Sharon H. Hsu

Mindfulness-Based Relapse Prevention for Substance Use Disorders: A Pilot Efficacy Trial

ABSTRACT The current study is the first randomized-controlled trial evaluating the feasibility and initial efficacy of an 8-week outpatient Mindfulness-Based Relapse Prevention (MBRP) program as compared to treatment as usual (TAU). Participants were 168 adults with substance use disorders who had recently completed intensive inpatient or outpatient treatment. Assessments were administered pre-intervention, post-intervention, and 2 and 4 months post-intervention. Feasibility of MBRP was demonstrated by consistent homework compliance, attendance, and participant satisfaction. Initial efficacy was supported by significantly lower rates of substance use in those who received MBRP as compared to those in TAU over the 4-month post-intervention period. Additionally, MBRP participants demonstrated greater decreases in craving, and increases in acceptance and acting with awareness as compared to TAU. Results from this initial trial support the feasibility and initial efficacy of MBRP as an aftercare approach for individuals who have recently completed an intensive treatment for substance use disorders.

Mindfulness-Based Relapse Prevention for Substance Craving

Craving, defined as the subjective experience of an urge or desire to use substances, has been identified in clinical, laboratory, and preclinical studies as a significant predictor of substance use, substance use disorder, and relapse following treatment for a substance use disorder. Various models of craving have been proposed from biological, cognitive, and/or affective perspectives, and, collectively, these models of craving have informed the research and treatment of addictive behaviors. In this article we discuss craving from a mindfulness perspective, and specifically how mindfulness-based relapse prevention (MBRP) may be effective in reducing substance craving. We present secondary analyses of data from a randomized controlled trial that examined MBRP as an aftercare treatment for substance use disorders. In the primary analyses of the data from this trial, Bowen and colleagues (2009) found that individuals who received MBRP reported significantly lower levels of craving following treatment, in comparison to a treatment-as-usual control group, which mediated subsequent substance use outcomes. In the current study, we extend these findings to examine potential mechanisms by which MBRP might be associated with lower levels of craving. Results indicated that a latent factor representing scores on measures of acceptance, awareness, and nonjudgment significantly mediated the relation between receiving MBRP and self-reported levels of craving immediately following treatment. The mediation findings are consistent with the goals of MBRP and highlight the importance of interventions that increase acceptance and awareness, and help clients foster a nonjudgmental attitude toward their experience. Attending to these processes may target both the experience of and response to craving.

The mindfulness-based relapse prevention adherence and competence scale: Development, interrater reliability, and validity

Abstract The present study describes the development of the Mindfulness-Based Relapse Prevention Adherence and Competence Scale (MBRP-AC), a measure of treatment integrity for mindfulness-based relapse prevention (MBRP). MBRP is a newly developed treatment integrating core aspects of relapse prevention with mindfulness practices. The MBRP-AC was developed in the context of a randomized controlled trial (RCT) of MBRP efficacy and consists of two sections: Adherence (adherence to individual components of MBRP and discussion of key concepts) and Competence (ratings of therapist style/approach and performance). Audio recordings from 44 randomly selected group treatment sessions (50%) were rated by independent raters for therapist adherence and competence in the RCT. Findings evinced high interrater reliability for all treatment adherence and competence ratings, and adequate internal consistency for Therapist Style/Approach and Therapist Performance summary scales. Ratings on the MBRP-AC suggested that therapists in the recent RCT adhered to protocol, discussed key concepts in each session, and demonstrated the intended style and competence in treatment delivery. Finally, overall ratings on the Adherence section were positively related to changes in mindfulness over the course of the treatment.

Examining psychometric properties of distress tolerance and its moderation of mindfulness-based relapse prevention effects on alcohol and other drug use outcomes

Distress tolerance refers to the degree to which an individual is able to withstand negative psychological and/or physical states. Empirical literature has indicated that lower distress tolerance is associated with a number of negative alcohol and other drug (AOD) use outcomes and psychopathology. Mindfulness meditation focuses on enhancing affect regulation, and may be particularly beneficial for individuals with lower distress tolerance. This secondary analysis evaluated the basic psychometric properties of the Distress Tolerance Scale (DTS) in a clinical sample of individuals with AOD-use disorders and tested whether distress tolerance for negative psychological states moderated treatment effects on AOD outcomes in an initial efficacy trial of mindfulness-based relapse prevention (MBRP). It was hypothesized that participants with lower distress tolerance would report fewer AOD use days over the 4-month follow-up if they received MBRP versus treatment as usual (TAU). Participants (N=168) in the parent RCT were recruited from a private, nonprofit agency providing inpatient and outpatient care for individuals with AOD-use disorders. Assessments of 60-day frequency of AOD use, as measured by the Timeline Followback, were conducted at baseline, immediately postintervention, and 2months and 4months following the intervention. Distress tolerance, as measured by the DTS, was assessed at baseline. Results indicated a one-factor solution, which is consistent with how the DTS has been implemented in other studies. As predicted, DTS was positively associated with all mindfulness subscales, suggesting its convergent validity in this clinical sample. Findings showed the hypothesized time×treatment×distress tolerance interaction, and thereby indicated that participants with lower distress tolerance who received MBRP treatment experienced a greater curvilinear decrease in AOD use days over time than those with lower distress tolerance who received TAU. However, the observed plateau effect suggests that these effects were not maintained at the 4-month follow-up. Findings suggest that distress tolerance is a clinically relevant client characteristic to consider in matching participants to aftercare treatment and that MBRP may be particularly helpful for individuals with lower distress tolerance.

Exploring relationships between facets of self-esteem and drinking behavior among diverse groups of young adults

Theory and empirical evidence suggest that North American-based measures of self-esteem, which measure individualistic positive self-regard, may be less applicable to Eastern cultures. In the present exploratory study, we examined how different conceptualizations of self-esteem, as measured by the Rosenberg Self-esteem Scale and the Collective Self-esteem (CSE) Scale, predicted drinking behavior among three groups of American college students (N=326) with varying ethnicities: White, Korean, and Chinese/Taiwanese. Hierarchical negative binomial regression was employed to evaluate these relations. Ethnic identity was controlled for in all analyses. Findings indicated that while global self-esteem was positively associated with drinking for the whole sample, ethnicity moderated this relationship such that global self-esteem was related to drinking for White participants but not for their Chinese/Taiwanese counterparts. In addition, while CSE did not associate with drinking for the whole sample, effects emerged for specific ethnicities. Specifically, private CSE was associated with less drinking for Korean and Chinese/Taiwanese participants. Depending on specific Asian ethnicity, public CSE served as a risk (Korean participants) or a protective factor (Chinese/Taiwanese participants) for drinking. Findings suggest that above and beyond ethnic identity, differential relationships between facets of self-esteem and drinking behavior may exist among White, Korean, and Chinese/Taiwanese young adults. Intervention and prevention programs should develop strategies to help Chinese/Taiwanese and Korean American young adults cultivate protective factors within domains of CSE.

The Relationship Between Collective Self-Esteem, Acculturation, and Alcohol-Related Consequences Among Asian American Young Adults

We examined the relationship between collective self-esteem (i.e., the value one places on being part of a collective group), acculturation, and alcohol-related consequences in a sample of 442 Asian American young adults. We found that membership self-esteem and public collective self-esteem interacted with acculturation such that low levels of both predicted greater rates of consequences. Participants with lower acculturation and greater private collective self-esteem experienced more alcohol consequences. This study suggests that differential aspects of collective self-esteem may serve as protective or risk factors for Asian American young adults depending on degree of acculturation.

Corrigendum to “Mindfulness-based relapse prevention for substance craving” [Addictive Behaviors 38 (2013) 1563–1571]

The authors regret that in the abovementioned article there was an error in the description of the items in the Acceptance and Action Questionnaire (AAQ; Hayes, Strosahl, Wilson, Bissett, Pistorello, Toarmino, et al., 2004). The AAQ was described as a 9-item instrument; however, the published paper and analyses used a 12-item instrument created for the purposes of the research. The 12-item measure used in the abovementioned article included the 9-items from the original AAQ as described by Hayes et al. (2004), and three additional items created by the research team to assess acceptance of uncomfortable presentmoment private experiences. The additional 3 items (all reverse scored) included: (1) When I am upset or anxious, I try to distract myself from feeling that way by engaging in other activities; (2) When I feel discomfort in my body (e.g., pain, tension), I focus on something else or do something to make it go away; and (3) When I feel discomfort in my body (e.g., pain, tension), I tend to get irritated at myself for feeling that way. All 12 items were rated on a 7-point Likert scale (Hayes et al., 2004) from 1 = Never true to 7 = Always true. Higher scores on the 12-item measure indicated greater acceptance. There was also a typographical error in the reporting of the reliability of the measure. The internal consistency of the 12-item measure was reported as α= 0.68 and it should have been reported as α = 0.58 at baseline and α= 0.65 at post-treatment. The authors would like to apologize for any inconvenience caused.

Understanding differences in alcohol consumption and depressed mood between U.S.- and foreign-born Asian and Caucasian college students

ABSTRACT The number and proportion of foreign-born individuals in the U.S. population has increased in recent decades. From 1970 to 2007, the foreign-born population more than tripled to approximately 37 million (U.S. Census Bureau, 1997, 2008). Foreign-born students are a key subpopulation of college students. About 23% of U.S. undergraduate college students in 2007–2008 were either born outside of the United States (10%) or were children of at least one first-generation immigrant parent (13%; National Center for Education Statistics, U.S. Department of Education [NCES], 2012). Asian students constitute the majority (30%) of foreign-born undergraduates. Although foreign-born Asian students compose nearly one-quarter of the college population, limited research has examined how rates of alcohol use and depression differ between foreign-born and U.S.-born Asian college students (Gonzalez, Reynolds, & Skewes, 2011; Ralston & Palfai, 2012). The limited research is worrisome given their increasing rates of college enrollment (U.S. Census Bureau, 2011), alcohol consumption (Aud, Fox, & KewalRamani, 2010), alcohol abuse and dependence (Grant et al., 2004), and underutilization of mental health services (U.S. Department of Health and Human Services, 2001). Collectively, these factors point to the need for further research tailored to Asian college drinkers.