptations, MBSR can
be implemented successfully for relapse prevention in early recovery. Client
ratings indicated high levels of acceptability and satisfaction.
BACKGROUND
Researchers and treatment providers in the field of addictions have become
increasingly aware of the strong relationship between substance abuse and
Correspondence should be addressed to Zayda Vallejo, 62 Commodore Road, Worcester,
MA 01602. E-mail: zvallejo1@aol.com
The Humanistic Psychologist, 37: 192–206, 2009
Copyright #Taylor & Francis Group, LLC
ISSN: 0887-3267 print=1547-3333 online
DOI: 10.1080/08873260902892287
192
stress. It has been shown that stress induces some individuals to use drugs
(Dawes et al., 2000; Kosten, Rounsaville, & Kleber, 1986; Sinha, Fuse,
Aubin, & O’Malley, 2000). In fact, substance abuse can be viewed as a mala-
daptive response to stress, discomfort, and emotional pain. In treatment,
stress is one of the strongest predictors of drug craving, relapse, and contin-
ued drug use (Brewer, Catalano, Haggerty, Gainey, & Fleming, 1998;
Dawes et al., 2000; Goeders, 2003; Kosten et al., 1986; Kreek & Koob,
1998; Leiden University, 2007; National Institute on Drug Abuse, 2002;
Sinha et al., 2000). As a group, women with addictions face many stressors
in early treatment, and most have high levels of depression, anxiety, and
posttraumatic stress disorder (Amaro et al., 2005; Brady, Kileen, Saladen,
Dansky, & Becker, 1994; Hien, Cohen, & Campbell, 2005; Stevens, Murphy,
& McKnight, 2003; Weaver, Turner, & O’Dell, 2000).
In 2002, the Boston Consortium of Services for Families in Recovery
(BCSFR), a collaborative of residential and outpatient substance abuse
treatment programs for women, began exploring the possibility of using
mindfulness-based practices as part of a new initiative aimed at developing
positive coping skills and life habits for self-care in dealing with stress and pre-
venting relapse. The Mindfulness-Based Stress Reduction (MBSR) Program
at the Center for Mindfulness in Medicine, Healthcare, and Society (CFM)
in Worcester was selected as the vehicle for teaching women how to do this.
In 2003, the BCSFR implemented the Mother’s Hope, Mind, and Spirit
Project, a 5-year service intervention and evaluation study to improve treat-
ment outcomes and reduce HIV=AIDS risk behaviors among Latina and
African American women in recovery from addiction. The BCSFR and
the CFM collaborated in implementing the MBSR program with clients
from four residential and one outpatient treatment program serving largely
poor, inner-city African American and Latina women.
It was thought that improving ability to cope with and respond to stress
would be an important skill in relapse prevention, and could even reduce the
risk of HIV infection. From the outset, it was apparent to the program man-
agers and developers that adaptations would be needed. For example, some
community-based substance abuse treatment providers were hesitant to use
meditation and yoga with people in early recovery (less than 6 months).
Some of their concerns included the following:
1. The stillness required to do seated meditation may simply be impossible,
because the body in the early stages of recovery is often still quite
hyperactive;
2. Drugs prescribed to treat addiction, along with the very busy schedules
in most treatment facilities, tend to induce sleep and=or attentiveness
gaps any time the person closes the eyes even for a few moments;
ADAPTION OF STRESS REDUCTION PROGRAM 193
3. Sustained attention placed on previously abused parts of the body during
the body scan can cause memories leading to retraumatization;
4. The loud mental noise present in early recovery can be amplified, instead
of bringing serenity; and
5. Attention to bodily sensations might exacerbate the cravings and urges
present immediately after detoxification treatment.
Nevertheless, the program developers believed that there was a way for
people in early recovery to benefit from a well-designed stress-reduction
program if mechanisms were put in place to minimize the risks.
BRIEF DESCRIPTION OF MBSR
At the CFM, the MBSR program consists of an 8-week course, offered
weekly for 2.5 hr per class, with approximately 25–35 participants per class.
Participants are trained in mindfulness meditation of 45 min duration, and
carry out assigned exercises from a practice manual. They are also encour-
aged to bring mindfulness into their daily activities as best they can. Atten-
dance at a 7-hr silent retreat in the sixth week of the session is part of the
course. The core beliefs underpinning the program are the interconnected-
ness and wholeness inherent in human life, the understanding that, regardless
of what is happening, there is always more right than wrong in any person’s
life, and the recognition of the boundless inner resources available at all times
that could be used for healing (Kabat-Zinn, 1994, 2005; Santorelli, 1999).
The four main formal experiential practices of the MBSR program and
the rationale underlying these practices are described in the following
(Kabat-Zinn, 1990; Santorelli, 1999).
1. The Body Scan
The body scan exercise is used to reestablish conscious contact with the
body. It consists of a systematic scanning of the different parts of the body
to actually feel each region of focus, mentally exploring inner and outer sen-
sations with curiosity and without judgment. This technique is effective for
developing both concentration and flexibility of attention, and for training
the mind to come back to the here-and-now through moment-to-moment
awareness. Transformation and change occur by learning to be open and
accepting of whatever is present—good, bad, or neutral; to be intentional
in the way we pay attention; to skillfully relate to difficulties, distractions,
and the wanderings of the mind, and to be more compassionate and
befriending of whatever arises.
194 VALLEJO AND AMARO
2. Seated Meditation
In this exercise, participants are invited to consciously adopt an alert, digni-
fied, and relaxed posture, and to bring the mind to the present moment by
selecting an object of focus such as the breath, bodily sensations, sounds,
emotions, or thoughts. Once participants are able to sustain their attention
on the object for longer periods, they are invited to open their field of aware-
ness to witness anything that arises inwardly. This is known as choiceless
awareness. After a period of systematic practice, participants begin to
observe the impermanence of all thoughts. People start to notice that they
can witness their own thoughts objectively without having to act on them.
This is particularly helpful in working with impulse control when a craving
arises. It is also possible to realize that the part observing is not in pain, con-
fused, or damaged. This silent witnessing allows participants to see unantici-
pated possibilities in managing adversity. Transformation and change occur
by learning to anchor awareness in the present moment and to live life in a
curious interested way, instead of the usual ‘‘I like’’ or ‘‘I don’t like’’ mode.
3. Mindful Hatha Yoga
Yoga means union of body and mind. The exercises are performed in a slow
and mindful manner, keeping the mind focused on the parts of the body that
are engaged in a particular exercise, and allowing the muscles that are not
engaged to rest and relax. The aim of the exercise is to notice the changing
sensations, not necessarily to do the exercise perfectly. Self-care is a central
and repeated theme during the yoga exercises. Participants are encouraged
to take responsibility for listening to the body and never to force the body
to go beyond its limits. This attentive movement allows a discovery of the
body’s ability to gradually surpass initial limits of stamina and flexibility.
Awareness of attempts to anesthetize feelings of anxiety and distress by
overeating, overworking, drinking, and using drugs also increases. Transfor-
mation and change occur by learning to be aware of bodily experience and
sensation and to see more clearly the extra ‘‘layer’’ added by feelings and
thoughts of likes and dislikes.
4. Walking Meditation
This practice consists of focusing one’s attention on the actual experience of
walking while walking. Generally, the instruction is to start very slowly,
focusing attention on sensations on the feet, the legs, and finally the entire
body. This can be combined with respiration or the awareness of breathing.
Attention is given to the intrusion of any thoughts or emotions and
ADAPTION OF STRESS REDUCTION PROGRAM 195
returning attention to the bare sensations of movement. Transformation
and change occur by using walking as a connection or bridge between
periods of practice and daily life.
DEVELOPMENT OF MBRP
Initially, the overarching guideline was to maintain a high fidelity to the ori-
ginal MBSR program. The MBSR curriculum had already been adapted for
use at an inner-city clinic in Worcester (Kabat-Zinn, Mumsford, Levi-
Alvares, Santorelli, & Skillings, 1993).
Yet it became clear even during the preimplementation period that these
moderate adaptations would be insufficient. To educate staff about the role
of mindfulness-based practices in stress reduction, the Mother’s Hope,
Mind, and Spirit staff was invited to participate in the 8-week MBSR inter-
vention concurrently with implementing the first MBSR cycle with clients.
Staff feedback on the sessions was mixed, but sufficiently negative to alert
us to low buy-in among staff.
The main dissatisfaction with the MBSR program related, in part, to the
apparent lack of direct relevance to issues of addiction and relapse, early
recovery, trauma, mental illness, and literacy in the client population. With
this information in mind, we began to reconceptualize the program, giving it
a relapse prevention focus while continuing to gather information on the
efficacy of our changes for addressing client needs. Thus, the goal of the
initial implementation of the first few cycles was to learn about MBSR’s fea-
sibility, acceptability, and fit for the clinical populations and treatment set-
tings, as well as helping the clients as much as possible. In the cycles that
followed, adaptations were introduced while continually assessing and
adapting them further.
THE MBRP-W PROJECT
The most fundamental change was the reshaping and reorientation of
MBSR into a mindfulness-based relapse prevention program whose central
focus is the role of stress in relapse. Particular effort was made to take into
account the women’s history of trauma and their daily experiences of stress
and then apply mindfulness-based skills to assist them in relapse prevention
and early recovery. The goals of the adapted program (from hereon
referred to as MBRP-W or Moment-by-Moment in Women’s Recovery:
A Mindfulness-Based Approach to Relapse Prevention) were to refine
self-regulatory skills; increase relaxation and awareness skills; decrease
196 VALLEJO AND AMARO
symptoms of stress and stress reactivity; and increase an overall sense of
well-being to prevent relapse. These skills would be learned in part by
becoming aware of the craving, observing it with a certain spaciousness
and affectionate curiosity instead of reacting in habitual ways. The program
also aimed to foster the recognition of early warning signs of relapse, teach-
ing skills to come back to present, moment-by-moment awareness whenever
the mind started to dwell in the past or future and teaching how to access
inner resources through the acquisition of mindfulness skills. Within this
context, the role of stress in the curriculum was reoriented to relate specifi-
cally to its impact on substance use, cravings, and relapse and its prevention
among this population of women with a high rate of co-occurring disorders.
Participants
The women attending the program had very distinct characteristics and
needs. Most were very bright, creative, vivacious individuals whose lives
had been severely damaged due to trauma, mental illness, and substance
abuse. In most cases, they had lost the support of their families. Most
women had not graduated from high school, had been homeless or impri-
soned at least once, and had lost custody of their children. The fact that they
had entered treatment was a huge accomplishment. After living with very
little structure and few rules, participants found it very challenging to have
to abide by the rules of residential treatment or outpatient substance abuse
treatment, regardless of how warm and supportive their new surroundings
were. Furthermore, living together with a large group of other women
who were also in recovery, along with their children, and dealing with their
children’s interactions with other adults and children, all combined to test
their resources to the limit.
In some instances, the courts had mandated the women into treatment.
Most of the participants were concerned about regaining custody of their
children and were motivated by that desire to be in treatment. A majority
had a history of sexual and=or physical abuse and mental illness.
Design and Implementation of MBRP-W
Two MBRP-W classes per week–one in English and one in Spanish—were
held for 9 weeks, during a period of 4 years. The two classes were
back-to-back with a half-hour break in between. From May 2003 to May
2007, 262 women enrolled in the classes and 61% completed the interven-
tion. Of those who started the intervention, 32 (12%) did not attend enough
sessions to be considered completers; this was largely due to appointments
ADAPTION OF STRESS REDUCTION PROGRAM 197
that conflicted with the scheduled groups. And 58 (22%) did not complete
because they dropped out of the treatment programs.
Each class was divided into five segments comprising (a) a welcome med-
itation, (b) setting out the objectives of the class, (c) a brief didactic psychoe-
ducational presentation based on each theme of the class, (d) experiential
and formal practices, and (e) readings of recovery literature and poems by
the participants and setting assignments for the next class.
Some of the class themes included learning to prevent relapse through
mindfulness, responding creatively and developing positive coping mechan-
isms during recovery, and understanding how perceptions could compro-
mise treatment and lead to relapse. Other themes were associated with
learning how to use mindfulness skills to relate differently to difficult feel-
ings such as anxiety, panic attacks, fear, guilt, and shame; to improve com-
munication with oneself and others; and to manage anger, self-violence, and
violence to others.
Outcomes of the program were evaluated with the use of structured inter-
views with individual participants conducted by the research staff at the
initial phase, and at 6- and 12-month intervals. A separate paper is being
prepared with those findings, which are not reported here. A participant-
satisfaction form was collected by the research team at the last MBRP-W
group session. In addition, instructors provided written observations on
the specifics of how the groups had been implemented and about their per-
ception of participants’ responses.
CHALLENGES AND EVOLUTION OF THE MBRP-W PROGRAM
Emergence of Challenges
During the first cycle, there were two classes—one for the clients and one for
staff—to provide them with tools to cope effectively in a highly stressful
environment and to familiarize them with the overall intervention. Atten-
dance at both classes was poor, partly because there were many conflicting
appointments with doctors and courts, for both clients and staff.
Other challenges related to the content and approach of the standard
MBSR program. Initial adaptations to the curriculum were minor, primarily
affecting the sequence and length of the exercises. However, serious concerns
remained about the vast array of negative responses from participants. It had
been hoped that most participants would come to derive some satisfaction as
the course progressed, but often the opposite occurred. Many women
expressed that they ‘‘just hated’’ coming to class. Anxiety and agitation often
increased as the class progressed. For clients taking sedative medication for
198 VALLEJO AND AMARO
withdrawal, mindfulness practice increased drowsiness resulting in deep sleep
during the class. Other participants were clearly upset by just being in the
classroom. Participants had a strong negative association with the assigned
homework of daily practice and no one did it. Almost universally, women
resisted the meditations focused on awareness of breath as they found it anxi-
ety provoking to be still and to connect with their bodies. Most women were
unable to see the relevance of meditation to their recovery. Yoga was the only
thing that almost everyone participated in and enjoyed.
It was apparent that the groups needed more structure. Attention span
was relatively short, so the activities needed to be shorter and more varied
to engage participants and facilitate learning. Participants needed more
information about how stress reduction would help with relapse prevention
and recovery. They needed to see the information on a flipchart, as well as
to hear it to remember. More stimulation through movement was also
required to meet the women where they were.
Evolution of MPRP-W
After the fifth cycle, a new curriculum was developed, taking into considera-
tion the input of participants and staff. The revised program focused on spe-
cific stressors faced by women in the program. A more didactic approach
was followed to teach clients about the relationship of stress to relapse
and how mindfulness could be useful as a relapse prevention tool. Subse-
quently, there were significant positive changes in attendance, attitudes
about the class, attention during the class, and written evaluations at the
end of the intervention.
ADAPTATIONS TO THE MBSR-W PROGRAM
In this section, we discuss how the MBSR program was adapted for the
MBSR-W project. The four practices employed in the traditional MBSR
classes were used but the length, sequence, and ways of presenting them var-
ied substantially. Additionally, the topics, examples, and exercises for apply-
ing mindfulness practices now relate more directly to specific stressors
experienced by the participants in their recovery and to relapse risks.
The body scan has been shortened and changed drastically from the way
it is presented in the MBSR program to reduce potential interference from
trauma experiences. It is performed in a sitting or standing position, nonse-
quentially, and interspersed with yoga movements. The eyes are open to
promote a sense of safety among women with a history of trauma. The scan
begins with the feet and legs, followed by yoga for the feet and legs. This
ADAPTION OF STRESS REDUCTION PROGRAM 199
process is repeated for all the different parts of the body. Instead of a
detailed scan of the pelvic area and breasts, the revised body scan focuses
on the abdominal area and the front of the chest. At times, the movement
takes place first followed by the scanning.
Sometimes the body scan is preceded by very fast walking meditation,
running, or jumping in place, decreasing the movement gradually and end-
ing in the mountain pose. The goal is to meet the participants where they
are, matching the movement to the agitation and pent-up energy they would
exhibit, then to progressively slow down this practice. The importance of the
2-min body scan throughout the day as one of the main tools of mindfulness
in daily life was emphasized and encouraged among the participants.
Seated guided meditation starts with awareness of sounds because parti-
cipants are able to connect more easily with sounds than with body sensa-
tions or the breath. After sounds comes awareness of body sensations—
primarily accessed through points of contact—and finally the breath. Initi-
ally, group members generally found it extremely difficult to focus on the
breath. Participants often experienced it as boring and abstract. At times,
it also triggered flashbacks for some of the women with trauma histories
that included choking or a hand being held over their mouths. The adapta-
tion was to shorten the guided meditations, performing them with eyes open
if desired, and placing the hands on the abdomen to follow the rhythmic
expanding and contracting of the breath.
Walking meditation often starts with fast-paced walking, not in a line or
circle, but randomly, progressively decreasing to slow walking. Most of the
participants were receptive to this practice if the walking was not too slow.
Yoga is the basic staple of the MBRP-W classes, and is performed in any
of the segments if the mood of the participants is too lethargic or too dis-
tracted. The exercises are much the same as in a MBSR class. One exception
is that there are no pelvic rocking exercises, because those triggered symp-
toms for the women who had been sexually abused.
At the core of the MBRP-W is the informal practice of mindfulness in
everyday living. Participants are encouraged to frequently take moments
to stop, to breathe, and to bring awareness to the body, the five senses,
the breath, or whatever activity is being performed. The triangle of aware-
ness (thoughts, emotions, and body sensations) is repeatedly emphasized.
A drawing of a triangle with thoughts, feelings=emotions, and body sensa-
tions represented in a corresponding apex was presented in every class
and created a visual tool that the women remembered easily.
The triangle of awareness is a framework for observing more clearly how
the mind operates. By separating the emotions, bodily sensations, and
thoughts, and paying attention to each of these individually in a systematic,
moment-to-moment, non-judgmental way, participants begin to experience
200 VALLEJO AND AMARO
the freedom of choosing how to respond, instead of reacting in automatic
habitual ways.
Most participants found this visual exercise helpful, and one participant
explained how it helped her to deal with her feelings:
Last week on Tuesday I heard that my best friend had died. By Friday I was so
depressed! All I wanted was to go to bed, cover my head with a blanket, and
disappear from the world. I walked to my bed, got inside the blankets, and
then remembered that you had said that thoughts are just like clouds, that they
come and go, and that I could just watch them and say ‘‘next.’’ You said that
I did not have to believe or behave the way I was thinking. So I got out of bed
and the whole weekend kept saying ‘‘next’’ when a thought of going to bed or
leaving the program was there. This is new. For years I have been going to bed
and staying in bed for days when I feel horrible. This stuff works!
In comparison with the MBSR classes, there needed to be much more
flexibility with the curriculum in each class. Early warning signs of possible
relapse had to be addressed. Even though the full curriculum may not be
implemented in a particular class, ideally the instructor would still be able
to teach mindfulness, underscoring what is unfolding with mindfulness
tools, and also by embodying total presence, centeredness, and curiosity
in responding to critical and immediate issues introduced to participants.
Additionally, the following considerations were taken into account in the
formulation of adaptations:
1. If a participant relapses and=or drops out of the program, there is a
strong impact on the group members. Instructors must cope with their
own and the group’s grief reaction and help the remaining participants
to adjust to the changed dynamics.
2. Instead of a 7-hr retreat with participants bringing their own food, there
is a 4-hr retreat with food provided. A body scan while lying on the floor
for up to 40 min is part of the retreat.
3. Tapes=CD’s with meditation of 5–7 or 15 min duration were available to
support a daily practice.
4. Therapists were available after group sessions to help participants deal
with feelings and reactions that came up during the class.
5. Group dynamics in the residence strongly influence the dynamics in
MBRP-W sessions, and instructors were made aware that these feelings
need to be addressed during class.
6. Especially in situations where the MBRP-W instructor is not a staff
member at the treatment facility, the instructor’s authority may be chal-
lenged by participants. Having a staff person from the facility assisting
ADAPTION OF STRESS REDUCTION PROGRAM 201
or as a coinstructor reduced client resistance and helped to set clear
expectations of behaviors and boundaries for participants.
7. Participants rarely completed homework, although they received
much encouragement, so the emphasis on homework was decreased to
avoid provoking shame and guilt. In addition, we found that use of
the word homework brought back negative experiences in school and
anticipated feelings of failure. In response, homework was changed to
daily practices. A typical comment from the participants is: ‘‘I like what
we are doing here but I hate the homework. I just don’t like homework.
Look, I did not graduate from high school because I refused to do
homework.’’
OUTCOMES AND PARTICIPANT FEEDBACK
Participant ratings on various dimensions of our mindfulness-based relapse
program for women in addictions recovery were obtained from 161 women
who completed the program. The majority of women who did not complete
the program were ones who dropped out of substance abuse treatment (57%
of 101 women who did not complete). The remainder who did not complete
the program were not able to attend enough sessions to be considered com-
pleters—this was most often due to conflicting appointments.
Participant ratings on 13 items were compared between those of the first
year of implementation (prior to the adaptation to a relapse prevention
approach) and those in the fourth year of implementation (after the adapta-
tion to relapse prevention approach). All but two items showed statistically
significant improvements from 2003, the first year of implementation, to
2006, the next to last year of implementation for which data were collected.
Overall, the results indicate high rates of satisfaction and acceptability, espe-
cially with the adapted model.
Participant responses to several open-ended items provide additional
insight as to what women liked most about the group, what they liked least
about the group and what they would tell other women in recovery about
this group. Many of the responses were written in Spanish and have been
translated into English here.
Common responses to what women liked most about the group included
learning about specific practices taught in the sessions such as ‘‘awareness of
the breath,’’ ‘‘learning to be mindful about the breath,’’ and learning the
body scan, meditation, and yoga exercises. Participants also responded with
observations about what they had gained as a result of the group such as ‘‘I
learned to know myself,’’ ‘‘learning how to release stress,’’ ‘‘I learned to con-
centrate and get in touch with my inner self,’’ ‘‘being able to meditate brings
202 VALLEJO AND AMARO
me closer to my higher power,’’ and ‘‘learning to be mindful and live in the
present moment.’’
To the open-ended question about what women liked least about the
group, most who responded to this item said ‘‘nothing.’’ Others noted that
they liked least ‘‘sitting still for long periods;’’ a few felt that ‘‘it was too
long,’’ yet others felt that ‘‘it could have been longer.’’
The open-ended item that received the most responses and the most spe-
cific observations was the question that asked participants about what they
would tell other women in recovery about the group. Typical responses to
this item were: ‘‘I’ll tell them that I learned to sit with myself and notice
my body signals and my mind signals. How these two worked out differently
at times or they can work together at times.’’ ‘‘How to identify your addic-
tion when it comes to you, and there are a lot of ways (feelings) that the
addiction comes to you and mindfulness teaches you how to deal with those
feelings—that they are only feelings that come and go.’’ ‘‘To be mindful
helps you to deal with your feelings and you don’t have to stay stuck. Being
compassionate with yourself is very important.’’
The final open-ended item invited women to share any other comments
and also resulted in many responses. Most of these were directed to the
group instructors and expressed gratitude for their dedication, their calm
approach, and the teachings they had shared. Several typical examples are
‘‘Thank you both for such an experience. And I will use this meditation
for the rest of my life. I LOVE YOU BOTH!!!’’ ‘‘May God bless the instruc-
tors.’’ Some of the women’s comments underscored their interest in continu-
ing to participate in groups: ‘‘I’d like to take the class again so I can be more
patient with myself.’’ ‘‘I really enjoyed it.’’ and ‘‘You need to continue fund-
ing this program so more women can heal properly.’’
CONCLUSIONS
In this article, we described our experiences in implementing the MBRP-W pro-
gram with women in treatment for addictions recovery within community-
based programs serving primarily African American and Latina women in
residential and outpatient modalities. We have not focused on the outcome
evaluation findings, which will be reported separately. Rather, we wanted to
describe the process of implementation and adaptation; share lessons learned
regarding acceptability, fit, and feasibility; and give a snapshot of some of
the positive results that the participants reported.
Our experiences lead us to conclude that the mindfulness-based stress
reduction approaches, such as the one described here, are feasible within
the setting described. However, we found that adaptations were needed to
ADAPTION OF STRESS REDUCTION PROGRAM 203
help women see the program as relevant to their recovery in terms of relating
the skills learned to the stress they experience and in applying the practices
learned to their everyday life.
A major lesson learned was the importance of reframing the approach to
focus on relapse prevention. We described a number of ways in which we did
this with what appears to be significant success, as reflected in participant
ratings and feedback. These changes included spending more time explain-
ing the relationship of stress to craving and relapse, and relating key aspects
of the intervention to relapse prevention and the situations that can be trig-
gers for cravings and relapse.
A second lesson was related to the adaptations needed to adjust to parti-
cipants’ trauma histories, short attention span, and low literacy. Modifica-
tions included refocusing the body scan away from areas of the body that
are common targets of assault, shortening the length of sitting and walking
meditations, and adapting the walking meditations to a fast-to-slow pace.
We took great care to simplify the language, eliminate jargon, repeatedly
explain key terminology, and used visual aids with handouts as much as
possible. We also simplified homework assignments so that participants
could engage with them within their limited free time. Stressing the role of
informal practices rather than focusing on formal practices was also an
important modification.
A third lesson pertains to the adjustments needed to cater for the women
in residential settings, where they have highly demanding treatment sche-
dules during the day and responsibilities for community tasks and for the
care of their children during evenings and weekends. To the extent possible,
it would be useful if residential settings rework treatment schedules to
ensure fewer conflicting appointments, create quiet practice places and times
for participants, and integrate short practice times with other treatment
activities.
In summary, ratings and open-ended comments on satisfaction surveys
from participants suggest that the program was well received, and that satis-
faction with the intervention increased after the adaptations were put in place.
ACKNOWLEDGEMENTS
We would like to thank the program participants and staff from the Boston
Consortium of Services for Families in Recovery who were part of this
project and the Center for Mindfulness in Medicine, Health Care, and
Society at the University of Massachusetts Medical School. This work
was funded by the Substance Abuse and Mental Health Services Adminis-
tration Grant #TI14442, Hortensia Amaro, Ph.D., Principal Investigator.
204 VALLEJO AND AMARO
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ADAPTION OF STRESS REDUCTION PROGRAM 205
AUTHOR NOTES
Zayda Vallejo is a senior teacher at the Center for Mindfulness in Medicine, Health Care
and Society, University of Massachusetts Medical School, where she teaches both the MBSR
program, and the Practicum in MBSR. She received her Bachelors degree in Psychology at
Loyola University and her M.Litt degree from Oxford University in England. She has practiced
meditation for over 30 years and taught mindfulness classes in a variety of settings.
Hortensia Amaro is Distinguished Professor and Associate Dean at the Bouve
´College of
Health Sciences and Director of the Institute on Urban Health Research at Northeastern
University. In 1982, she received her doctoral degree in psychology from the University of
California, Los Angeles. She has published over 100 articles and has developed numerous com-
munity-based addictions treatment and HIV prevention programs with inner city minority
populations.
206 VALLEJO AND AMARO
  • Article
    Although therapeutic treatments exist for substance use disorder (SUD), about half of individuals who enter treatment leave early and relapse to substance use. Early dropout from residential treatment places individuals at risk of relapse, and women in SUD residential treatment represent a vulnerable population. Evidence gaps persist for the use of mindfulness-based interventions (MBIs) among racially and ethnically diverse women with SUDs, especially regarding the efficacy of MBIs adapted to prevent residential dropout and relapse. We previously developed and pilot tested an MBI, Moment-by-Moment in Women's Recovery (MMWR), adapted to support women with SUD during residential treatment. The 12-session MMWR program tested in the present study integrates relapse prevention, addresses literacy level and trauma experiences and mental health problems, and is relevant to issues surrounding treatment- and relapse-related stressors among women. The primary objective of the current Phase II randomized controlled trial is to adequately test the efficacy of MMWR on residential treatment retention and substance use relapse and determine psychosocial and neural mechanisms of action underlying MMWR. Participants are women in residential SUD treatment from a community-based residential site that serves mainly women who are low-income and racially and ethnically diverse. A subgroup of participants from each treatment group also completes functional and structural neuroimaging assessments before and after the intervention to explore possible structural and functional brain correlates of change associated with participation in the MMWR program. Findings are expected to inform the utility of adapting MBIs to improve treatment success among vulnerable women in SUD residential treatment.
  • Article
    This field report provides a rationale for the potential of yoga to support reductions in stress and substance use among people returning to the community from jail or prison and describes an agency-based example of yoga classes offered in this context. People who have recently experienced incarceration face a multitude of stressors, which can heighten the risk of substance use and support the need to address stress reduction as a pathway to reduced substance use. One promising intervention is yoga, which has demonstrated significant stress-reduction effects among several populations. Feedback from participants in this field report’s practice example reinforces the potential for yoga to decrease stress and complement substance use treatment in supporting health during the transition from incarceration to community return. Further scholarship is needed to explore the benefits and limitations of yoga in this context.
  • Article
    Full-text available
    Background Depression is very common among stroke survivors with estimated prevalence rates of approximately 33% among stroke survivors, but treatment options are limited. Mindfulness-Based Stress Reduction (MBSR) is an effective treatment for depression generally, but benefits in stroke patients are unclear. The aim of this study was to determine the feasibility of delivering MBSR to stroke survivors and their caregivers in the community. We conducted a study to gain views of MBSR as a potential treatment option among stroke survivors and their caregivers in the community. Methods Participants were recruited from an urban community in Scotland (UK) using newspaper adverts, social media and support groups run by health charities. A 2-h MBSR taster session was delivered by two experienced mindfulness instructors, followed by focus group sessions with all participants on their user experience and suggestions for MBSR modifications for stroke survivors. The focus group sessions were audio recorded and transcribed verbatim. Transcript data were analysed thematically using the framework approach. Results The study sample consisted of 28 participants (16 females); there were 21 stroke survivors (11 females) and 7 caregivers (5 females). The median age for participants was 60 years. Most participants described the MBSR taster session as a positive experience. The main challenge reported was trying to maintain focus and concentration throughout the MBSR session. Some participants expressed reservations about the duration of standard mindfulness course sessions, suggesting a preference for shorter sessions. The potential for achieving better control over negative thoughts and emotions was viewed as a potential facilitator for future MBSR participation. Participants suggested having an orientation session prior to starting an 8-week course as a means of developing familiarity with the MBSR instructor and other participants. Conclusion It was feasible to recruit 21 stroke survivors and 7 caregivers for MBSR taster sessions in the community. A shorter MBSR session and an orientation session prior to the full course are suggestions for potential MBSR modifications for stroke survivors, which needs further research and evaluation. Electronic supplementary material The online version of this article (10.1186/s40814-018-0244-1) contains supplementary material, which is available to authorized users.
  • Article
    Prolonged exposure to ‘toxic stress’ caused by financial hardship and social exclusion can result in reduced well-being, increased risk of illness and impaired cognitive function and can negatively impact the physiological processes underlying ageing. Evidence suggests that mindfulness-based interventions (MBIs) may reduce stress and improve well-being in clinical and non-clinical populations, and recent studies indicate they may also help address well-being-related effects of poverty. This study aimed to evaluate the feasibility of delivering an adapted MBI training to adults living with the psychosocial stress caused by poverty and its effectiveness in improving participants’ well-being. In this mixed method, non-randomised waitlist-controlled feasibility pilot study, 40 adults (n = 20 in the training group) from regeneration areas in Scotland earning less than the Living Wage completed the adapted MBI. Delivery proved feasible, even though, as with previous studies on psychosocial interventions in socioeconomically deprived (SED) areas, the rate of participant attrition from recruitment (n = 107) to completion (n = 40) was high (58%). The results showed significant increases in well-being post training for the training group only (p < 0.001). No changes in mindfulness were found in either group. Further qualitative analyses suggested a possible shift in participants’ conceptualisation of well-being from being difficult to manageable or workable. These results indicate that MBI training can be feasibly delivered within SED communities and potentially improve the well-being of course participants. The practicalities of developing accessible MBIs for those living in areas of multiple deprivation are discussed.
  • Article
    Research shows that racial discrimination results in adverse behavioral health outcomes for African–American young adults, including risk for depression, anxiety, and substance use. Although high levels of mindfulness have been shown to reduce risk for such health outcomes, it is unknown whether mindfulness can reduce risk as a consequence of racial discrimination, particularly among African Americans. Three-hundred and eighty-eight African–American young adults between the ages of 18 and 24 (M = 20.6, 62% female) completed measures assessing past-year experiences of racial discrimination, depressive symptoms, anxiety symptoms, alcohol use, and trait mindfulness. A positive correlation was found between racial discrimination and the behavioral health outcomes, as well as a negative correlation between mindfulness and the behavioral health outcomes. Moreover, mindfulness was found to significantly moderate the effect of racial discrimination on mood symptoms. Although mindfulness was found to lessen the effect of racial discrimination on alcohol use, this difference was not statistically significant. In line with previous literature, racial discrimination was shown to have a negative impact on behavioral health outcomes among African Americans. Moreover, our findings provide support for the buffering effect of mindfulness on mood symptoms as a consequence discrimination. This suggests that increasing mindfulness may be an effective strategy to include in interventions targeting improvement in mood symptoms for African–American young adults. However, alternative strategies may be more appropriate to address outcomes, such as alcohol use, as a consequence of racial discrimination.
  • Article
    This study leverages critical race and legal epidemiological frameworks to illustrate the race-based historical evolution of U.S. rehabilitation paradigms directed at imprisoned heroin and opioid users. What began as a racist early-20th-century federal antinarcotic trafficking effort has since assumed a state-based treatment agenda whose programmatic operations are largely based in correctional settings disproportionately reserved for poor substance abusers of color. Even in contemporary carceral facilities, where incarcerated populations are teeming with White addicts, in the aggregate, White drug abusers have been protected from the depraved, incorrigible, and inherently pathological drug-using caricature assigned to their non-White counterparts. This historical examination demonstrates how links between broader drug policy and prison-based drug treatment support a legally codified White supremacist narrative that erodes health and wellbeing for program participants of color, and the communities to which they inevitably return.
  • Article
    Objective: Substance use is common among adolescents with post-traumatic stress disorder (PTSD). We aimed to develop and study an integrated treatment for adolescents with co-occurring disorders. Design: This is a therapy development and open pilot trial study of a manualized therapy for adolescents with post-traumatic stress, depression, and substance use that uses a combination of cognitive therapy (CT) and mindfulness. Methods: Descriptive statistics and paired sample t-tests were calculated to assess for changes in PTSD symptoms, depression, and substance use frequency from baseline to end of treatment using standardized measures and validated by urine drug screens. We also examined for safety, predictors of clinical outcomes, and treatment retention. Results: Thirty-seven adolescents participated in the study; 62% were study completers as defined by retention for at least 6 weeks of treatment. There were significant improvements in PTSD and depression symptoms from baseline to end of treatment, reflecting medium effect sizes, and which was associated with changes in trauma-associated cognitions. There was a reduction in cannabis use, which was the most commonly used substance. Conclusions: Preliminary results suggest feasibility, safety, and potential clinical effectiveness of an integrated therapy for adolescents with PTSD, depression, and substance use. Retention was comparable to other therapy clinical trial studies of adolescents despite the high risk for poor treatment retention and poor clinical outcomes among adolescents with PTSD and co-occurring disorders. We discuss the rationale for continued research of this mindfulness-based CT for adolescents with co-occurring disorders. Practitioner points: Adolescents with co-occurring PTSD and substance use achieved meaningful improvement in PTSD and depression symptom severity after receiving a CT and mindfulness dual diagnosis approach. An integrated manualized therapy for dual diagnosis shows promise for reducing cannabis use in adolescents with PTSD. Changes in trauma-related cognitions have the potential to improve PTSD and depression symptoms in adolescents with substance use problems.
  • Article
    The Five Facet Mindfulness Questionnaire (FFMQ), a widely used and comprehensive assessment of mindfulness, has demonstrated promising psychometric properties among non-clinical and clinical samples and among diverse international samples. Yet, to date, no studies have examined its factor structure, reliability, and validity in a clinical sample of United States (USA) underrepresented minorities. The current study addressed this by investigating the factor structure, internal consistency, test-retest reliability, and construct validity of the FFMQ among 283 low-income African American adults with a recent suicide attempt. Exploratory factor analysis revealed a 20-item, five-factor measure: acting with awareness, describing, non-judging, observing, and non-reacting. Confirmatory factor analysis supported this reduced item five-factor structure. Internal consistency coefficients ranged from 60–86, but test-retest reliability coefficients did not support the temporal stability. Construct validity was supported; FFMQ facets were correlated with theoretically related constructs, such as self-compassion and self-criticism. Several facets were negatively associated with depressive symptoms and suicidal ideation, and the describing facet demonstrated unique predictive validity for depressive symptoms. These findings support the cultural relevance and utility of the FFMQ with African Americans with significant psychological distress.
  • Article
    Mindfulness interventions are becoming increasingly popular across a wide variety of clinical and non-clinical settings where they are often employed to promote psychological well-being. Mindfulness in its original context presented in Buddhist practice is used to systematically understand one’s moment-to-moment experience, and to gradually develop self-knowledge and wisdom. Buddhist teachings describe wisdom as seeing things just as they are - a requisite for the complete freedom from suffering. In psychological writings, although the construct of wisdom lacks a commonly accepted definition, direct experiential self-knowledge is considered to be an essential element of wisdom. The purpose of this article is to examine the three major trainings of the Buddhist path, as well as some of the key Buddhist theoretical constructs, in order to explore their contribution to the gradual development of experiential self-knowledge and wisdom. In Buddhist traditions, mindfulness is practised in the context of a moral and philosophical system, and the mind is described as a sequence of momentary mental states, each distinct and discrete, their connections with one another being causal. We explain how a clear understanding of mindfulness within the context of this broader theoretical framework can be helpful to individuals engaging in different levels of the mindfulness meditation practice, and how this understanding can result in more sustained outcomes for mindfulness interventions. Further explorations are made into how various barriers and motivators to mindfulness meditation can be better understood by linking the theoretical aspects with current research literature on mindfulness.
  • Article
    To further explore the complex relationship between posttraumatic stress disorder (PISD) and substance use disorders, the authors compared 30 women with PTSD in substance abuse treatment with 25 women without PTSD in substance abuse treatment on degree of addiction severity, psychopa-thology, and aftercare compliance. Women with PTSD were more likely to have been victims of sexual and physical abuse, particularly childhood abuse. They had significantly higher scores on the Addiction Severity Index, were more likely to have comorbid affective disorder, and less likely to comply with aftercare. These results suggest that screening for victimization and PTSD among women presenting for substance abuse treatment may have important prognostic and treatment implications.
  • Article
    Abstract Aims. Many people treated for opiate addiction continue to use drugs during and after treatment. It may be possible to improve outcomes by addressing patient characteristics that predict continued drug use. This review uses meta-analytic techniques to identify risk factors for continued drug use in patients treated for opiate abuse. Design and Measurements. A thorough search of the published literature yielded 69 studies that reported information on the bivariate association between one or more independent variables and continued use of illicit drugs during and after treatment for opiate addiction. Findings. Most of the patient variables summarized have weak longitudinal relationships with continued drug use, although several variables display moderate longitudinal associations. Ten variables show statistically significant and longitudinally predictive relationships (average r 0.1) with continued use, including: high level of pretreatment opiate/drug use, prior treatment for opiate addiction, no prior abstinence from opiates, abstinence from/light use of alcohol, depression, high stress, unemployment/employment problems, association with substance abusing peers, short length of treatment, and leaving treatment prior to completion. Several other variables may be potentially longitudinally predictive. Conclusions. To prevent relapse, treatment interventions should address multiple variables because no single variable strongly predicts continued drug use.
  • Article
    Little attention has been given to racial/ethnic differences in studies of co-occurring disorders among women. In this article, we present findings from analyses conducted on the influence of racial/ethnic differences on the demographic and clinical profiles of 2,534 women in the Substance Abuse and Mental Health Services Administration-sponsored Women, Co-Occurring Disorders and Violence Study. Black and Hispanic women demonstrated more disadvantaged economic and social life conditions than White women. After controlling for socioeconomic differences, Hispanic women experienced more criminal justice involvement than others did, and both Black and Hispanic women were more likely to be exposed to community violence although they did not demonstrate more severe clinical symptoms than White women. In the design and delivery of services racial/ethnic differences should be considered, and research questions regarding underlying explanatory factors raised. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 495–511, 2005.
  • Article
    Follow-up studies have suggested that treatment increases addicts' likelihood of remaining abstinent and that depression and life crises are associated with decreased abstinence. An important issue is to what extent receiving treatment can ameliorate psychosocial risk factors such as life crises and depression and decrease ex-addicts' vulnerability to continued drug abuse. In our 2.5-year follow-up of 268 opiate addicts, drug abuse treatment was generally associated with increased abstinence, and life crises and depression were significant risk factors for continued drug abuse. The impact of these risk factors, however, was ameliorated by drug abuse treatment. Although life crises had a greater impact than depression, these two risk factors had additive effects in increasing the risk for continued drug abuse. Among the types of life crises, arguments and losses ("exits") had very strong additive effects with depression as predictors of drug abuse.
  • Article
    Many people treated for opiate addiction continue to use drugs during and after treatment. It may be possible to improve outcomes by addressing patient characteristics that predict continued drug use. This review uses meta-analytic techniques to identify risk factors for continued drug use in patients treated for opiate abuse. A thorough search of the published literature yielded 69 studies that reported information on the bivariate association between one or more independent variables and continued use of illicit drugs during and after treatment for opiate addiction. Most of the patient variables summarized have weak longitudinal relationships with continued drug use, although several variables display moderate longitudinal associations. Ten variables show statistically significant and longitudinally predictive relationships (average r > 0.1) with continued use, including: high level of pretreatment opiate/drug use, prior treatment for opiate addiction, no prior abstinence from opiates, abstinence from/light use of alcohol, depression, high stress, unemployment/employment problems, association with substance abusing peers, short length of treatment, and leaving treatment prior to completion. Several other variables may be potentially longitudinally predictive. To prevent relapse, treatment interventions should address multiple variables because no single variable strongly predicts continued drug use.
  • Article
    This article focuses on the variability in well-being of 102 women in continuous recovery from addiction for 1 to 5 years. Univariate and bivariate analyses of cross-sectional data on recent depressive symptomatology, and psychosocial stress and coping strategies before and during recovery yielded the following findings: (a) Nearly a third of the sample reported scores above the 16-point cut-off on the Center for Epidemiologic Studies Depression Scale, indicating risk for depression; (b) over half had a history of diagnosed depression; (c) perceived stress in 16 life domains significantly decreased from prerecovery to recovery; (d) by recovery, participants significantly increase their use of positive strategies, but they continued use some negative ones; and (e) risk for high depressive symptomatology was greatest among those who were married or cohabiting, had a history of clinical of depression, high perceived stress in areas of money and emotional and physical health. Findings are discussed in terms of their implications for treatment and aftercare.
  • Article
    While several environmental situations may produce cocaine craving, there is little research on whether patterns of drug cue reactivity are similar across different environmental situations. This study examined whether two different environmental situations, psychological stress and drug cues, produce similar or varying patterns of cue reactivity in 20 cocaine dependent individuals. All subjects participated in a single laboratory session and were exposed to stress, drug cues and neutral-relaxing imagery conditions. Cocaine and alcohol craving, emotion state ratings, subjective anxiety, heart rate and salivary cortisol measures were assessed. Significant increases in cocaine and alcohol craving were observed with stress and drug cues imagery but not with neutral-relaxing imagery. In addition, stress and drug cues situations produced similar increases in subjective anxiety, heart rate and salivary cortisol levels. Significant increases in negative emotion ratings and decreases in positive emotion ratings were found for stress and drug cues conditions as compared to the neutral condition. The findings indicate that a similar and comparable pattern of cue reactivity is induced by stress and drug cue manipulations. Furthermore, the comparable increases in subjective anxiety and negative affect observed with stress-induced and drug cue-induced craving provides support for the negative reinforcement model of drug craving and relapse. The negative affectivity co-occurring with the craving state appears to be an important target in the development of new treatments for cocaine dependence.