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Mindfulness-Based Relapse Prevention

Created by the late G. Alan Marlatt, a professor at the University of Washington and his colleagues, including Dr. Sarah Bowen, mindfulness-based relapse prevention (MBRP) has been shown through research and practice to be effective in reducing relapse rates in substance use disorders.

MBRP, which is a contextual cognitive therapy, augments cognitive behavioral therapy during all phases of treatment at Urban Recovery. Research on outcomes shows it to have a positive effect on stress-reduction, relapse-prevention, anxiety, depression, managing chronic pain, and on trauma. Experts on our staff can help you overcome the impediments to a successful meditation practice, show you how to be response-able rather than reactive to triggers and cravings, and work with you to coordinate training and support in your community to deepen the proven positive effects of mindfulness on relapse prevention, recovery, and quality of life.

Two key MBRP concepts you can begin to put into practice include Urge Surfing and STOP. Urge surfing is a skill that allows one to get on top of an increasing wave of anxiety, whether in the form of panic, a craving, or an urge to use. This wave may seem like it will never end but research shows that waves of panic or waves of cravings follow a bell curve: They rise, peak, and flatten out. The concept behind urge surfing is to use breath meditation much like a surfer uses a surfboard to ride a wave to the shore. It may take practice to master this skill, but that practice has been shown to be highly effective in reducing the impact of cravings and anxiety on one’s thoughts and behaviors.

STOP is a mindfulness acronym for “Slow down, Take a breath, Observe, and Proceed.” As with urge surfing, STOP allows you to become an unattached spectator to the river of thoughts and feelings that might otherwise wash you away. It ramps up the parasympathetic nervous system to assist you in moving out of the fight-flight-freeze mode of sympathetic nervous system reactivity. By slowing down long enough to breath and observe what you are feeling, you create space for choice and new options. This allows you the opportunity to proceed with a measured and healthy response rather than give into to impulses with blind reactivity.

Since Jon Kabat-Zinn, PhD, and colleagues began the practice of mindfulness meditation with patients at the University of Massachusetts Medical Center’s Stress Reduction Program in 1979, the use of mindfulness meditation to treat a host of physical and psychological disorders has expanded to more than hundreds of hospitals and treatment centers throughout North America and Europe. Over that same period, a growing number of research studies have demonstrated the therapeutic effects of meditation for physical ailments such as chronic pain, cancer, and AIDS, as well as for depression, anxiety, and borderline personality disorder.

Although mindfulness meditation is free of any religious sectarian ideology, its roots may be traced back to Theravada and Mahayana Buddhism practiced in India around 500 BC. The practice of mindfulness meditation focuses on insight or vipassana, as it was called in a 5th-century text known as the Visuddhimagga (Path of Purification). The goal of this form of meditation is not to eliminate pain or stress or addiction but to use intentional, focused awareness to achieve a sense of nonjudgmental self-acceptance in the present moment.

Intentional awareness may be understood as putting one’s attention to one’s intention. It is through this willful, directed attention that the structure and chemistry of the brain begin to change, in what is now called neuroplasticity. Just as a constant state of stress or the use of alcohol and drugs can dysregulate the components of the central nervous system, the daily regular practice of mindfulness meditation can enrich the brain’s neuronal structures, acting in effect like an antidepressant but without the accompanying side effects.

Achieving a state of nonjudgmental acceptance is, as the Buddhists say about meditation, “simple but not easy.” Individuals new to recovery may be deeply self-judgmental, slinging arrows of guilt and shame at themselves for the destructive consequences of their addictive behaviors. In group, I hear stories of legal problems, financial ruin, damaged relationships, and physical and emotional self-destruction. Though some members have found a temporary peace by coming to detox, almost all feel trapped by the past and fearful for the future. To sit still in the present moment and simply breathe is difficult enough given their circumstances, but to cast off critical self-judgment seems nearly impossible.

Mindfulness-based relapse prevention (MBRP) stems from the work of the late G. Alan Marlatt, a professor at the University of Washington and his colleagues, including Dr. Sarah Bowen. MBRP, which is a contextual cognitive therapy (much like Acceptance and Commitment Therapy), augments Cognitive Behavioral therapy during all phases of treatment at Urban Recovery. Research on outcomes shows it to have a positive effect on stress-reduction, relapse-prevention, anxiety, depression, managing chronic pain, and on trauma.

Experts on our staff can help you overcome the impediments to a successful meditation practice, show you how to be response-able rather than reactive to triggers and cravings, and work with you to coordinate training and support in your community to deepen the proven positive effects of mindfulness on relapse prevention, recovery, and quality of life.

The STOP approach to Relapse Prevention

STOP is a mindfulness acronym for “Slow down, Take a breath, Observe, and Proceed.” Using the STOP approach to managing urges and cravings allows you to become an unattached spectator to the river of thoughts and feelings that might otherwise wash you over the waterfall of relapse.

Practicing STOP ramps up the parasympathetic nervous system, which assists you in moving out of the fight-flight-freeze mode of sympathetic nervous system reactivity. By slowing down long enough to breath and observe what you are feeling, you learn to tolerate discomfort and create space for healthy choices choice and new behaviors. This allows you the opportunity to proceed with a measured and healthy response rather than give into to impulses to use substances despite the harm they cause.

Observing one’s thoughts

How, then, can the practice of mindfulness meditation possibly work when one is detoxing from alcohol or other substances? Rather than target distorted thoughts with the goal of changing them, as in cognitive-behavioral therapy, mindfulness works through a mechanism that may be understood as metacognitive in nature. Mindfulness seeks to change our relationship to our thoughts without changing the thoughts themselves.

Where CBT asks us to challenge distorted thoughts so that we can replace them with more balanced ones, mindfulness follows the path of un-attachment. Rather than change our stinkin’ thinkin’, mindfulness-based relapse prevention offers skills to allow us to let go of thoughts, feelings, and physical sensations that cause urges, cravings, emotional pain, and suffering. It teaches us how to become detached spectators – or observers – of our thoughts, in the sense that it shows us how to recognize intrusive thoughts and feelings without having to act upon them. Pain may be chronic, but suffering remains optional. Meditation allows us to respond rather than react. It reintroduces choice into our lives. From that powerful sense of choice comes a renewed confidence that we can manage our lives from the “inside-out” without defaulting to chemical coping as the thing to fix us.

Urge Surfing with Mindfulness

Urge surfing, which is a mindfulness skill created by G. Alan Marlatt, is a skill that allows us to get on top of an increasing wave of anxiety, whether in the form of panic, a craving, or an urge to use.

Urges, like panic attacks, follow the shape of a classic bell curve. They curve up, peak, and curve down until flattening out… much like waves rolling toward a sandy beach. Think of a monster wave offshore and how, if you were under neath it when it breaks, it might pummel you to the point where you fear drowning. But that same wave – when it reaches the beach – has flattened out enough for toddlers to run through it.

Research shows that waves of panic or cravings rise, peak, and flatten out. The concept behind urge surfing is to use breath meditation much like a surfer uses a surfboard to ride a wave to the shore. It may take practice to master this skill, but that practice has been shown to be highly effective in reducing the impact of cravings and anxiety on one’s thoughts and behaviors.

This notion of continually drifting from and returning to the present moment is essential to an understanding of how meditation works. The mistake most beginners make when trying to meditate is that of trying to clear their thoughts or push away negative thoughts and feelings in order to have a “good” meditation. This quickly becomes a futile exercise that leads to frustration and a sense of failure. On the contrary, the inevitable thoughts, emotions, and physical sensations that arise during meditation are exactly the material each of us needs to experience and release to make the meditation work. Each return to nonjudgmental self-acceptance— to self-compassion— is the healing, the practice, and the therapy of mindfulness.

This leads to a most crucial message: Cravings and urges are a desire for things to be different from the way they are. Most addiction grows out of a conditioned response between attachment and aversion. Triggers cause cravings to be perceived as overwhelming. The subsequent bliss achieved through substance use creates its own attachment, which is compounded by an aversion to both the impermanence of the high and the suffering caused by withdrawal.7 Suffering grows out of attachment to intrusive thoughts themselves, especially with regard to wanting physical states to be different. Just wishing for them to be different won’t make them different, however. Thus, relentless mind activity (ruminating, obsessing, etc.) causes at least as much suffering as the physiologic symptoms of addiction do.

A Starry Night – A Mindfulness Meditation You Can Do Right Now

Close your eyes and imagine staring up at the stars at night. Breathe quietly and begin to observe certain objects: A satellite may glide across the quilt of stars or a meteor may blaze across the horizon. The blinking lights of a plane cross the sky more slowly, and the moon rises with its own deliberate speed.

All these objects are like our thoughts, feelings, and physical sensations. Some flash for an instant, while others take hold of our attention for what feels like an eternity. Through mindfulness meditation, we accept that these objects exist, but without having to pay them more than passing attention. The detached observer notices the ebb and flow of his/her thoughts, accepts that these are occurring, and then lets them go, through the act of bringing attention back to breathing.

Mindfulness practice consists of both formal and informal meditations, in which everything – from attention to breathing to mindful walking to the silent gratefulness one brings to the eating of a meal – becomes an opportunity for meditation. Once you begin to bring mindfulness into your life in recovery, you see how you can take a mindful shower or do a mindful engine repair, practice drumming with mindfulness, or even turn making a bed into a mindfulness meditation. We may not be able to meditate hours a day like monks, but we can live mindfully when we put our attention to the here-and-now.

Responding to resistance

The reluctance to enter into a daily practice is perhaps the greatest resistance to living mindfully in recovery. Yet, consider this metaphor: We are holding a glass beaker, much like the kind we may have used in a chemistry lab. Now think of all the toxins in our lives – addictions, depression, chronic pain, shameful secrets, even self-destructive behaviors— and pour these into this beaker as if they were a dense black liquid like the ink of a squid. Then imagine a huge glass bowl on the floor beside you. Pour the noxious black liquid into the bowl.

Now use your imagination to pick up an invisible hose that comes from a pure mountain stream. Only, that hose can only release one droplet at a time. Even so, we put the end of the hose over the lip of the bowl and add that pure spring water drop by drop.

How long will it take before that black grunge begins to dissipate and dissolve? How much water will we need to add for the gunk to disappear completely, as if it had never existed?

Is there any less toxic liquid in that bowl than there was before? Of course not. But longer visible. Just clear fresh water. And that’s why we meditate every day.

Chief among the complaints that practicing mindfulness is too hard is that sitting and breathing is “boring” and that therefore it is impossible to meditate. Actually, early recovery may be a very good place to begin the practice of meditation. Not only are individuals feeling the physical effects of withdrawal, but they have become saturated with boredom, frustration, cynicism, fatigue, depression, and restlessness. Working with these states allows one the opportunity to begin to practice meditation when the iron is a little “hot.” Just as the time to weave your parachute together is not after you’ve jumped out of the airplane, the time to meditate for the first time is not in the midst of a superheated argument with your spouse, or during an overpowering urge to use when drugs are at hand. Within the safe confines of a treatment center like Urban Recovery, individuals can focus on their own physical, emotional, and spiritual well-being.

Do Mindfulness and the 12 Steps Mix?

As most treatment programs either follow or encourage participation in a 12-Step program, individuals naturally wonder whether the practice of mindfulness meditation is compatible with the 12 Steps. At Urban Recovery, the response is “Absolutely.” Step 11 speaks directly to meditation as part of recovery and, for those utilizing a 12-Step approach to recovery from addiction, mindfulness meditation can be a useful tool.

For those seeking to learn more how to integrate other spiritually-based recovery practices with a 12-Step program,  we recommend the following books: One Breath at a Time by Kevin Griffin, Mindful Recovery by Thomas and Beverly Bien, and The Zen of Recovery by Mel Ash.

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